Psychiatry Reborn: Biopsychosocial Psychiatry in Modern Medicine by Will Davies;Julian Savalescu;Rebecca Roache;J. Pierre Loebel;

Author:Will Davies;Julian Savalescu;Rebecca Roache;J. Pierre Loebel;
Language: eng
Format: epub
Publisher: Oxford University Press USA
Published: 2020-06-15T00:00:00+00:00

The role of expectations

There is evidence for many psychological illnesses that the symptoms presented are influenced by the patient’s expectations. One extreme of this comes with psychosomatic illness: here it may be that the entire nature of the symptoms is determined by the patient’s expectations. We need not venture into cases as extreme as these, but can focus on those where the expectations have some impact on the symptoms. Here are two examples, which vary in the degree of controversy they will elicit.

Shell-shock.First World War shell-shock produced a wide range of symptoms, some of which have been much less noticeable in other conflicts: witness the many kinds of odd gait that were remarked on by doctors at the time.2 There is good evidence that at least some of these were affected by the attitudes of the patients. For instance, in their comparison of patients in Berlin and London, Linden and Jones found that functional seizures were over three times more common in the former group than the latter. Various factors could explain this, but they concluded that the most likely were cultural; more crudely put, that the German patients were more likely to expect to suffer seizures (Linden and Jones, 2014, pp. 542–4).3

Eating disorders.This is a more controversial case, but there is some reason to think that the particular form that eating disorders take is affected by the expectations of those who suffer from them. First, there is the issue of change over time. For many years it was thought that rates of anorexia nervosa increased dramatically from the 1960s until at least the 1990s. More careful studies called that into question, and rates from around 1990 look to be fairly steady.4 But there does seem to have been a strong increase in the incidence of bulimia nervosa: that rose threefold in the period from the early 1980s to the end of the century (Currin et al., 2005; Hudson et al., 2007). Second, there is the issue of cross-cultural change. The best documented here is a set of studies by Lee Sing concerning anorexia in Hong Kong. Lee contends that a form of anorexia existed in the Chinese population but that it was very different to that seen in the West—it wasn’t characterized by unhappiness about being overweight, nor was it connected with an unrealistic body image. This changed, he thinks, in the mid 1990s when a Western idea of anorexia was introduced (partly by journalists and by well-meaning public health official alarmed at the lack of preventative programmes), so that now most sufferers conform much more closely to those in the West. If eating disorders change across time and culture, an obvious explanation is that this is mediated by the attitudes of those involved.5

Other examples could be given—the increased prevalence of cutting among Western adolescents6; the rise, and decline, of multiple personality disorder7; the presentation of depression in cultures like Japan (Kitanaka, 2012). And there are many historical cases. All are somewhat controversial but all seem to show some evidence of an impact on the symptoms of the expectations of the subjects.

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