At the Mind Body Interface: Somatisation, Psychoneuroimmunology, and the Ancients

[The mystical physician to the King of Thrace] said the soul was treated with certain charms, my dear Charmides, and that these charms were beautiful words.

Somatisation involves the transformation or conversion of psychological distress into more tolerable physical symptoms. This might involve a loss of motor function in a particular group of muscles, resulting, for example, in the weakness or paralysis of a limb or a side of the body. This loss of motor function might be accompanied by a corresponding sensory loss. In some cases, sensory loss might be the presenting problem, particularly if it is independent of a motor loss or if it involves one of the special senses such as sight or smell. In other cases, the psychic material is converted into an unusual pattern of motor activity such as a tic or even a seizure (sometimes called a ‘pseudoseizure’ to differentiate it from seizures that have a physical or organic basis, for example, epilepsy or a brain tumour). Pseudoseizures can be very difficult to distinguish from organic seizures. One method is to take a blood sample 10-20 minutes after the event and to measure the serum level of the hormone prolactin, which tends to be raised by an organic seizure but unaffected by a pseudoseizure. More invasive but more reliable is video telemetry, which involves continuous monitoring over a period of several days with both a video camera and an electroencephalograph to record the electrical activity along the skull.

Given that all these different types of somatised symptoms are psychological in origin, are they any less ‘real’? It is quite common for the person with somatised symptoms to deny the impact of any traumatic event and even to display a striking lack of concern for his disability (a phenomenon referred to in the psychiatric jargon as la belle indifference), thereby reinforcing any impression that the somatised symptoms are not quite kosher. Ego defences are by definition subconscious, such that the somatising person is not conscious or, at least, not entirely conscious, of the psychological origins of his physical symptoms. To him, the symptoms are entirely real, and they are also entirely real in the sense that they do in fact exist, that is, the limb cannot move, the eye cannot see, and so on. In fact, some authorities advocate replacing older terms such as ‘pseudoseizures’ or ‘hysterical seizures’ with more neutral terms such as ‘psychogenic non-epileptic seizures’ that do not imply that the somatised symptoms are in some sense false or fraudulent. The reader may recall from the discussion on depression that many people from traditional societies with what may be construed as depression present not with psychological complaints but with physical complaints such as headache or chest pain; like many ego defences, this tendency to somatise or physicalize psychic pain is deeply ingrained in our human nature, and should not be mistaken or misunderstood for a factitious disorder or malingering.

A factitious disorder is defined by physical and psychological symptoms that are manufactured or exaggerated for the purpose of benefitting from the rights associated with what the American psychologist Talcott Parsons called ‘the sick role’ (1951), in particular, to attract attention and sympathy, to be exempted from normal social roles, and, at the same time, to be absolved from any blame for the sickness. A factitious disorder with mostly physical symptoms is sometimes called Münchausen Syndrome, after the 18th century Prussian cavalry officer Baron Münchausen who was one the greatest liars in recorded history. One of his many ‘hair-raising’ claims was to have pulled himself up from a swamp by the hair on his head, or, in an alternative version, by the straps of his boots. Whereas a factitious disorder is defined by symptoms that are manufactured or exaggerated for the purpose of benefitting from the privileges of the sick role, malingering is defined by symptoms that are manufactured or exaggerated for a purpose other than benefitting from the privileges of the sick role. This purpose is usually much more concrete than the secondary gain deriving from the sick role, for instance, evading the police, claiming some form of compensation, or obtaining a bed for the night. It should be absolutely clear that such patterns of behaviour are very different from somatisation – even though, it has to be said, I have often observed cases of overlap.

In recent decades, it has become increasingly clear that psychological stressors can lead to physical symptoms not only by the psychological defence of somatisation but also by physical processes involving the nervous, endocrine, and immune systems. Since Robert Ader’s initial experiments on lab rats in the 1970s, the field of psychoneuroimmunology has taken off spectacularly. The large and ever increasing body of evidence that it has uncovered has led to the mainstream recognition not only of the adverse effects of psychological stress on health, recovery, and ageing, but also of the beneficial effects of positive emotions such as happiness, motivation, and a sense of purpose. Here again, modern science has only just caught up with the wisdom of the Ancients, who were well aware of the link between psychological wellbeing and good health.

In one of Plato’s early dialogues, the Charmides, Socrates tells the young Charmides, who has been suffering from headaches, about a charm for headaches that he had recently learned from one of the mystical physicians to the king of Thrace. According to this physician, however, it is best to cure the soul before curing the body, since health and happiness ultimately depend on the state of the soul. ‘He said the soul was treated with certain charms, my dear Charmides, and that these charms were beautiful words.’ As the virtue of temperance (sophrosyne) is the marker of the health of the soul, Socrates asks Charmides whether he thinks that he is sufficiently temperate. The Charmides takes place in 432 BC, the year of Socrate’s return to Athens from service at the battle of Potidaea, and its subject, as it turns out, is no less than the nature of sophrosyne, a philosophical term loosely translated as ‘temperance’ but with the etymological meaning ‘healthy mindedness’. As is typical with Plato, the dialogue ends in a state of aporia (a state of inconclusive non-knowledge), with Socrates accusing himself of being a worthless inquirer and a ‘babbler’. Charmides concludes that he can hardly be expected to know whether he is sufficiently temperate if not even Socrates is able to define temperance for him.

Whereas Plato associates health with the virtues and in particular with temperance (‘healthy mindedness’), Aristotle associates health with the Supreme Good for man. This Supreme Good, he says, is eudaimonia, a philosophical term that is often translated as ‘happiness’ but is perhaps best translated as ‘human flourishing’. In short, Aristotle argues that to understand the essence of a thing, it is necessary to understand its distinctive function. For example, one cannot understand what it is to be a gardener unless one can understand that the distinctive function of a gardener is ‘to tend to a garden with a certain degree of skill’. Whereas human beings need nourishment like plants and have sentience like animals, their distinctive function, says Aristotle, is their unique capacity to reason. Thus, the Supreme Good, or Happiness, for human beings is to lead a life that enables them to exercise and to develop their reason, and that is in accordance with rational principles. Part of living life according to rational principles is to seek out the right sorts of pleasure, underplaying those brutish pleasures such as food and sex that are only pleasurable incidentally in that they act as restoratives, and privileging those higher pleasures such as contemplation and friendship that are pleasurable by nature and therefore cannot admit of either pain or excess. To pursue the higher pleasures is ‘to stimulate the action of the healthy nature’ (NE, Book VII), and to be healthy is not only to be free from pain and disease, but also and most importantly to flourish according to our essential nature as human beings. So, although Plato associates health with ‘healthy mindedness’ and Aristotle with the Supreme Good, once the Supreme Good is unpacked it becomes very clear that this is merely a difference of emphasis, and that Plato and Aristotle are not in any fundamental disagreement on this issue.

Adapted from Hide and Seek: The Psychology of Self-Deception.

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Gnothi seauton: Mature ego defences

The Oracle of Delphi

Whilst no one can escape using ego defence mechanisms altogether, some ego defence mechanisms are thought to be more helpful or ‘mature’ than others. For example, if a person feels angry with his boss, he may go home and kick the dog (‘displacement’), or he may go out and play a good game of tennis (‘sublimation’). Sublimation is the channeling of negative feelings into useful activities such as study, sport, or art, and is thought to be a far more mature defence mechanism than displacement, which is the redirection of negative feelings towards someone or something less important.

There are a number of other ‘mature’ ego defence mechanisms like sublimation. Altruism, for example, is (contentiously) thought of as a form of sublimation in which a person copes with his anxiety by stepping outside himself and helping others. By focusing on the needs of others, people in altruistic careers such as nursing or teaching may be able to push their needs into the background. Similarly, people who care for a disabled or elderly person may experience profound anxiety and distress once this role is removed from them.

Another mature ego defence mechanism is humour. By seeing the absurd or ridiculous aspect of an emotion, event, or situation, a person is able to put it into its proper context and thereby to diffuse the anxiety that it provokes in him. If human beings laugh so much, this is no doubt because they have the most developed unconscious in the animal kingdom, and Freud himself famously noted that ‘there is no such thing as a joke’. The things that people laugh about most are their errors and inadequacies, and the difficult challenges that they face such as personal identity, social and sexual relationships, and death.

Further up the scale of mature ego defence mechanisms is ascetism, which involves denying the importance of what people normally fear and strive for, and so denying the very grounds for anxiety. The Austrian psychoanalyst Wilhelm Stekel (1868–1940) felt that ‘anxiety is fear of one’s self’; if the importance of the self can be denied, so too can the grounds for anxiety. If people in modern societies are more anxious than people from another time or people from traditional societies, this is perhaps because of the undue emphasis that modern societies place on the self. In the Bhagavad Gita, the Hindu ‘Song of God’, the god Krishna appears to the archer Arjuna in the midst of the battlefield of Kurukshetra and tells him not to give up but to do his duty and fight on. In either case, all the men on the battlefield are one day condemned to die – as are all men. Their deaths are trivial, because the spirit in them, their human essence, does not depend on their particular forms or incarnations for its continued existence. Krishna says, ‘When one sees eternity in things that pass away and infinity in finite things, then one has pure knowledge.’

There has never been a time when you and I have not existed, nor will there be a time when we will cease to exist (…) the wise are not deluded by these changes.

– Bhagavad Gita

Arguably the most mature of all ego defence mechanisms is anticipation. Anticipation involves finding self-knowledge and, like the blind prophet Teiresias, using this self-knowledge to predict or ‘anticipate’ our feelings and reactions. In the Ancient World the greatest of all the oracles was the oracle at Delphi, and inscribed on the forecourt of the temple of Apollo at Delphi was a simple two-word command.

Γνῶθι σεαυτόν

‘Know thyself.’

Adapted from

Ego defence mechanisms

In Freudian psychoanalytic theory, ego defence mechanisms are unconscious processes that we use to diffuse the anxiety that arises when who we really are (our unconscious ‘id’) comes into conflict with who we think we are or who we think we should be (our conscious ‘superego’).

Being entirely honest with oneself is a good exercise.
- Sigmund Freud

In Freudian psychoanalytic theory, ego defence mechanisms are unconscious processes that we use to diffuse the anxiety that arises when who we really are (our unconscious ‘id’) comes into conflict with who we think we are or who we think we should be (our conscious ‘superego’). For example, at an unconscious level a man may find himself attracted to another man, but at a conscious level he may find this attraction completely unacceptable. To diffuse the anxiety that arises from this conflict, he may use one or several of a number of defence mechanisms. For example, (1) he may refuse to admit to himself that he is attracted to this man. Or (2) he may superficially adopt ideas and behaviours that are diametrically opposed to the fact that he is attracted to this man, for example, go out for several pints with the lads, speak in a gruff voice, and bang his fists on the counter. Or (3) he may transfer or ‘project’ his attraction onto somebody else and then berate him for being ‘gay’ (young children can teach us much through utterances such as ‘mirror, mirror’ and ‘what you say is what you are’). In each case, he has used one of three common ego defence mechanisms which are, respectively, denial, reaction formation, and projection. A broad range of such ego defence mechanisms are recognised, and the combination in which we use them reflects our personality. Whilst we cannot escape using ego defence mechanisms, we can gain some insight into how they are used and of how we use them. This self-knowledge enables us to better understand what is happening to us and around us, and, quite simply, to make the best of it.

Related posts:
The manic defence

The manic defence

The 20th century psychoanalyst Melanie Klein called it the manic defence: the tendency, when presented with uncomfortable thoughts or feelings, to distract the conscious mind either with a flurry of activity or with the opposite thoughts or feelings.

One of the central tenets of the Western worldview is that one should always be engaged in some kind of outward task. Thus, the Westerner structures his time – including, sometimes, even his leisure time – as a series of discrete programmed activities which he must submit to in order to tick off from an actual or virtual list. One needs only to observe the expression on his face as he ploughs through yet another family outing, yet another cultural event, or yet another gruelling exercise routine to realise that his aim in life is not so much to live in the present moment as it is to work down a never-ending list. If one asks him how he is doing, he is most likely to respond with an artificial smile, and something along the lines of, ‘Fine, thank you – very busy of course!’ In many cases, he is not fine at all, but confused, exhausted, and fundamentally unhappy. In contrast, most people living in a country such as Kenya in Africa do not share in the Western worldview that it is noble or worthwhile to spend all of one’s time rushing around from one task to the next. When Westerners go to Kenya and do as they are wont to do, they are met with peels of laughter and cries of ‘mzungu’, which is Swahili for ‘Westerner’. The literal translation of ‘mzungu’ is ‘one who moves around’, ‘to go round and round’, or ‘to turn around in circles’.

The 20th century psychoanalyst Melanie Klein called it the manic defence: the tendency, when presented with uncomfortable thoughts or feelings, to distract the conscious mind either with a flurry of activity or with the opposite thoughts or feelings. A general example of the manic defence is the person who spends all of his time rushing around from one task to the next like the mzungu; other, more specific, examples include the socialite who attends one event after another, the small and dependent boy who charges around declaiming that he is Superman, and the sexually inadequate adolescent who laughs ‘like a maniac’ at the slightest intimation of sex. It is important to distinguish this sort of ‘manic laughter’ from the more mature laughter that arises from suddenly revealing or emphasising the ridiculous or absurd aspects of an anxiety-provoking person, event, or situation. Such mature laughter enables a person to see a problem in a more accurate and less threatening context, and so to diffuse the anxiety that it gives rise to. All that is required to make a person laugh is to tell him the truth in the guise of a joke or a tease; drop the pretence, however, and the effect is entirely different.

In short, laughter can be used both to reveal the truth or – as in the case of the manic defence – to conceal it or to block it out. Indeed, the essence of the manic defence is to prevent feelings of helplessness and despair from entering the conscious mind by occupying it with opposite feelings of euphoria, purposeful activity, and omnipotent control. This is no doubt why people feel driven not only to mark but also to celebrate such depressing things as entering the workforce (graduation), getting ever older (birthdays), and even – more recently – death and dying (‘Halloween’). The manic defence may also take on more subtle forms, such as creating a commotion over something trivial; filling every ‘spare moment’ with reading, study, or on the phone to a friend; spending several months preparing for Christmas or some civic or sporting event; seeking out status or ‘celebrity’ so as to be a ‘somebody’ rather than a ‘nobody’ like everybody else; entering into baseless friendships and relationships; even, sometimes, getting married and having children.

In Virginia Woolf’s novel of 1925, Mrs Dalloway, one of several ways in which Clarissa Dalloway prevents herself from thinking about her life is by planning unneeded events and then preoccupying herself with their prerequisites – ‘always giving parties to cover the silence’. Everyone uses the manic defence, but some people use it to such an extent that they find it difficult to cope with even short periods of unstructured time, such as holidays, weekends, and long-distance travel, which at least explains why airport shops are so profitable. As Oscar Wilde put it, ‘To do nothing at all is the most difficult thing in the world, the most difficult and the most intellectual.’

Adapted from The Art of Failure: The Anti Self-Help Guide