The History of Psychosomatic Illness: An interview with Edward Shorter
In Paralysis to Fatigue: A History of Psychosomatic Illness in the Modern Era, Edward Shorter sets out to illustrate a few simple ideas. Most of the medical symptoms your typical American suffers from are psychosomatic--in other words, they can't be traced to any organic cause but are rather the result of some mind-body interaction. The symptoms may be real, but the cause is psychological, stemming from depression, anxiety, or stress. Today, this manifests itself in the headaches, backaches, fatigue, diarrhea, dizziness, and joint pains that concern so many patients.
While exploring the history of psychosomatic illness, Shorter looks at how the symptoms have changed over time and at the forces behind those changes. His thesis is that psychosomatic symptoms change with the culture--meaning, among other things, that they evolve to match the prevailing medical diagnoses of the day. In the early 1800s, for example, doctors talked about "spinal irritation," believing that when a certain point along the spine was pressed or hurt, it created peripheral pains and other motor (muscular) system problems. Conse-quently, doctors increasingly began seeing patients whose problems conveniently fitted the diagnosis. These patients--usually women--complained of temporary blindness, paralysis, and other ills. Some couldn't walk, others couldn't move their arms, many remained paralyzed for months in bed. Doctors would come across patients so catatonic that it was impossible to tell whether they were alive. Unable to detect pulses or respiration, doctors found that the only sure sign of death was when the body emitted a "cadaverous smell."
Some of these patients no doubt had undiagnosed organic diseases. But Shorter convincingly argues that the majority of cases were psychosomatic.
It's a funny thing: by the early 1900s, these symptoms had virtually disappeared. Medicine had started to shift away from the spine to the brain. Also, the social position of women improved. Whereas Victorian era mores had rendered women immobile--unable to have careers or lives of their own--psychogenic paralyses were, Shorter contends, "a metaphorical way for women to convey their dysphoria." Once women won greater freedom, these kinds of symptoms became obsolete.
Psychosomatic symptoms didn't disappear, however -- they simply changed with the times. In case after case, from somnabulism to neurasthenia to "Yuppie flu," we see how medical and cultural trends alternately reinforce and erode particular psychosomatic symptoms. Shorter argues that this is because patients don't want to be seen as crazy and they therefore unconsciously or semiconsciously exhibit the "right" symptoms. Someone who complained of temporary blindness or paralyzed arms today would be sent straight to a psychiatrist, whereas head-aches or joint pain would be taken more seriously. This isn't to say patients deliberately choose their symptoms--quite the contrary. While Shorter cites historical examples of patients who controlled, or even faked, their symptoms, most of these people were most likely unaware of the mind's role. Even if patients somehow did become aware, there would be little they could do directly to stop the symptoms. Through a mysterious quirk of the unconscious, inner turmoil was masked by the common symptoms of the day. Or, I should say, is masked. Although Shorter's book says little about the contemporary experience of psychosomatic illness, it's clear that similar mind-body-culture interplay is very much alive today.
Professor Shorter is the Hannah Chair in the History of Medicine at the University of Toronto. The author of over a dozen books, he is currently researching the history of sexuality and the history of psychopharmacology. We spoke by telephone in June 2003. --Carrie McLaren
STAY FREE!: In a past issue of Stay Free!, we looked at how TV and advertising shape the public's understanding of illness. One of the things I thought was interesting about your book is that it shows how this process of "shaping" goes way back--it didn't begin with TV or the internet. William Whyte published a book in 1750 on nervous illness. Could you talk a bit about that and how it affected patients at the time?
SHORTER: The underlying process going on here is that patients endeavor in an unconscious or semiconscious way to produce symptoms that will correspond to the medical diagnostics of the time. Whyte's focus on nervous diseases caused lots of patients to orient themselves away from their bowels and abdomens, where humankind had been fixated for about 500 years, to the central nervous system. Rather than talking about dysphorias in terms of the spleen, patients would increasingly start talking about nerves.
STAY FREE!: Were people actually reading medical literature or did they find out about these things from doctors?
SHORTER: Whyte's book did not have a wide circulation among the public. How people pick up their medical ideas is an interesting point. Today they take them from the media, from television. Back in the 18th century, it was from the upper-middle-class drawing room, where people would talk about the newest medical fads and ideas of the day. The world of science and medicine was much more generally accessible to the literate public than it is today. It would be unusual for nonphysicians now to discuss an article in the New England Journal of Medicine, but in the 18th century it was quite common among educated people.
STAY FREE!: In your book, you mention that anorexia dates from the late 1800s, which strikes me as odd because I've always considered it a contemporary problem stemming from media influence. What was the genesis of this particular illness? Was it similar to anorexia in the modern sense in that patients wanted to be thin?
SHORTER: No, the fixation on thinness certainly did not exist then. Women's ideal weight was set about twenty pounds heavier than it is now. I think it was sociogenic; you can see it arising at the family dinner table. The whole concept of the emotionally involved family is a relatively recent construct. Before that families were much more functional. They were oriented to running the craft shop or the farm. People didn't see themselves finding their personal happiness in family life. This new type of family affected large numbers of the population around the middle of the 19th century. And not everyone was comfortable with the intense sentiment.
STAY FREE!: What do you think caused this shift in family life?
SHORTER: There are lots of theories. One is that capitalism created a hostile environment and the need for people to find some emotional place to shelter themselves against competition. There's lots of speculation on the part of academics. But, regarding anorexics, let's say you have young women who are trying to establish an independent realm for themselves, who are trying to get away from the intense parenting that would go on until they got married. With the dinner table becoming the primary family focus, food refusal is a way of declaring a kind of time out. It's a way of saying "I don't want to be a part of this scene so I'm not going to eat." Only later does the intense interest in slimness arise. That doesn't surface until the 1920s, when women started wearing revealing clothing.
STAY FREE!: Many of the treatments for medical symptoms were brutal: doctors would place burning rods on patients' backs to cure a paralyzed arm; they would cauterize the clitoris to cure hysteria; women who complained of having paralyzed arms or legs would have the limbs amputated. It makes you wonder whether the doctors performing these savage operations were aware of the psychological causes. Some of the doctors clearly were--you mentioned one doctor who gave comatose patients enemas to see if they would get up to avoid soiling their beds.
SHORTER: Well, the moment that something becomes possible in medicine, it becomes probable that it will be done. There's a fascination with novelty that doctors share with everyone else. These are the very early days in abdominal surgery, where every incision seemed like a pioneering gesture. So here come these young women that have these chronic emotional problems that doctors have rolled their eyes about for centuries, and all of a sudden it becomes possible to remove the clitoris! remove the ovaries! Often the women and their families were in favor of it, so the temptation was irresistible. The ovaries were thought to be the seat of much irritation that would flood into the female nervous system; they were removed on a massive scale.
STAY FREE!: Even in recent times there have been a lot of unnecessary hysterectomies. Do you think this is a legacy of these ideas?
SHORTER: It probably is. Many women have [various] psychosomatic symptoms around the time of menopause, and it's very tempting to associate these problems with the uterus and the ovaries. This operation usually fails if the goal is to produce some psychic relief, because things like depression and anxiety don't begin in the uterus. Nonetheless, these operations are still done on a wide scale.
STAY FREE!: "Chronic masturbation" was treated by stitching the labia together. What happened to chronic masturbation as a symptom?
SHORTER: Masturbation ceased to be something that warranted medical attention in the 1930s. In fact, masturbation is now seen as therapeutic; people are taught how to masturbate to maximize their sexual pleasure.
STAY FREE!: You wrote about how some of the most fashionable people have the most cutting edge symptoms, the ones that are most medically up to date. Can you give me an example?
SHORTER: If we're talking about today, new illnesses appear first among educated people simply because they are more plugged into medical media. These middle- and upper-class people are the first to begin monitoring themselves or their children for evidence of peanut-butter allergies or excessive tiredness. It is from these relatively small social groups that the symptoms radiate out.
STAY FREE!: What's the evidence that this is in fact the pattern?
SHORTER: Historically, you can see how the patterns form. Concern about sensitivity to peanut butter, for example, used to be confined to upper middle class neighborhoods. Now it's epidemic. Same thing with multiple chemical sensitivities.
STAY FREE!: But this in itself doesn't necessarily mean it's psychosomatic, does it? It could be that uneducated people are less likely to identify health problems or less likely to visit the doctor.
SHORTER: But the evidence is clear that multiple chemical sensitivities are psychosomatic. These are not organic problems.
STAY FREE!: There are, however, people who are actually allergic to peanuts.
SHORTER: Yes, there is such a thing as peanut allergies, but that doesn't mean that everyone with the diagnosis has them. Peanut allergies are rare, but today it's hard to find a fourth-grade class without a couple of kids who are thought to have them. It's become an object of epidemic hysteria.
STAY FREE!: What's the difference between a real peanut allergy and a fake one? How does the patient's experience differ?
SHORTER: With a fake peanut allergy, it's the parents who have the symptoms--anxiety, unrealistic attributions of illness to banal symptoms in their children. In a real peanut allergy, the child is highly symptomatic.
STAY FREE!: Among French troops who suffered from shell shock in WWI, paralyses were common, whereas in WWII, no one had paralysis, they all had cardiac and gastrointestinal troubles. What's behind this? Was there a similar shift seen among American troops?
SHORTER: American troops were not as involved in WWI as the French were, so Americans didn't have a chance to develop as deep a revulsion to trench warfare. But it's interesting that the symptoms of shell shock seen in the first World War were not the ones seen in the second. By World War II, army doctors had started to associate paralysis or Parkinsonian trembling with hysteria, so they were much more inclined to say, "Get back in your tank, there's nothing wrong with you." The main difference between the two world wars is what the doctors learned in treating men rapidly to get them back in action.
STAY FREE!: Historically, some of the most respected doctors had some of the screwiest ideas. Do you see any parallel today?
SHORTER: My research field is psychiatry and psychiatry is filled with artifactual diagnoses, doubtful remedies, and drugs that don't work very well used instead of drugs with demonstrated track records simply because the good drugs have run out of patents and the drug companies aren't marketing them anymore. The drugs that are still covered by patents are the ones that are marketed systematically to physicians. So there's a lot going on today that isn't scientific.
STAY FREE!: You've written that patients today are more sensitive to body signals; they're more likely to go to the doctor for something than they would have a few decades ago. What's the evidence for this?
SHORTER: There are surveys by the National Center for Health Statistics with comparable surveys from the 1930s showing that patients are much more sensitive.
STAY FREE!: That's ironic. On one hand people are less trusting of their doctors, but on the other, they are more trusting of medical science because they believe that they can be relieved of every imaginable symptom.
SHORTER: Our confidence in science and medicine is very well placed. It's just a shame there has been a breakdown in the doctor-patient relationship, because doctors are able to help patients with psychosomatic problems if the patients are willing to trust them.
STAY FREE!: You've said that most of the things people visit their doctors for are psychogenic.
SHORTER: At the typical family practice, about half of patients' complaints are not the result of an organic disease; they are the result of some sort of mind-body interaction. That's what drives family doctors crazy--they see all this hysteria.
STAY FREE!: There needs to be another word than hysteria. It's so stigmatizing.
SHORTER: Of course, doctors don't use that word with patients. They'll say "functional," which means "not organic."
STAY FREE!: How do you think doctors should respond to patients when they suspect their problems are psychosomatic? Do you think doctors should recommend medication of some kind to help alleviate the symptoms?
SHORTER: One thing that helps psychosomatic patients is telling their story to the doctor, so giving patients ample time is very important. But there is no specific medication for psychosomatic problems, aside from a drug like clomipramine, which lessens anxiety.
STAY FREE!: So are you saying that doctors shouldn't tell patients to take Pepto Bismol? That, if they prescribe anything, it should be antianxiety meds?
SHORTER: A doctor tells patients anything that will be therapeutic: see a homeopathist if necessary. Valium by all means. What the doctor himself thinks is, "Another case of hysteria. Psychiatric material."
STAY FREE!: Didn't doctors used to prescribe sugar pills?
SHORTER: Yes, it was once very common for doctors to prescribe a placebo, and that went on for decades and decades to the benefit of patients, I might add, because placebo remedies really do work. You destroy their effectiveness when you tell a patient, "I'm prescribing baking soda." I have a lot of problems with a particular version of bioethics we have today that says it's unethical to lie to patients. If we can help patients by lying to them, then by all means, lie to them.
STAY FREE!: I want to talk about gender, since these problems, historically and now, are especially common among women and girls. Other than sexism, what do you think is behind this?
SHORTER: I don't think sexism is behind it at all; many women who have mystery illnesses are self-diagnosed. Now, there may be something about the interaction between male physicians and female patients that makes the doctors more likely to see psychosomatic issues in a female and organic issues in a male. But I don't think that's the major motor behind this. Women are more sensitive to their bodily signals and are more inclined to see them as evidence of disease. Why is that? Well, I think it's because women experience loss and grief and trauma more deeply than men do. The loss of a friend, for example, the death of a relative--these loom larger on the female radar than they do on the male radar.
STAY FREE!: You don't think women are just more expressive of these problems?
SHORTER: No, I think they psychologically experience the loss more deeply. Men express their inner dysphoria more in the form of sociopathy. They do tractor pulls and get into barroom fights.
STAY FREE!: What about class differences?
SHORTER: The middle classes are more symptomatic than working classes because they're more plugged into the media.
STAY FREE!: Race?
SHORTER: The racial differences I'm aware of would be explicable as class differences.
STAY FREE!: Do you consider clinical depression an organic illness?
SHORTER: Yes, I believe depression is caused by some kind of brain process. It's a disease that is in a way just as organic as mumps or liver cancer--although, unlike liver cancer it has a fluctuating course. It comes and goes in waves whereas liver cancer is chronically progressive: it only gets worse.
STAY FREE!: I have a quote from you from Reason magazine, 1997, regarding Gulf War Syndrome: It's absolutely unmistakable" that "the symptoms are thoroughly psychosomatic . . . The syndrome has no scientific status. It's entirely driven by political needs and the media's need for sensationalism."
SHORTER: By the way, I'm sure we're going to see the men and women coming back from Iraq with latent symptoms as well. This has become standard; every time there's a deployment, everybody comes back sick.
STAY FREE!: Have you ever gotten in trouble for statements like this?
SHORTER: People tell me to shut up, but I have tenure.
STAY FREE!: But you're a historian, you're not a doctor.
SHORTER: I'm a medical historian. I went to medical school, but I don't have an M.D.
STAY FREE!: But "absolutely unmistakable," "thoroughly psychosomatic"--is that necessary?
SHORTER: It hurts people to hear that, but these patients from the Gulf War have been investigated exhaustively and nothing has ever been found.
STAY FREE!: But there are plenty of diseases that were once falsely considered psychosomatic: multiple sclerosis, epilepsy . . .
SHORTER: Medicine today is much better. It's very different from medicine in the 1870s.
STAY FREE!: Asthma used to be considered psychosomatic.
SHORTER: Yes, by the Freudians. Asthma and high blood pressure and hives. And there were a bunch of other things that have since been recognized as organic, but that's simply the sign of the march of medical progress.
[ Photos in the print edition from Invention of Hyster-ia: Charcot and the Photographic Iconography of the Salpêriere, by Georges Didi-Huberman (MIT Press, 2003). Photography helped create hysteria as a syndrome in the late 19th century. ]