Psychosomatic Illnesses and the Cult of the Mind

I was talking to an old choir director years ago and the conversation turned to aging.

"Whatever happens to my body, I don't care. I just really don't want anything to happen to my mind" says he.

"That seems a little strong" says I. "Surely there's some amount of natural mind loss that would be better than losing all..."

"No, it doesn't matter. I really really hate the idea of losing my mental faculties. If my mind starts going at all, I mean, I don't want to live like that."

I can't say if this is a common feeling beyond my choir director. But it taps into something I want to explore. Why do we consider the mind so much more sacred than the body? To what degree does that even make sense? And what should we do about that belief?

This is in the normal journal vein (i.e. not for sharing widely) and I'm worried about maintaining structure here, so to be explicit. I want to explore psychosomatic diseases, other human conditions/disorders, possible rationales between the mind/body disparity, and finally how I think we should most rationally work with this belief.

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Psychosomatic conditions - roughly physical symptoms that are caused or aggravated by mental phenomena including stress or depression - are on the mind lately. First, there was the Astral Codex Ten article on Long Covid, which touched on the subject:

Fifth, maybe some long COVID is psychosomatic. People hate when doctors bring up the possibility of psychosomatic conditions, and I won’t deny that we tend to overuse the “psychosomatic” diagnosis like it’s going out of style - but some things really are psychosomatic. Chronic Lyme disease (“Long Lyme” rolls off the tongue nicely) is basically universally considered 100% psychosomatic by the medical establishment, although now that I’m thinking about it I wonder if maybe we should be less sure. Lots of people act like psychosomatic = not a real problem. Unfortunately, having a symptom for psychosomatic reasons sucks just as much as having it for any other reason. Sometimes it sucks more, because nobody takes you seriously. I’ll discuss the argument around psychosomatic symptoms more later.

Note the position that Long Lyme is almost universally considered to be psychosomatic. Following up on this has been Ross Douthat's podcast book tour. I had heard him speak to his experience with Chronic Lyme disease much earlier, so I was primed to make the connection as soon as I read the ACX piece, but it's really been in my face as of late on a variety of my favourite podcasts (e.g. his guest hosting of the Ezra Klein show). Ross strongly rejects any suggestion that Long Lyme might be psychosomatic. He makes reasonable points about the science of the disease and the nature of the healthcare system, and at no point did I think he crossed the line of attacking anyone for their belief or claiming things he can't know. Notably, he said that it was hard to hear anyone say it was psychosomatic, when during the worst symptoms, it felt like his mind was the only thing that was working (he continued to write columns in his role as a journalist, and could think clearly).

My uncharitable response to this and similar discussions is that there's more than a smattering of mind-body dualism. The mind is a part of the body, after all. If the bacteria causing lime disease gives you a skin rash, that's an effect on the body. If that same bacteria sends a stress response to your brain that causes you to feel itchy, that's also a bodily effect. I've skipped two important things to note. Lab tests will show a physical cause for itchiness in the case of a rash, but not for the stress. Antibiotics will stop the rash by killing the Lyme bacterium. In the case of Long Lyme, antibiotics... have a less obvious effect. More charitably, people are using these terms in colloquial, non-dualistic ways. If a Ross Douthat had been experiencing severe brain fog as part of Long Lyme (as many long Covid sufferers are), he wouldn't have complained that his mind was the one thing working fine, and maybe long-Covid sufferers with brain fog are less worried about the psychosomatic distinction.

I had a good friend in grade 2 who's mother was suffering from Lyme Disease. I remember asking my mom about her, and needing more help understanding what that was, and not feeling satisfied with the answer. Of course, I was 8, so any answer other than "cancer" or "diabetes" was pretty confusing to me, but there's a chance that I was picking up on something else. Perhaps there was a little bit of doubt there - how much of this was "real" disease and how much was not getting a hold of life. It should go without saying that not everyone is as driven as Ross Douthat, and my friend (who's mother had Lyme disease) probably missed half the school year "sick" himself in ways that weren't believable - obvious enough that 8 year olds weren't believing it. That prejudice, right there, has surely been harming the treatment of chronic disease patients for decades.

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I'll get to why this matters soon, but first, let's throw this at another (hot) topic.

Months ago I got into a debate with someone on the cesspools of the internet. I believe their offending sentence was calling transgender people "mentally disabled", or something like that. Suffice it to say, the context was not exculpatory. To be clear, I was very much on the "don't be a fucking asshole" side of this debate.

However offending the exact wording, this is a common attack, and universally agreed on AS an attack by both sides. A list of the main reasons why Ben Shapiro is unconscionable would probably include his claims that being transgender is a psychological/mental disorder. Ben Shapiro explicitly thinks this is a reason not to provide transgender people with affirmative health care (my cesspool debate partner sure as shit thought so). In the way that progressives attack "mental disorder" statements, it seems as though they agree (if it were true, obviously).

We have to deal with two things first.

1. The people crying "mental disorder" on the internet are usually fucking assholes. And there comments, videos, screeds are typically full of statements characteristic of fucking assholes well beyond the words of interest.

2. "Disorder" takes on an unusual character in controversial topics. While we don't complain about Attention Deficit Disorder or Autism Spectrum Disorder. We have changed "Disorders of Sexual Development" to "Differences of Sexual Development" in a medical setting because of culture wars.

With that out of the way, I want to highlight just one thing about labelling gender dysphoria a "mental disorder" (it used to be labelled thus in the DSM, but no longer, similar to homosexuality). When talking to a transgender person about themselves, or about their childhood, it's common to hear terms like "trapped in the wrong body" or "my mind couldn't accept the person I saw in the mirror". I think it's fair to summarize this kind of scientifically as "during development, my mind and my body developed in ways that didn't feel right together." Obviously that doesn't speak to everyone's experience, but I don't think I'm inventing a phenomenon here. It's also a description of gender dysphoria that I find 100% scientifically believable and non-dualistic.

In this blog, I only care about one thing. Why are both transgender activists and conservative critics so likely to act as follows.

Body developed to be incompatible = Good and valid condition

Brain developed to be incompatible = Bad, crazy person

Quick reminder: both your brain and your body are part of your body. They develop at the same time under the same laws of physics.

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What isn't interesting to me is who's "right" in the above examples. I can easily imagine that some Long Lyme sufferers have residual levels of bacteria remaining that periodically jolt their immune system, and other Long Lyme patients may have been very stressed out by the continued medical experience and noticing that stress through symptoms of heart palpitations and leg aches. I'm only interested in why we might stigmatize conditions that are "mental" more than "physical".

Credibility: If a doctor and a blood test can detect a bacterium in your blood, it fits neatly into our understanding of medical conditions. Then, if a friend asks what's wrong, you can tell them that the doctor found a bacterium in your blood. If not, we use our old heuristics to decide whether to believe the severity of someone's illness. Ross Douthat is a serious, hard-working guy, I'm sure he's not overclaiming about his symptoms. My 8 year old friend is always lying about strep throat to get out of school, maybe his mom isn't really as tired as she always claims to be. I find it believable that we have a mental map of what our body should look like and your body doesn't match yours. This man on the internet thinks you're claiming to be Napolean Bonaparte and is looking at lobotomy options.

Treatment: With many conditions affecting the brain, treatment is much harder. Eye glasses work great at correcting vision problems caused by the eye, but not by the brain. Many doctors have found a similar story between Lyme disease and antibiotics. We apply this lesson to places that we shouldn't, however. If you're having trouble focusing because of the clown playing Metallica next to you, you should remove the clown - whereas if you can't focus because you have ADHD, maybe consider Adderall. But here, as often in life, removing the clown helps in both cases... and so does Adderall, for that matter. Sex assignment surgery might help with gender dysphoria caused by hormonal imbalance OR the wrong synapse connections. You actually have to do the studies to show that it does, but the dichotomy is unwarranted.

Our society prioritizes "natural" fixes to mental problems. We might accept Prozac to help with depression, but we think meditation is a better option. There are some reasons for this, but what someone with a mind-influenced condition might hear is "you don't need any help from us, you just need to think better".

The Cult of the Mind: Finally, we just don't like the idea of our mind failing us. This goes back to my choir director, but we hate the thought that our mind isn't working like it "should" or is causing us pain.

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If it's not clear by now, I'm skeptical that we should change our opinions of something or someone based on whether their mind or their body is affected, but we should maybe change our course of action - which is why it's important to remove the stigma differentiating the two.

We used to really talk up the chemical imbalance theory of depression. If you were sad, you just need to get the right mixture of drugs to correct that imbalance. This probably helped to remove the stigma for some people suffering from depression, who would have sought treatment and become happier after realizing that it wasn't all in their head.

But at some point, it became a visionary thing to point out that, no, sometimes depression comes on because life is kinda shit. Your job is hard and unfulfilling while all your old friends moved farther away and you're often lonely. A medical doctor can no longer wave their wand and fix your condition, but there is still an important list of actions to take so that your mind stops feeling depressed, and this might still include medications.

I think we differentiate the two because we don't expect people to have control over their bodies - you can't decide to not have a skin rash - but we do expect people to have control over their minds. Alas, maybe you can predict what I'm going to say, the mind is part of the body, and they're governed by the same physics.

Nobody has control over their minds in a "cosmic free-will" sense. In the local, colloquial sense, of course we have control over our minds in the same way that we have control over our hands. Different people have different levels of control over their mind, and of course we have no control over how much control we have...

In essence, we should seek to help people suffering from painful conditions in whatever way we can. This should include antibiotics, hormone treatments, experimental medications, lifestyle changes, and meditation. We should follow common sense medical ethics and use rigorous follow ups to determine what works best. As a society, we should stop judging treatments as superior or inferior based on whether they target the body or the mind. The same goes with the conditions themselves. We should of course continue to judge treatments based on side effects.

When I get old, I may start to have memory problems, and that will change me as a person. But of course, when I read my mail today that will change me as a person. This anchored identity of Jasper is a lost cause that I abandoned by writing this sentence. I hope in old age to be happy, and to add to the lives of others. That will be difficult if I can't remember my name, but I'd much rather not do it all from bed either, and damned where I put my glasses.