Wednesday, 27 August 2008

Chronic Fatigue Syndrome and Mind-Body Dualism


I want to start this post with a disclaimer. I am not claiming, in what I'm about to write, to provide an aetiological theory of CFS. I have no special knowledge beyond what can be read in journals and books; I am not an 'expert', self-proclaimed or otherwise, on this condition. I have no very decided opinion about causes or maintaining factors.

But here's the thing. I've been reading up on CFS and what I'm most struck by right now is the character of the controversy around the diagnosis, its meaning and its validity. More struck by the way that the claims are made, than the content of the claims themselves. It is, I believe, my countertransference to the character of these controversies which has made me feel the need to issue the above disclaimer. At any rate, here are some of the key rhetorical details I've noticed in what I've been reading:

  • CFS may be said to be either a 'real' or an 'unreal' condition.


  • When people deny the 'reality' of the condition, they are taken by others to be denying the 'reality' of the experience of the people who are described as suffering from CFS. However they do not tend to take themselves to be denying the experience of those whose condition they claim is 'unreal'.


  • When people assert the 'reality' of CFS, they are tacitly taken by others, and often by themselves, to be making a claim about the kind of reality CFS enjoys. That is, they are taken either to be making an assertion that it has organic causes (e.g. a pathogen), or to be making an assertion that it is a biological or physiological condition. Where what it is to be a biological or physiological condition is for it to just be that abnormal (e.g. diseased) state of the body which is creating the symptoms experienced by people who are described as suffering from CFS.


  • Next, when people make positive assertions about the reality of CFS, they are often taken, or often take themselves, to be saying something which is in contradiction with the idea that CFS is either caused by, or is itself, a 'psychological condition'.


  • When the idea that CFS is a 'psychological condition' is mooted, this tends to be associated, sometimes by the people making or often by the people responding to the mooted idea, with the following ideas: It is not 'real'. It is 'all in the mind' (taken to mean: 'it's all just been imagined'). It does not involve changes in the body of a sort which constitute it.


  • These claims are often taken by those involved in these debates to be substantive rather than rhetorical.


  • Sometimes people who experience CFS seem to believe that the phenomenology of CFS can be used to establish its non-psychological character. As if the fact of its sometimes sudden onset, or of its bodily presentation (extreme tiredness, pains, etc.), was evidence of its being 'real' (i.e. 'biological') and not 'all in the mind' (i.e. 'psychological').


  • Finally, when attempts at theoretical clarification are made, we tend only to be offered platitudes about the need to avoid dualism, or about the benefits of a biopsychosocial model - and then the thinking seems just to stop.

Let me reiterate: I am not for one moment denying the painfulness, the life-disrupting-ness (er...), or the severity of the impairment, of the symptoms of CFS. Please don't read me with that idea in mind! It could be that CFS is the most dangerous and debilitating condition on the planet, for all that the argument here would be affected. And I'm not putting forward an opinion as to whether CFS is organic or psychological in either causation or constitution.

But what strikes me is the following: Why are the above rhetorical details so common in the literature? Where does the assumption come from that psychological conditions are not real (if they do not enjoy the kind of reality enjoyed by biological conditions), do not involve profound changes in the body, are not profoundly debilitating, are being 'put on' or are somehow 'imagined'?

For what we know, after goodness knows how much medical observation, is that psychological disorders are profoundly disabling, are certainly not contrived by their sufferers, can involve serious bodily alterations, etc. etc. People can be paralysed for years from psychological conditions. They can die from fear. They can cause people to lead the most restricted, debilitated, unrewarding lives. Psychological factors can cause parts of the body to swell up, become incredibly painful, or painfree, become paralysed. They can cause the sufferer to temporarily go blind, lose their hearing. There is nothing 'all in the mind' (in the sense of imaginary) about the most common psychological disorders - depression and the anxiety disorders (phobias, OCD, extreme shyness, agoraphobia, panic attacks, etc.) Yet this makes them no less psychological.

And what many of us take ourselves to know too, after goodness knows how much philosophy and neuropsychology, is that psychological states (e.g. happiness, sadness, melancholy, fear) do not somehow float free of the physiological body. Rather they are instantiated in the body, in its muscular, endocrine, and neurological substance, in the way the body is moved and is postured. We pretty much take such understandings for granted today.

What does it mean to call a condition 'psychological'? I would suggest that it implies that either the causes and maintaining factors of the condition are psychological (i.e. are a function of the person's understanding of their world, relationships, selves, futures, pasts - including that understanding manifest primarily in our affective responses, micro-dispositions, etc., as well as that manifest in our cognitive reflections), or that what is being referred to is a disturbance of the person's understanding (in the broadest sense - more technically, a disturbance in their being-in-the-world, in their 'intentionality').

So where does the belief that, if CFS is psychological, it must be somehow 'unreal' or 'imaginary' come from? It seems to me that there are three possible related sources, one philosophical and the other two psychological. I shall discuss these in turn.

Philosophical: A reductive form of scientific naturalism may have a role to play. So, we start to believe, under the pressures of implicit or explicit philosophical pressures, that the word 'real' is only to be sanctioned of conditions or entities or states or dispositions or processes which can be shown to be, to consist in, physical conditions (or entities, or...).

Psychological: This is just that equation of 'mind' with 'imagination' which I mentioned above. It seems to go along with a kind of blitheness about the unconscious, and a view of mind as fundamentally to do with representation. Either our representations are veridical (and so supposedly wouldn't lead to any kind of disorder), or they are false (imaginary, out of kilter with reality, mad). I don't imagine anyone would really reflectively hold to this bizarre view of the nature of the mind, but it does seem to take hold of people in unreflective moments.

Psychological 2: Here I want to moot a more controversial suggestion. This is that there may be something in our culture - a prevalent mind-body dualism of the sort described above - which shapes our being-in-the-world in such a way that both: i) a CFS diagnosis is far more likely to be both socially constructed (which is not a statement about causality!!!) and also socially contested; ii) CFS arises in the lives of individuals (which is a causal statement!!!). Now I'm just mooting this, working out what can be said for it at the level of intelligibility, rather than at the level of empirical evidence. I've no more evidence than anyone else, nor do I have an opinion about it.

What might this clinical dualism look like for the CFS sufferer? One idea is that it might manifest primarily as alexithymia. Here is what to my mind is a plausible theory of certain forms of CFS at the level of initial intelligibility, whether or not it is empirically true. Someone is experiencing profound unconscious affective stress. The stress remains unconscious because it cannot be worked through, understood, connected up with other aspects of the mind, etc. If it could, then they would feel the appropriate extreme emotion such as anger or grief. Conscious understanding, working through, and adjustment could take place. But this does not happen, and instead they suffer a profound bodily breakdown. Energy is massively withdrawn from the body. The somatic aspects of extreme emotions are constantly felt without their meaning being disclosed to the sufferer. Immunological functioning and other aspects of their neurological and physiological functioning are greatly altered and perhaps damaged, as is usually the case with such profound unconscious emotional reactions. Mental, emotional, and social life becomes greatly restricted. Life becomes a field of symptoms. Appropriate despair can be allowed about the symptoms, but not about the original stressors or conflicts which remains unconscious.

Does this happen or not? Well, I have no idea! It doesn't strike me as implausible, given what I take myself to know about the functioning of the human organism. But my suspicion is that it does strike some of those who experience, care for someone suffering, or are sceptical about, CFS, as deeply implausible. And what I'm trying to do is to discover the reason for this apparent face implausibility to others. The only reason I can think of for this deep scepticism regarding a psychological view of the aetiology of CFS, barring knowledge that the rest of us just don't have, is the kind of philosophical and psychological confusions (psychological = imaginary = unreal; the unconscious does not exist; etc.) detailed above.

Appendix

On dualism. Something else I've noticed in my reading is that sometimes people seem to think that they are doing enough to refute accusations that their thinking about the mind and body is dualistic by stating that they do not believe in dualism. (A bit like denying that one could be suffering from polio because one doesn't believe that one is suffering from polio - clearly daft, but we get the picture.) So I thought it might be worthwhile putting down an understanding of what it is to be dualistic which would refer to what is implicit in a text, rather than explicit in someome's mind:

i) Assume that all nouns work by referring to objects.
ii) Assume that therefore mental nouns (thoughts, feelings, beliefs) refer to mental objects. Call this position 'mentalism'. Perhaps these mental objects are what something called 'consciousness' is to be directed towards.
iii) So you have two types of objects: mental and physical objects. This is 'metaphysical dualism'.
iv) Look around (conceptually, as it were) and see if you can find these mental objects. If you think you can, then you can be a 'substance dualist'. Two types of things: minds and bodies. If you think you can't, then you say that mental things are physical things 'under a different (mental) description'. Call this 'property dualism'.

Now it seems to me that when people deny that their position regarding CFS is dualist, they are denying that they explicitly hold to substance dualism. Whereas it seems to me that what the accusation of dualism usually amounts to in this context is the broader one of metaphysical dualism and the mentalism it typically involves.

How not to be a metaphysical dualist:

i) Don't suppose that psychological nouns refer to things.
ii) Instead ask what adjectives and adverbs these nouns are derived from, and see them accordingly as dispositions and capacities and characteristics of human beings and human actions.
iii) As a result find no tension in the idea that a psychological disturbance might involve profoudn physiological changes. Different reactive dispositions will obviously be instantiated in different physiological mechanisms.
iv) See an unconscious emotion as one which manifests behaviourally (including the kinds of micro-behaviours associated with ) , but which the subject cannot verbally, directly, avow.

Appendix 2

Here is an extremely large working paper devoted to promoting an understanding that CFS 'is biological' in nature:

It quotes the psychology professor, Leonard Jason, as saying that

there has been an ignoring of “a large body of medical research demonstrating biological abnormalities in individuals with ME/CFS. For years, investigators have noted numerous biomedical abnormalities among ME/CFS patients, including over-activated immune systems, biochemical dysregulation in the 2-5A synthetase / RNASE L pathway, muscle abnormalities, cardiac dysfunction, abnormal EEG profiles, abnormalities in cerebral white matter, decreases in blood flow throughout the brain, and autonomic nervous system dysfunction. Unfortunately, some uninformed physicians continue to believe that (ME)CFS and other disorders like it are primarily psychiatric in nature. Some confuse (ME)CFS with neurasthenia. Biases such as these have been filtered through to the media, which portrays ME/CFS in an overly simplistic and stereotyped way (which) compromises patient-doctor relationships and medical care for patients”

What is so striking about this, to me, is that we all now know that both placebo interventions and psychological therapies can deliver highly significant impact on biochemical, immunological, muscular, cardiac, ANS, CNS, etc. structure and function. Look in any relevant journal! (A place to start online might be http://en.wikipedia.org/wiki/Psychoneuroimmunology or http://www.psychnet-uk.com/pni/pni.htm.) Doesn't this in itself cast doubt on the use of such evidence to discount a psychogenic hypothesis? And doesn't it force on us the question as to what the philosophical and psychological currents are that inspire the use of biochemical evidence of the sort mooted to argue against a psychogenic hypothesis? Again, to reiterate a final time: I am not saying that any of this shows that CFS is not, or is not caused by, a biological agent. I am just commenting on the reasoning manifest in the controversies surrounding the diagnosis.