The mind in modern medicine

It is curious that the mind, so important at the turn of the 20th century, is experiencing today a reawakening in scientific and societal consciousness. The founders of modern medical science in the 18th and 19th centuries had clearly conceived the mind to be a representation of the brain; people like Alois Alzheimer demonstrated pathological abnormalities in the brain of people affected with dementia. Indeed, centuries earlier, the father of modern medicine, Hippocrates, had firmly placed “our joys, sorrows, desires and feelings” in the brain.

Sigmund Freud, who started his career as a neurologist, developed an interest in the mind while a student of the legendary neurologist Charcot in Paris. Charcot was deeply interested in hysteria, that condition where physical symptoms like fainting, seizures and paralysis are expressed due to an abnormal emotional state, rather than an abnormal physical state. Many aspiring neurologists of the time including Freud were attracted to Paris by Charcot’s knowledge and erudition.

Sigmund Freud, however, branched off from Charcot to develop his own hypothesis of the human mind, in what famously became the school of psychoanalysis. Freud took the exploration of the mind in hysterical states deeper, into areas that few physicians before him had dared to tread. His theory of “consciousness” attempted to explain the role of deep-rooted emotional conflicts originating in early life, in developing symptoms of the mind later on. Freudian thought is complex, requiring many hours of concerted study. In a nutshell, Freud proposed that the human tendency was to repress anxiety provoking emotional conflicts that the conscious mind could not possibly contemplate. While these thoughts were confined to the unconscious mind, there were, inevitably, times when they emerged into the conscious, and given their unacceptable nature manifested (were converted into) a physical symptom, instead. Freudian thought spawned a school of psychoanalysis which dominated the practice of “psychological medicine” for over a century. However, his all-pervasive view of sexual underpinnings for all manner of emotional conflict, for example the Oedipus complex where the mother is the inappropriate object of sexual attention of the male child, was not accepted in its totality by his contemporaries.

Two milestones in the latter half of the twentieth century brought the mind firmly back into the realm of brain science. The first, the discovery of the neuroleptic drug chlorpromazine that could control effectively the symptoms of serious mental illness like schizophrenia, followed on by a range of psychotropic drugs with potential to address a range of other emotional symptoms, provided indirect evidence that the brain had a role in the development and manifestation of human emotions. The second, the development of several dynamic brain-imaging tools in the last two decades of the twentieth century and the first decade of the twenty-first, has transformed our understanding of the human brain and mind, permitting us to visualise live, brain activity during a psychological task.

Crossroads

The brain and mind interface is therefore at an interesting crossroads in modern medicine. There is a growing understanding in medical science of the role our brains play in determining what are predominantly emotional symptoms. Research, for example, has shown that people with psychopathic personalities, hitherto considered to suffer from a disorder of the mind, have a poor perception of others’ facial emotions, and experience difficulties in affect recognition (that is, gauging the other person’s mood). These abnormalities in perception have been linked to abnormalities in brain function, the amygdala, part of the emotional brain, being implicated in many instances. Clearly, as our ability to image the mind expands, so will our understanding of brain-mind relationships and knowledge of “how the mind works!”

From a social and health policy perspective, the mind has assumed considerable importance. In a seminal paper, “The Mental Wealth of Nations,” published in Nature (Volume 455; October 23, 2008), Beddington and colleagues emphasise that countries must learn to capitalise on their citizens’ cognitive resources if they are to prosper, both economically and socially, and that early interventions for emotional health and cognition will be the key to prosperity. Reporting the Foresight Project on Mental Capital and Wellbeing commissioned by the U.K. Government Office for Science, they introduce two important concepts. Mental capital encompasses both cognitive and emotional resources. It includes people’s cognitive ability; their flexibility and efficiency at learning; and their emotional intelligence, or social skills and resilience in the face of stress. Mental well-being, on the other hand, refers to individuals’ ability to develop their potential, work productively and creatively, build strong and positive relationships with others and contribute to their community. The importance of detecting mental disorders early, the role of science, for example neural markers for childhood learning disability; the development of early interventions that enhance mental capital and mental well-being, boosting brain power through the lifespan; and encouragement for processes that will help people adapt well to the changing needs of the workplace, as also engage in life-long learning, are highlighted here.

From a clinical practice perspective, the importance of mental health, wellness and health-related quality of life as outcome indicators of both physical and mental disorders is becoming widely accepted. The view is that it is not enough to heal the body of a person affected with physical disease; it is also crucial that we heal the mind, enhancing wellness, is gaining credence in modern medicine, quality of life having become established as the best outcome of treatment. Indeed, the reintegration of people into society as they recover from illness requires as an imperative the restoration of both their mental capital and mental well-being.

Pray, what is the status of hysteria, that original symptom of the mind, in this era of modern medicine, you may well ask. It is noteworthy that a whole range of bodily symptoms that have no physical basis — tension headache and chronic fatigue, atypical facial pain, atypical chest pain, irritable bowels and bladder, fibromyalgia, burning in the private parts, to name just a few — all have their putative origins in the theory of hysterical conversion. It is estimated that between 20 per cent and 35 per cent of all primary care consultations and about a fifth of all emergency room visits are for physical symptoms such as these, that do not have a physical basis. They are also responsible for the loss of many patient and caregiver workdays; untold suffering and burdensome expense, both personal and social; and unnecessary investigations in pursuit of that elusive diagnosis.

Physicians who frequently encounter these symptoms have learnt to spot the telltale signs that are their forerunner: multiple consultations (doctor shopping); the large bag filled with a variety of investigation reports that have mysteriously failed to identify “anything wrong”; the constant need for reassurance, combined curiously with disbelief in the doctor’s opinion, notwithstanding his erudition; the development of new symptoms, without any apparent physical basis, soon after old ones disappear; disenchantment with the medical profession for failing to diagnose, sometimes even subtle pride in being “such a difficult diagnostic dilemma”; as indeed the failure of any serious setback to manifest itself despite months, sometimes years, of ongoing symptoms… the list of diagnostic clues is endless.

The French physician Briquet described this syndrome which for many years carried his name. In modern medicine this ailment goes by the name “Somatisation Disorder.” And in the clinic setting, in an era of advancing diagnostic technology, it has become the most common manifestation of hysteria. Indeed, somatisation, thought to be more common in non-western cultures with traditionally limited verbal expression of emotions, is almost becoming fashionable, akin to “swooning” (another hysterical symptom) in the Victorian era.

Hysteria does therefore exemplify the importance of the mind in modern medicine. It may well have origins in the brain, which future research may reveal: it clearly is a significant public health problem that does affect mental capital and well-being; it does pose a tremendous drain on the public exchequer and private resources; it has potential for cure through early diagnosis and intervention; and interestingly, may well be the last frontier to traverse at the interface between the brain and mind.

( Dr. Ennapadam S. Krishnamoorthy is Honorary Secretary & T.S. Srinivasan Chair in Clinical Neurosciences and Health Policy, Voluntary Health Services. E-mail: esk@nsig.org)