Monday, August 31, 2009

Isolating a cause, among the possible lot, for understanding a phenomenon has been an eternal exercise. More broadly, to make plausible decisions and particularly, in medicine (including psychology). Knowing the telltale symptoms and zeroing in on the body organ/system from where the problem erupted is the pulse of medicine (technically called etiology). This may sound easy for well-known diseases like diabetes or cardiac arrest. But diseases are different from illnesses – as the former is mostly objective in nature, while the latter is subjective. Specifically, by illness, I mean something subjective like feelings of malaise or pain. Quite different from something like a disease physiologically rooted in pathogens like viruses or in revealing symptoms like memory loss. That’s why illnesses are what afflict the brain (and by extension, the mind).

So in this difference lies what’s so peculiar about psychiatry, psychology or broadly, any attempt to study the mind.

Let me take a nice strand of medical thought, backed up by some concrete examples to illustrate my point.

Psychosomatic illnesses were quite popular in the early 20th century. And who else but Sigmund Freud who would use it for a somewhat vacuous purpose. A clinical case will suffice here. A kid used to peep into his parent’s bedroom, out of curiosity and otherwise; soon, his eye was infected. This is what psychosomatic illness was made out to be. But it hardly has this color.

Psychosomatic indicates a very general relationship between life events and bodily discomforts. It also includes specific relationship between thoughts, conflicts, needs and physiological changes. Most clinicians now believe that illnesses can be influenced by psychological factors and that many are precipitated by perceptions, thoughts and feelings. There is a continuum of socio-psychological, individual development and biological factors involved in the causation of a disease.

For instance, certain emotional states like anxiety are characterized not only by fear or dread as a subjective psychological experience but also by the release of epinephrine by the adrenal medulla, part of the adrenal gland that caps the kidneys, and other autonomic changes leading to physiological variations.

The physiological changes are not necessarily a result of symbolic conflicts, nor are they directly expressive of psychological factors (as both Freud, and his friend dubbed the father of psychosomatic medicine Gregory Goddeck believed). But the physiological changes are what accompany the activity in central nervous system (that envelops the nervous system and the brain) associated with specific emotions or behavior or preparation for that behavior. It is wrong to attribute physical illnesses purely to psychological causes. This concept of strict psychogenesis of organic disease is as reductionistic as the germ theory against which pioneers of psychosomatic medicine inveighed. Neither is a disease all about a host and infection nor is it only about psychological hara-kiri.

What emerges from all this is that most diseases have multiple causes. The dynamic interaction of multiple factors occurring in varying constellations across various time sequences, modified by feedback effects, underlies changes in health.

That was a long, rather boring but necessary, introduction to what psychosomatic medicine is. So let me switch to two examples: one concerning gross medicine and the other about decision making in general.

Peptic ulcers are ulcers in the stomach and a structure to its left, the duodenum. An ulcer is actually a “destruction of the skin’s surface tissues resulting in an open sore.” A peptic ulcer rupture the surface of the mucous membrane lining body cavities of the stomach/duodenum.

An ulcer is the result of an imbalance between aggressive and defensive factors. On one hand, too much acid and pepsin can damage the stomach lining and cause ulcers. On the other hand (and more commonly), the damage comes first from some other causes, making the stomach lining susceptible to even an ordinary level of gastric acid.

The trouble with this view is that medical advances repeatedly show that it goes too far. Stress certainly causes physical symptoms – for example, DYSPEPSIA – but the belief that it caused peptic ulcers vanished with the discovery of the true cause: colonization of the stomach by the bacterium, Helicobacter pylori. Of course, stress and social adversity affect the risk of many diseases.

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