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Illness and Attitude – Richard Holton’s 3rd Uehiro Lecture

By Jonathan Pugh


In the final lecture of the 2018 Uehiro lecture series, Richard Holton concluded his reflections on the theme of ‘illness and the social self’ by turning to questions about how attitudes can play a role in the onset of medical disorders, with a particular focus on psycho-somatic disorders.


You can find a recording of the lecture here


Self Conception and Psycho-Somatic Disorders


Holton paves the way into this topic by briefly tracing the history of the concept of addiction, and highlighting that the notion of addiction undermining choice is a relatively modern idea, arising only in the mid-19th century. For Holton, this historical curiosity raises a deeper question about the potential role that the social conception of addiction (as undermining choice or not) may be playing; does the conception of addiction that patients and others have affect the course of an individual’s addiction?

Although there is little empirical research directly on this question, Holton draws on research on self-efficacy to support his initial hypothesis that the conception of a disorder one has may play a role in the course that it takes. Self-efficacy refers to the concept that an individual’s beliefs about their ability to succeed in a particular task can significantly influence how they approach that task. Crucially in the current context, if I don’t believe that I will be able to succeed in task X, I will be less able to adopt coping behaviours, and to sustain effort in the face of obstacles to achieving X. To extend this to addiction, it seems plausible to suppose that if I believe that I cannot overcome an addictive craving, my low self-efficacy judgement will mean that I will be less likely to exert the sort of effort that might in fact lead me to succeed in resisting the craving.

Rather than focus primarily on addiction though, Holton’s main focus in this lecture is on psycho-somatic illness. These illnesses might plausibly be understood as extreme cases of something like the phenomenon Holton is interested in, namely, attitudes mediating illness in some sense.

How we should actually characterize psycho-somatic is a matter of some contention that Holton will spend some time addressing. However, non-contentious examples of psycho-somatic symptoms can include non-epileptic fits, blindness, and paralysis. In each of these examples, patients may present with the relevant symptoms, despite the fact that diagnostic attempts have been unable to reveal an underlying neurophysiological pathology. Psycho-somatic illness is of course a hugely contested area, as evidenced by the hotly contested PACE trial into myalgic encephalomyelitis/chronic fatigue syndrome in 2011, and the nosological boundaries remain sketchy in this area.

Existing attempts to characterise psycho-somatic illness are problematic according to Holton. For example, the claim that in these illnesses ‘physical symptoms occur for psychological reasons’ has unappealing anti-materialistic dualistic overtones. Moreover, attempts to define it negatively (the approach taken by DSM IV) as ‘disease which isn’t physiologically explained’ are too broad; according to the negative approach AIDs should have been classified as a psychosomatic illness prior to the discovery of the HIV virus.

Instead, Holton initially proposes the thesis that psycho-somatic illness involves non-psychological symptoms that occur because of the psychological attitude of the subject. Again though, he acknowledges that this also seems too broad – our attitudes can cause physical symptoms in a familiar indirect sense that does not seem to amount to psycho-somatic illness. Consider, for example, an individual whose depressive attitudes lead them to perform acts of self-harm, which naturally bring about physical symptoms.

After considering some unsuccessful attempts to refine this picture, Holton suggests that there just may not be the kind of neat distinction between psychosomatic illness and other conditions that we are looking for. Indeed, the claim that attitudes can mediate the manifestation of psychiatric disorders seems very plausible; consider again the self-harm case. Holton also cites in support of this claim the rise in the prevalence of bulimia, and the recent development of “The Truman Show” delusion. Why not suppose that psycho-somatic illness is one extreme version of thought or attitudes having a similar kind of influence?


Psychosomatic Illness, Intention, and Neuroscientific Evidence


It is important to distinguish psycho-somatic illness from patients who are, in one way or another, faking illness. Malingerers fake or exaggerate medical symptoms in order to accrue a personal gain from doing so (such as committing insurance fraud); however, not all individuals who fake medical symptoms are malingerers in this sense. Some individuals develop factitious disorders, such as Munchausen’s disorder, in which they fake/exaggerate medical symptoms (like malingerers), but do so because they have an unreasonable attachment to the notion of being ill, rather than for other sorts of personal gain.

It might be claimed that factitious disorders are consciously intentional, in the sense that those with such disorders consciously want others to think that they have a medical disorder. Perhaps then, psycho-somatic illness could be understood as unconsciously intentional? But this does not distinguish factitious disorders from psychosomatic disorders; those suffering from the latter also intend others to think they have a medical disorder, given that they are suffering from the relevant symptoms. The difference here lies in the counterfactual: if those with psycho-somatic disorders did not have the symptoms, they would not have the conscious intention to get others to think that they have the disorder (unlike a Munchausen sufferer who maintains this intention despite lacking the relevant symptoms).

Perhaps psycho-somatic illness can be distinguished by the fact that the actions that are symptomatic of psychosomatic disorders are unconsciously intentional? As Holton points out though, this approach also seems too broad. For example, limping after a foot injury is clearly non-psycho-somatic; however, it is plausibly unconsciously intentional. To illustrate, suppose you had a foot injury, and someone was threatening you; you may be able to adopt a non-limping walk for a short while, despite your injury, in order to escape. The problem is that many illnesses have intentional aspects; the question with psycho-somatic illness is how could the symptoms characteristic of psycho-somatic disorder fail to be intentional in the relevant sense. What could provide proof of such a possibility?

Unfortunately, Holton suggests that there is little neuroscientific research to help us here. However, the existing evidence does suggest that there are systematic differences between subjects who have unexplained paralysis and those who are instructed to feign similar symptoms. Moreover, the former subjects have some inhibition of the normal sensory and motor networks, and he suggests that there have been some indications of affective influence in these cases. Interestingly, work in this area has also suggested some broad similarities between conversion paralysis and hemispatial neglect in stroke patients. Although evidence in this area is contentious, for Holton, this similarity suggests the hypothesis that conversion disorders may involve attentional deficit of a broadly similar sort to that which is apparent in hemispatial neglect.

This provides a model for thinking how attitudes might play a role in illness without involving those attitudes leading to straight out intentional feigning (even unconsciously). Rather, developing on the earlier theme of self-efficacy in light of evidence about attitudinal deficit, perhaps the attitude may be working on the basis of patients’ low judgements of self-efficacy, an attitude partially grounded in attentional deficits.


Motivated Beliefs, Self-Signalling, and What’s Left for Attitude-Mediated Symptoms


Holton next considers two other hypotheses concerning phenomena that might be involved in psycho-somatic illness; motivated belief, and self-signalling. I shall outline each in turn.

Typically, we tend to think that our normal beliefs are formed independently of our desires (indeed, the two have different directions of fit with the world). However, motivated beliefs are formed on the basis of our desires; we believe something because we want it to be true. Could psycho-somatic illness be grounded by such motivated beliefs? Holton is sceptical, since there is little evidence that motivated beliefs undergird psycho-somatic illness. Although individuals might benefit from psycho-somatic illness, Holton points out that benefit alone does not entail motivated belief. To bridge the gap, we need a mechanism by which the perception of the benefit in question is giving rise to the belief. Yet, we have no evidence of such a mechanism.

Self-signalling behaviour is behaviour that is motivated in part to gain evidence of one’s situation; it might be to find out what sort of things you enjoy for example. Self-signalling is often fully rational; if I don’t know whether or not I like a particular food, it makes sense to try it. However, self-signalling is less rational when the behaviour you are engaging in does not provide evidence about the target of your enquiry (Holton provides an example of this by citing Max Weber’s interpretation of Calvinistic pre-determination). The trick is to make sure the behaviour you are engaging in is a good indicator of what you are trying to find out about; but this can be very difficult.

Holton suggests that addiction can involve self-signalling; addicts will try to abstain to see what they are capable of, to test themselves. If doing so is easier than they thought, they might abstain for longer. Might self-signalling be happening in psycho-somatic illness? The hypothesis here would be that such patients may be trying to find out what they are like via the behaviours that are constitutive of the illness. However, Holton concedes that there is no good evidence in favour of or against this hypothesis.

So where does leave the idea of attitude-mediated symptoms? Holton suggests that patients presenting with psycho-somatic disorders may genuinely believe (in a non-motivated sense) that they have a disorder (based on evidence of their own symptoms), and that this belief leads them to manifest the symptoms more strongly. It is essentially a self-re-inforcing loop; to put it crudely, the symptoms cause the belief, and the belief causes further manifestations of those symptoms. Holton claims that the picture here looks simplistic, but we do not yet have evidence that would give us sufficient reason to abandon it.

Although simple, the model has striking consequences. One of the reasons that the debate over psycho-somatic conditions can become so bitter is that patients suffering from such disorders currently seem to face an unappealing set of options. Either the patient is deemed to be malingering, or they are ‘mad’. The attitude-mediated approach however lends support to more integrated forms of care, of the sort that we already see in the treatment of type II diabetes. In type II diabetes, it is already recognised that although effective treatment must involve physiological interventions (like insulin pumps), treatment must also target the attitudes of the patient that may have contributed to the onset of the disorder in some cases. Both kinds of psychological and physiological treatment should be implemented in a broadly simultaneous fashion.

However, there is a problem. Currently, this more comprehensive form of treatment involves liasonal psychiatry. Yet, whilst some psychiatric illnesses may involve attitude-mediated symptoms, it seems that psycho-somatic illness are very different from standard psychiatric disorders. Perhaps then, psychiatry is not the right discipline to tackle problems with psycho-somatic illness. Nonetheless, Holton finally concludes with the broader concern that if psychiatric illnesses are in fact attitude-mediated, then it is very important for us to find out how much of a role attitudes are playing. To somewhat reverse the theme of the lecture, this is an area where lessons from the role of attitudes in psycho-somatic illness could be particularly helpful in the psychiatric context.



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1 Comment on this post

  1. In the long run, it doesn’t matter what Holton thinks about the PACE trial. PACE is dead, or at the very least, on its last gasps. Only in the minds of psychosomatic doctors is PACE still considered “controversial”.

    The results of PACE have been completely rejected as unreliable in the United States by government agencies and major healthcare companies. It’s only a matter of time before the UK also rejects PACE.

    The PACE model: that patients are merely deconditioned and that physical symptoms are perpetuated by inactivity and false illness beliefs is not supported by the evidence. PACE treatment recommendations are no longer recommended by any US health agency, including the CDC.

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