| OTTAWA
CITIZEN
Sunday,
March 16, 2003
Page: C3
Section: The Citizen's Weekly
WHEN THE BODY SAYS NO: This B.C. doctor insists
that emotional repression and psychological stress play
a powerful role in the onset of chronic illness
By Shelley Page
New York Yankees first baseman Lou Gehrig was known as
the Iron Horse because he refused to pull himself from
the lineup regardless of injury or illness. In the 1930s,
Gehrig set a record for consecutive games played -- 2,130
-- that would stand for six decades.
When his hands were X-rayed it was found that every one
of his fingers had been broken, some more than once. He
had sustained 17 fractures. Someone once described Gehrig
"grinning crazily as a macabre dancer in a gruelling
marathon."
While Gehrig was known for his refusal to quit, years
later, he also became known as the most famous person
to be felled by ALS or amyotrophic lateral sclerosis,
a degenerative, muscle-wasting disease. ALS became known
as "Lou Gehrig's disease."
According to Vancouver physician and bestselling author
Dr. Gabor Maté, those who develop Lou Gehrig's
disease share more in common with its namesake than just
the illness. ALS patients the world over are frequently
described as the "nicest people you could ever meet,"
says Maté.
Like Gehrig, they never complain, don't say a bad word
about anyone, never admit or confront any fear, anxiety
or sadness in their lives. Maté, who met many ALS
patients working as the director of palliative care at
Vancouver General Hospital, found that they never asked
for help or admit to emotional or physical pain.
Instead, Maté claims they always tried to be cheerful.
Even in the face of death, his patients spoke "casually
of their deterioration or did so with engaging smiles."
In his just-published book, When The Body Says No:
The Cost of Hidden Stress, Maté wondered if
his observations could be supported in the scientific
literature. What he found -- albeit not a lot -- convinced
him that something about ALS patients' emotional-coping
style might trigger their illnesses.
"Why Are Patients with ALS So Nice?" was the
title of a paper presented by neurologists from the Cleveland
Clinic at an international symposium in Munich a few years
ago. Technologists conducting diagnostic testing on people
suspected of having ALS would sometimes write "This
patient cannot have ALS, he (or she) is not nice enough
... "
A 1970 study of 10 ALS patients said "hard, steady
work without recourse to help from others was pervasive."
In Maté's book, he attempts to show that continuing
emotional repression and psychological stress play a powerful
role in the onset of chronic illness. In his more than
two decades of medical practice, he noticed that those
patients who developed cancers and chronic illnesses,
such as the autoimmune diseases rheumatoid arthritis,
scleroderma, lupus, as well as asthma, multiple sclerosis,
and bowel disorders, have lived lives of excessive stress, often invisible to the individuals themselves.
From an early age, many of them developed a psychological
coping style that kept them out of touch with the signs
of stress. They suppressed any negative emotions, especially
anger, which triggered biochemical processes -- or a predisposition
to a certain illness -- that led to illness.
Maté first received international attention for
his bestselling book Scattered Minds, in which
he argued that attention deficit disorder was not a "biological
disease" to be treated solely with medication, but
a result of a frenetic society and unhealthy social circumstances.
With When the Body Says No, he follows the same
path, this one more well-travelled, but dangerous. Numerous
authors before him have written about the so-called mind-body
connection, everyone from Dr. Bernie Siegel in his groundbreaking
Love, Medicine and Miracles, to more obscure works, such
as the recent Irritable Bowel Syndrome and the MindBodySpirit
Connection by William Salt. There are newsletters devoted
to the topic, such as Mind Body & Soul. Type "mind
body connection" into Google and you get more than
1.2 million hits.
Attempts to connect personality to coping styles have
run into all sorts of criticism, especially linking cancers
to what has been dubbed the "type C" personality
-- passive, emotionally inexpressive, conforming and unassertive.
In Illness as Metaphor (1978), Susan Sontag famously wrote,
"such preposterous and dangerous views manage to
put the onus of the disease on the patient and not only
weaken the patient's ability to understand the range of
plausible medical treatment but also, implicitly, direct
the patient away from such treatment.
"Cure is thought to depend principally on the patient's
already sorely tested or enfeebled capacity for self-love."
Many of these mind-body books have been lumped together
in what is known as the "blame the patient" movement.
Maté is well aware that he may be criticized for
"blaming" the ill for their bad health, but
he says he hopes to force both patients and their doctors
to confront the western style of medicine, which scrupulously
ignores emotional influences. "Not all aspects of
illness can be reduced to facts verified by double-blind
studies and by the strictest scientific techniques."
In the interests of full disclosure, it's important to
say I approached Maté for an interview with both
trepidation and curiosity. Having suffered from an autoimmune
disease for 20 years, I don't like to think this has been
a hell of my own making, or of my parents' making. There
are more palatable culprits: some as yet undiscovered
genes or a mystery virus that caused the immune system
to turn against the body.
Still, I felt he was correct to some degree. Before being
diagnosed with lupus, a disease that would eventually
attack my brain, heart, lungs, kidneys, muscles and joints,
I lived a life of chronic stress. Obsessive studying in
university; participation at an elite level in basketball;
far too many extracurricular activities; too many parties;
and an over-arching pressure on myself to succeed in everything.
When I was diagnosed, my Vancouver-based rheumatologist
didn't ask about any of this, he just gave me fistfuls
of Prednisone and sent me packing. I remember begging
my mother every day to drive me to my first daily newspaper
job, despite my slow, rigid gait, shortness of breath
and tear-inducing chest pain: I never took a sick day.
Later, a social worker pointedly said: "Your problem
is you want to play all of the strings of your violin
at once." Those words haunt me, and it took years
to come to terms with the truth of that statement, and
much longer to figure out how to not to be that way.
Maté, as have others before him, talks about people
who "die of loneliness," or of a sadness that
"eats someone to death." I could be a metaphor
for an autoimmune disease: my own harshest critic, my
immune system began to attack myself.
Surveys of chronically ill people and cancer patients
show that many develop their own personal scenarios linking
stressful life events to their initial diagnoses. A recent
study found that 42 per cent of breast-cancer patients
believed their disease was caused, at least in part, by
"stress."
But most medical professionals -- and numerous patients'
rights advocates -- have been very critical of this "blame
the patient" movement, contending that while there
may be some mind and body interaction, it is far more
complex than is now understood, and that emotional harm
can result from simplistic theories of causality, thoughtlessly
applied.
I found this excerpt from Advanced Breast Cancer: A Guide
to Living with Metastatic Disease (1998), which summed
up many medical professionals' view: "While all sorts
of fanciful theories abound, and have since recorded history
began, it's important to remember that despite decades
of research, no one has yet proven that traumatic events
cause cancer or worsen prognosis, or that certain kinds
of people are more prone."
I approached Maté certain about two things. Almost
everyone I know represses their emotions, particularly
anger, and most of them seem healthy. In fact, I count
among my friends many thriving passive-aggressives. However,
I, like many other patients, have a "gut" feeling
that there is more to many illnesses than simply a mysterious
biomechanical malfunctioning, and perhaps chronic stress
or some other psychological component is a necessary ingredient.
On the phone from Vancouver, Maté speaks quickly
and mumbles often. He does not seem as self-assured as
he comes across in the book. There is a sweetness to him.
When he talks of the "wonderful, lovely" patients
he watched die, he grows even quieter. More than once
during the interview, we'll slide into my own circumstances.
His compassion and concern are touching.
A family physician for more than 20 years, Maté,
59, was the medical co-ordinator of the Palliative Care
Unit at Vancouver General Hospital. He is also staff physician
at a facility for street people in Vancouver's downtown
eastside. He was a long-time columnist for the Vancouver
Sun and the Globe and Mail.
He is both a survivor and a child of Nazi genocide, having
lived most of his first year in Budapest under Nazi occupation.
His maternal grandparents were killed in Auschwitz when
he was five months old; his aunt was deported and was
never again heard from; his father was in a forced labour
battalion in the service of the German and Hungarian armies.
His mother and he barely survived their months in the
Budapest ghetto.
His mother suffered inhuman stresses, and he says she
"was rarely up to the tender smiles and undivided
attention a developing child in fact requires to imprint
a sense of security and unconditional love in his mind."
On many days, his mother only got out of bed in order
to care for her son.
"I learned early that I had to work for attention,
to burden my mother as little as possible and that my
anxiety and pain were best suppressed," he writes
in his book.
This created a lifelong pattern of both needing to overachieve
for attention, while at the same time hiding his pain
and suffering from others, particularly his mother. As
an adult, he was diagnosed with attention deficit disorder.
Even when he was writing this book, he marvelled at how
he subconsciously stopped limping when going to visit
his mother, in order to hide an injury so she wouldn't
worry.
In his life as a doctor, Maté has always been fascinated
by the psychological roots of illness. His book relates
many haunting and tragic stories about his patients.
He writes of Joyce, who describes how a recent asthma
flare-up occurred after a family get-together that brought
up emotions of fright and suppressed anger from her childhood.
"We all had dinner together. (My brother) just went
over the top --critical, angry, directed at me. I woke
up Monday morning and couldn't talk, couldn't walk, couldn't
do anything," she recalled.
Maté writes of ill patients who describe having
happy childhoods. Then he quizzes them, only to find they
had made themselves "numb" to a destructive
family dynamic.
Iris, who suffered from autoimmune disease, "disappeared"
and went into a fantasy world whenever her father unleashed
his temper.
"I couldn't talk to my mother because I didn't want
her to know I was unhappy, for one thing. For another,
she didn't really exist as a separate entity apart from
my father. She was a neutral person ... I was numb, but
on the other hand I was quite happy in my numbness."
"Oh?" he asked.
"I played with dolls ... OK, never mind about that,
I was going to say I chewed dolls."
"What do you mean?"
"I'd chew their fingers and toes."
She was mutilating them in her suppressed rage, Maté
offered.
Knowing he may be accused by critics of engaging in psycho-babble,
Maté mined data bases for "scientific proof"
to support his thesis. He also focused on the new science
of psychoneuroimmunology.
He describes his correspondence with Noel Hershfield,
a professor of medicine at the University of Calgary,
who said the new discipline "has now matured to the
point where there is compelling evidence, advanced by
scientists from many fields, that an intimate relationship
exists between the brain and the immune system ... An
individual's emotional makeup, and the response to continued
stress, may indeed be causative in the many diseases that
medicine treats but whose (origin) is not yet known."
Hershfield goes on to name the vast majority of rheumatic
disorders, inflammatory bowel disorders, diabetes, multiple
sclerosis and others.
Maté writes that stress is a complicated cascade
of physical and biochemical responses to powerful emotional
stimuli. Physiologically, emotions are themselves electrical,
chemical and hormonal discharges of the nervous system.
Emotions influence -- and are influenced by – the
functioning of our major organs, the integrity of our
immune defences and the working of the many circulating
biological substances that help govern the body's physical
states. When emotions are repressed, studies have repeatedly
shown that this inhibition disarms the body's defences
against illness. Even students studying for an exam are
found to be at a greater risk of getting sick because
stress suppresses their immune system.
In one chapter, Maté theorizes how repressed emotional
states have been linked to multiple sclerosis, the most
common of the so-called demyelinating diseases that damage
the spinal cord, brain stem and optic nerve.
Researchers in Colorado looked at 100 people with the
type of multiple sclerosis called relapsing-remitting,
in which flare-ups alternate with symptom-free periods.
Patients who experienced extreme stresses, such as major
relationship difficulties or financial insecurity, were
almost four times as likely to suffer exacerbations.
A 1969 study found that 85 per cent of MS patients first
experienced symptoms of their illness in the wake of a
highly stressful event. Another study found that severely
threatening events were 10 times more common among MS
patients, and marital conflict five times more frequent
than in a healthy control group.
Maté interviewed eight women with MS for his book.
Only one was in her first long-term relationship. The
others had divorced or separated. Four of the women had
been abused physically or psychologically by their partners
sometime before the onset of illness.
While Maté doesn't believe that stress alone causes
MS, he thinks stress is a required ingredient. The patients
had been exposed to acute and chronic stress in their
childhood, and their ability to engage in the necessary
flight-or-fight behaviour to protect themselves was impaired,
he writes.
It's not as simple as saying that the stress of losing
a job or a loved ne led to the illness, he writes. Instead,
these particular patients learned through their lives
to respond to their stresses in a way that was very physically
harmful. He says they had an "environmentally conditioned
helplessness" that meant they could neither stand
up to abuse or misery, or run away from it. Instead, they
just took it all in.
Susan Sontag once angrily wrote that "the cancer
personality is regarded .... with condescension, as one
of life's losers."
Maté says that's not what his exploration of the
"cancer personality" is intended to show at
all. He describes one study that looked at melanoma patients,
for which the Type C personality was first described.
The 1984 study measured the physiological responses to
stressful stimuli among three groups: melanoma patients,
people with heart disease, and a control group with no
illness. Each person was connected to a dermograph to
record the body's electrical reactions as the subject
looked at slides displaying statements such as "you're
ugly" or "you have only yourself to blame."
As their physiological responses were recorded, the subjects
also had to say how calm or disturbed they were after
reading each statement.
The physiological responses of the three groups were identical,
but the melanoma group proved most likely to deny any
awareness of being anxious or upset by the messages. The
authors described them as having "repressive"
tendencies.
Type A individuals are seen as "angry, tense, fast,
aggressive, in control" and more prone to heart disease.
Type B represents the balanced, moderate human beings
who can feel and express emotion without being driven
and without losing themselves in uncontrolled emotional
outbreaks. Type C personalities are "extremely co-operative,
patient, passive, lacking assertiveness and accepting."
Maté cites a study done on 10 per cent of the inhabitants
of Cvrenka, in the former Yugoslavia. One thousand men
and 400 women were interviewed for risk factors, as well
as life events, and coping skills. Ten years later, more
than 600 of the study participants had died of cancer,
heart disease, stroke or other causes. The single greatest
risk factor for death -- and especially for cancer death -- was called
rationality and anti-emotionality. Cancer incidence was
40 times higher in those who answered positively to 10
or 11 questions that showed they repressed anger, than
in subjects who answered positively to about three questions
on repressiveness.
The researchers found that smokers had no incidence of
lung cancer unless they also had a score of 10 or 11 on
rationality and anti-emotionality. In short, smoking was
not enough to cause lung cancer, certain psychological
factors were also required.
Does the same hold true for breast cancer? This is a case
of duelling studies. Perhaps no other cancer has been
studied as deeply looking for links to emotion.
A British study released last summer concluded that violence,
bereavement, debt and other stressful experiences did
not increase the chances of a recurrence of breast cancer
in women being treated for the disease. For five years,
202 women receiving treatment were followed. Seventy-six
per cent of the women did not suffer a relapse during
that period of time. In the remaining 24 per cent who
did suffer a relapse, stress was not found to be a factor.
Instead, risk factors for recurrence related to the type
of tumour and whether the cancer had spread to the lymph
nodes.
At the time, Dr. Donna Stewart, a professor at the University
of Toronto, commented that the study's findings "made
sense."
"People think stress causes everything. The evidence
for stress is pretty low. And the evidence for hormones
and genetics is pretty high."
Dr. Stewart was lead author of a 2001 study of nearly
400 women with a history of breast cancer who were asked
what they thought had caused their malignancy. Forty-two
per cent cited stress -- much higher than factors such
as diet, environment, genetics or lifestyle.
But Maté sides with the impressions of Stewart's
study patients, instead of Stewart. Only a small minority
of women with breast cancer -- seven per cent -- acquire
the disease because of genetics. And while he agrees hormones
are involved, and are active promoters or inhibitors of
malignancy, it is not true that their actions have nothing
to do with stress.
"Hormone production is intimately affected by psychological
stress," he writes.
Maté says an Australian study of breast cancer
patients is more significant.
Researchers looked at 512 women who required breast biopsies
and were interviewed before their diagnosis was known.
It found that women experiencing a highly threatening
life stressor and who were without intimate emotional
support had a ninefold risk of developing cancer of the
breast. Independently, neither factor by itself increased
the risk.
Maté writes most passionately about autoimmune
diseases. He has witnessed the death of two favourite
patients to scleroderma, a sometimes fatal illness with
symptoms ranging from skin thickening to the deterioration
of the internal organs. The cause of most autoimmune diseases
is unknown; however it has long been speculated that there
is a direct link to stress.
In 1892, William Osler, a Canadian and considered one
of the greatest physicians of all time, suspected rheumatoid
arthritis to be a stress-related disorder. But Maté
complains, rheumatology "all but ignores that wisdom
despite the supporting scientific evidence accumulated
in the 110 years since Osler first published his text."
Maté says that studies have shown that people with
rheumatoid diseases are "stoic to an extreme degree,"
and have a "deeply ingrained reticence about seeking
help." This non-complaining stoicism is a coping
style acquired early in life.
Those with rheumatoid illnesses also exhibit perfectionism,
a fear of one's own angry impulses, excessive self-criticism,
morality and religiousness. They are often from two-parent
households, but the parents are in conflict, either with
each other or the child, who instead of being angry at
the parent, directs the anger toward herself.
After reading the chapter, I did not think it applied
to me. If anything, I have a Type A personality. I'm a
confrontation, "say what I think" person.
I read the auto-immune disease profile to friends, who
agreed it was nothing like me -- of course, they might
have been afraid to say anything but that. And also, I
know lots of people who fit the profile who aren't sick.
Maybe Dr. Donna Stewart is right. We blame stress because
it's the only thing lay people understand. How can I blame
complex internal processes that I know nothing about?
As a patient, there is so much conflicting information.
I once read that left-handers have more autoimmune diseases.
I am left-handed. Perhaps it's the "stress"
of living in a right-handed world that made me sick. Another
study found that 99 per cent of those with lupus have
testified positive for Epstein Barr and this might be
proof that it's a trigger. I've had mono, too.
Maté asked for 30 minutes of my time and attempted
to go to the heart of why I'm so hard on myself. He helped
me see patterns I didn't realize existed. Meanwhile, I
have learned to play only one string of my violin and
try to accept if I do it badly sometimes. Surprisingly,
I'm somewhat healthier. Maybe stress triggered a disposition
I had to illness. Maybe it didn't.
Still, how does this jive with the medical model? A news
story last week told of a vaccine developed in Australia
that will apparently turn off autoimmune diseases. Obviously,
it's not a vaccine against chronic stress, so following
Maté's thinking, how could it work?
If we accept that chronic and often unrecognized stress
contributes greatly to illness, what do we do with this
information?
An entire industry has grown up around counselling patients,
particularly those with cancer, to think "positively."
Maté rejects this plan. He says that by encouraging
patients to be optimistic or look on the bright side,
we would be saying they are "not strong enough to
handle reality."
"The onset of symptoms or the diagnosis of a disease
should prompt a two-pronged inquiry: what is this illness
saying about the past and present, and what will help
in the future? Many approaches focus only on the second
half of that healing dyad, without considering fully what
led to the manifestation of illness in the first place.
Such 'positive' methods fill the bookshelves and the airwaves.
“In order to heal, it is essential to gather the
strength to think negatively. Negative thinking is not
a doleful, pessimistic view that masquerades as 'realism.'
Rather, it is a willingness to consider what is not working.
What is not in balance? What have I ignored? What is my
body saying no to?'
"Without these questions, the stresses responsible
for our lack of balance will remain hidden."
Maté spends considerable time exploring the "dance
of the generations," where our experience is shaped
by our parents' behaviour, which is shaped by their parents'
behaviour. He doesn't want to "blame" people's
parents, but understand them.
“All of us dread being blamed, but we all would
wish to be more responsible -- to have the ability to
respond with awareness to our circumstances, rather than
just reacting. We want to be the authoritative person
in our own lives: in charge, able to make the authentic
decisions that affect us. There is no true responsibility
without awareness."
Maté then explores how patients can confront their
ingrained patterns of behaviour and try to heal, if not
their physical selves, their psychological selves.
Many people will accuse Maté of hurting sick people
more than helping them. I can't help but think of all
the chronically ill patients who, upon diagnosis, run
out and buy every vitamin and supplement that has a tenuous
link to good health, in the hopes it will make them better.
Few stop to examine their emotional lives. Why should
that be something to be afraid of?
Maté quotes Dr. Robert Maunder, a psychiatrist
at the University of Toronto school of medicine, who says:
"Trying to identify and to answer the question of
stress is more likely to lead to health than ignoring
the question."
Shelley Page writes for the Weekly. BACK |
