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.

Are you an Epicurean?

Epicurus of Samos, who flourished not long after Aristotle died, founded a school of philosophy that convened at his home and garden in Athens and that dedicated itself to attaining happiness through the exercise of reason and the application of rational principles. According to Epicurus, reason teaches that pleasure is good and that pain is bad, and that pleasure and pain are the ultimate measures of good and bad. This has often been misconstrued as a call for rampant hedonism, rather than the absence of pain and tranquillity of mind that Epicurus actually intended. Indeed, Epicurus explicitly warned against overindulgence, because overindulgence so often leads to pain.

Epicurus wrote prolifically, but the early Christians thought of him as especially ungodly among the ancient philosophers, and almost none of his works survived their disapprobation. Epicurus held that the gods exist, but that they have absolutely no concern for, or even awareness of, humankind. Indeed, for them to get involved in the menial matters of men would be to perturb the supreme happiness and tranquillity that characterises and even defines them. Human beings should seek to emulate the gods in their supreme happiness and tranquillity, but they need not to fear them.

Neither need they to fear death, this for two principal reasons. (1) The mind of a person is a part of his body, and, just like other parts of his body (and everything else in the universe), it consists of atoms. The death of the person entails the death of both his body and his mind and the dispersion of their atoms. As there is no longer any person to be troubled, death cannot trouble the person after he is dead. And if death cannot trouble the person after he is dead, then nor should it trouble him while he is alive (this is the famous ‘no subject of harm argument’). (2) The eternity that comes before a person’s birth is not regarded as an evil. Therefore, nor should the eternity that comes after his death (this is the famous ‘symmetry argument’).

Epicurus himself died at the age of 72 from renal colic (kidney stones), which is associated with one of the sharpest and most intense of all bodily pains. On the last day of his life, he penned this remarkable letter to his friend and follower Idomeneus, which is nothing if not a testament to the overriding powers of philosophy.

I have written this letter to you on a happy day to me, which is also the last day of my life. For I have been attacked by a painful inability to urinate, and also dysentery, so violent that nothing can be added to the violence of my sufferings. But the cheerfulness of my mind, which comes from the recollection of all my philosophical contemplation, counterbalances all these afflictions. And I beg you to take care of the children of Metrodorus, in a manner worthy of the devotion shown by the young man to me, and to philosophy.

Epicurus agrees with Aristotle that happiness is an end-in-itself and the highest good of human living. However, he identifies happiness with the pursuit of pleasure and the avoidance of pain rather than with the pure exercise of reason. Pleasure is the highest good, and anything else that is good is so only by virtue of the immediate or deferred pleasure that it can procure. The behaviour of infants confirms that human beings instinctively pursue pleasure and that all of their actions, including those that may be construed as being either virtuous or altruistic, are ultimately aimed at obtaining pleasure for themselves. Just as human beings can immediately feel that something is hot or cold, colourful or dull, so they can immediately feel that something is pleasurable or painful. However, not everything that is pleasurable should be pursued, and not everything that is painful should be avoided. Instead, a kind of hedonistic calculus should be applied to determine which things are most likely to result in the greatest pleasure over time, and it is above all this hedonistic calculus that people seem unable to handle.

To help them a bit, Epicurus proceeds to distinguish between two different types of pleasure, ‘moving pleasures’ and ‘static pleasures’. Moving pleasures involve the satisfying of a desire, for example, eating a meal when hungry. Static pleasures on the other hand involve the state of having had a desire satisfied, for example, feeling sated after eating a meal. Static pleasures, says Epicurus, are better than moving pleasures because they free us from the pain of need or want. Epicurus also distinguishes between physical and mental pleasures and pains, and argues that anxiety about the future, especially fear of the gods and fear of death, are the greatest obstructions to happiness. To attain a state of perfect mental tranquillity or ataraxia, a person needs to avoid anxiety, which he can do by learning to trust in the future.

Pleasure often arises from the satisfaction of desire and pain from its frustration. Thus, any desire should either be satisfied to yield pleasure or eliminated to avoid pain, and, overall, it is elimination that should be preferred. There are, Epicurus says, three types of desires, (1) natural and necessary desires such as those for food and shelter which are difficult to eliminate but naturally limited and both easy and highly pleasurable to satisfy, (2) natural but non-necessary desires such as those for luxury food and accommodation, and (3) vain desires such as those for fame, power, or wealth which are inculcated by society and which are not naturally limited and neither easy nor highly pleasurable to satisfy. Natural and necessary desires should be satisfied, natural but non-necessary desires can be satisfied but should not be depended upon, and vain desires should be entirely eliminated. By following this prescription for the selective elimination of desires, a person can minimise the pain and anxiety of harbouring unfulfilled desires, and thereby bring himself as close as possible to ataraxia. Given the prime importance that he attaches to the avoidance of pain, the elimination of desire, and peace of mind, Epicurus is far more of a ‘tranquillist’ than a hedonist. ‘If thou wilt make a man happy’, he says, ‘add not unto his riches but take away from his desires.’

Adapted from

What is a Friend? – Part 1 of 3

Plato and Aristotle both gave an important place to friendship in the good life; Plato devoted the major part of three books (the Lysis, Phaedrus, and Symposium) to friendship and to love, and in Book VIII of the Nicomachean Ethics Aristotle lavished extravagant praise upon the Greek concept of friendship or philia, which included not only voluntary relationships but also those relationships that hold between the members of a family. Friendship, says Aristotle, is a virtue which is ‘most necessary with a view to living … for without friends no one would choose to live, though he had all other goods’.

If friendship is so important to the good life, then it is important to ask the question, what is friendship? According to Aristotle, for a person to be friends with another ‘it is necessary that [they] bear good will to each other and wish good things for each other, without this escaping their notice’. A person may bear good will to another for one of three reasons, that he is good (that is, rational and virtuous), that he is pleasant, or that he is useful. While Aristotle leaves room for the idea that relationships based on advantage alone or pleasure alone can give rise to friendships, he believes that such relationships have a smaller claim to be called friendships than those that are based partly or wholly on virtue. ‘Those who wish good things to their friends for the sake of the latter are friends most of all, because they do so because of their friends themselves, not coincidentally.’ Friendships that are based partly or wholly on virtue are desirable not only because they are associated with a high degree of mutual benefit, but also because they are associated with companionship, dependability, and trust. More important still, to be in such a friendship and to seek out the good of one’s friend is to exercise reason and virtue, which is the distinctive function of human beings, and which amounts to happiness.

For Aristotle, an act of friendship is undertaken both for the good of one’s friend and for the good of oneself, and there is no reason to think that the one precludes the other. In any case, to have a perfect friend is like to have ‘another self’, since perfect friends make the same choices as each other and each one’s happiness adds to that of the other. Unfortunately, the number of people with whom one can sustain a perfect friendship is very small, first, because reason and virtue are not to be found in everyone (never, for example, in young people, who are not yet wise enough to be virtuous), and, second, because a perfect friendship can only be created and sustained if a pair of friends spend a great deal of exclusive quality time together. Thus, even if one lived entirely surrounded by virtuous people, one would only ever have the time for at most a small handful of perfect friends.

The ideal of perfect friendship may strike the modern reader as being somewhat elitist, but Aristotle is surely right in holding that the best kinds of friendship are both rare and demanding. If the best kinds of friendship are those that are based on virtue, then this is above all because such friendships call upon the exercise of reason and virtue, which is the distinctive function of human beings, and which amounts to happiness. However, it could be that the distinctive function of human beings is not the exercise of reason and virtue, but the capacity to form loving and meaningful relationships. If this is the case, then friendships that are based on virtue are even more important to the good life than Aristotle thinks.

Despite the extravagant praise that he lavishes upon friendship, Aristotle is quite clear that the best and happiest life is not the life spent in friendship, but the life spent in the contemplation of those things that are most true and therefore most beautiful and most dependable. There is a contradiction here: if the best life is a life of contemplation, then friendship is either superfluous or inimical to the best life, and therefore undeserving of the high praise that Aristotle lavishes upon it. It may be, as Aristotle tentatively suggests, that friendship is needed because it leads to contemplation, or that contemplation is only possible some of the time and friendship is needed the rest of the time, or even that a life of friendship is just as good as a life of contemplation. So much for Aristotle, one might say. Plato also gives an important place to friendship in the good life…