25 January 2011

Unhealthful News 25 - cynicism, like acetaminophen, can come in too large a dose

In a column this morning, Columbia University medicine professor Richard Sloan declares that there is absolutely no evidence to support the widely held belief that having the right mindset or a "fighting spirit" can benefit your health.  The trouble with having a burning urge to debunk is that it is sometimes hard to know when to stop.

Most of what Sloan has to say is reasonable.  As much as someone might like to think that having a positive attitude can slow the growth of cancer cells or even bolster our immune system, the evidence shows that the effect is minimal.  The belief that there is a strong effect is easily attributable to selective memory and reporting.  No one ever says, "he did not have a spontaneous remission because he is such a lazy heathen."  Sloan also recounts stories of a few of the many movements and traditions that have put far too much faith in the power of thinking and belief (strategically avoiding mentioning any currently influential religion).

But his thesis statement is simply wrong.  He claims: 
But there’s no evidence to back up the idea that an upbeat attitude can prevent any illness or help someone recover from one more readily.
This is certainly not true for the many illnesses that have psychological distress at their core.  For depression and the other psychological diseases that arguably account for more of the total disease burden than physical conditions, Sloan's claim comes close to being wrong by definition.  Those conditions are not, of course, merely attitude, but many of them are obviously closely tied to it.  So perhaps Sloan had in mind the caveat "any physical illness" but was just so caught up in his point that he forgot that he needed to clarify. 

But many physical diseases also have causes in mood, attitude, or mindset.  He tries to dismiss this by pointing out old myths about breast cancer being caused by sexual inhibition and other bad attitudes (but when is it not possible to pull some absurd believe from the dark ages of medicine – by which I mean now or any earlier point in time – to illustrate that a particular pattern of belief led to some absurd claims?).  He also notes the belief that stomach ulcers are caused by "unresolved fear and resentment" (I would have gone with "stress and anger"), which was rather less absurd in its day.  But he includes in that list hypertension being caused by "inability to deal with hostile impulses", which is not a very strong argument.  While we now know that stomach ulcers are caused by H. pylori infection, it is not entirely clear that stress has no effect.  As for hypertension, while most causes have little to do with our thought patterns, some of them do.

It is on the recovery side that this blanket dismissal falls down completely.  Sloan uses the news about Gabrielle Giffords's recovering from the effects of our American culture of political violence as the hook to publish this column.  (Yes, I know, it is guns that shoot people.  Or violence-prone individuals.  It is not because of the cultural norms that make guns common, or the rhetoric that triggers the inclination some people have to pick up a gun and shoot people.  Oh, wait, yes it is.  In the spirit of yesterday's post, all of these are the cause of her injury.  Come to think of it, this is a much simpler example than I used yesterday.)

Anyway, Giffords's case is a particularly bad choice for Sloan.  It is true that her much cited "fighting spirit" probably did not help her survive the bleeding and brain swelling that could have killed her.  But recovery from a traumatic brain injury can depend hugely on someone's spirit or mindset.  Re-learning, in middle age (when we do not have the brain plasticity of young children) how to do thing things that the missing bits of brain used to control, dealing with frustration and a sense of loss, and overcoming the mood disorders that often result from such injuries require an enormous amount of work.  Such work is aided by having a fighting spirit.  I have personally witnessed the recovery from severe brain injury of a young highly-driven person who fought back hard and an older person who made some efforts but just did not have as much spirit.  The differences were enormous.  Obviously my two observations do not constitute a very good study, and I understand that many myths come from inadequate studies like this.  But I am not arguing the statistics; this is the type of causal pattern that you can observe without statistics.  Having less fighting spirit can obviously cause someone to not push hard enough through the difficult effort that improves recovery.

I can provide even more direct insight.  My shoulder was injured to the point that last summer I could not use my arm very effectively (we are talking not being able to wear most shirts due to loss of mobility).  After getting treatment and learning the right strategy for recovery, I was stoked to fight back, and endured serious pain to recover about 80% of what I had lost.  But when the point of diminishing returns coincided with other events that left me with rather less fighting spirit, I stopped pushing hard enough to finish the recovery and, surprise!, stopped recovering.  (Though failing to recover from an injury that ends one's rock climbing career might actually result in better health in the long run.  Causation is complicated.)

I understand that Sloan was probably thinking something like "a fighting spirit will not fix blood vessels or make chemotherapy agents work better" when he went overboard and made a much broader statement.  But even then, the claim is not entirely correct.  Even if fighting spirit, praying, anger, resignation, and boredom have no effect on a treatment, complete resignation can cause someone to give up on the medical efforts and just die.

As a broader lesson, this is a case of how easy it is to deny any broad phenomenon by picking its weakest claims and pointing out that they are wrong.  This is the counterpart of advocates of a theory cherrypicking evidence that seems to support it.  Instead of addressing the evidence about how willpower affects recovery from serious trauma, it is possible to observe that many people believe that cancer can be driven to remission by joyous prayer.  It is then easy to point out that studies have failed to show that this is true.  That does not mean that every claim of attitude affecting health is wrong, of course, but it is easy to write an essay that implies that it does. 

The lesson, then is of weak science and powerful rhetoric.  The fact that someone can attack weak claims and thereby get away with publishing statements that any editor or reader should realize are overly general (who among us has not observed someone taking actions to recover from a serious injury or illness make better progress when in a good mood?) is a good cautionary tale:  If someone wants to "debunk" what you are trying to support, there is a good chance they will find the least defensible claim that you make and use it to imply that the entire category of claims is wrong (a little hint to my colleagues in THR).

1 comment:

  1. We published two pieces related to the Sloan op-ed that readers might find of interest.

    The first is titled Dr. Sloan Misses The Point: A Fighting Spirit Is Vital In Overcoming Illness and can be read at this link:


    The other is titled Fighting Spirit And The Challenge To Live and can be read at this link:


    Thank you very much.

    Jim Prevor


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