Arguably, human beings are continually under the sway of placebo-like effects. The women who were injected with what they believed to be testosterone, which has been identified repeatedly as the “male” hormone, turned into caricatures of masculine brutes, as, by his own account, did the ordinarily pacific Sullivan. Placebo and belief effects open up possibilities for rethinking the mind-body and nature/nurture questions. Neurobiologists are interested in tracking the placebo effect through brain scans, relating it to particular areas (the anterior cingulate cortex, for example), but many of them skirt the uncomfortable questions placebo raises, and they usually do it by settling for a mind-body divide that makes little sense in terms of their own physiological models. In her introduction to an interdisciplinary book on placebo, Anne Harrington is more direct. After it became clear in the 1970s that expectation could trigger a neurochemical response in the brain, she summarizes the problem: “Endorphin release . . . became just one more placebo-generated phenomenon to be explained—and we still did not understand the processes whereby a person’s belief in a sham treatment could send a message to his or her pituitary gland to release its own endogenous pharmaceutics.”113 This is the conundrum precisely.
In the collection of texts on placebo she edited, Harrington includes one by Robert Ader, who writes about the experiment he and his colleagues conducted on rats in 1975. The rats were given a saccharine-flavored drinking water at the same time as they were injected with a drug that suppressed their immune systems, which made them ill and killed many of them. When a subgroup of the rats continued to get the harmless drinking water but no longer received the injections, they got sick and many died anyway. Why? The animals seemed to be under a kind of Pavlovian nocebo effect. The coupling of sugar water and deadly drug created a conditioned response, which affected their immune systems.114 They appeared to have been conditioned into immune collapse. The study showed that the noxious effects of nocebo are not limited to human beings. As far as we know, rats do not have reflectively self-conscious thoughts. They do not say, “I am going to get sick,” and get sick. They are not constantly narrating their lives to themselves. Rats, not known for reflecting on their own actions, nevertheless appear to have a version of the nocebo phenomenon.
Cases of false pregnancy have been documented since Hippocrates, and the physical changes that take place in people who believe themselves to be pregnant are objective, not subjective. There are those who suffer from delusions that they are pregnant or about to give birth, but it is obvious to everyone around them that they are crazy. The changes wrought by false pregnancy or pseudocyesis are not delusional. They include abdominal swelling that increases over time; cessation of the menstrual cycle; breast growth, often with secretions; fetal movements that can be felt, not only by the person herself but by others, including doctors; nausea; enlargement of the uterus; and changes in the cervix. There is no question that in these cases neuroendocrine and hormonal levels are altered by a wish to be pregnant. Although false pregnancy is now rare in developed countries, it is not uncommon in Africa. According to an estimate, 1 in every 160 patients who sought infertility treatment in a particular clinic in Sudan developed pseudocyesis. It is generally acknowledged that one of the reasons for the higher incidence among women in these countries is that fertility has greater social value than it does in more developed countries.115 Also the use of sonograms, now routine in the United States and Europe, is less common in Africa.116 Once a woman has been given proof she is not pregnant, the signs of pseudocyesis usually disappear.
Despite the many studies that have documented the physiological changes and speculated on various psychiatric and hormonal reasons for the transformation, there is no consistent neuroendocrine profile in these patients and no explanation for how these changes occur. A 1982 study on two patients suggested an impairment in dopaminergic function. The authors of the study do not speculate on how a wish is literally embodied in a person and can affect hypothalamic-pituitary processes.117 How does the content of a wish—I want to be pregnant—create the physical appearance and feelings of pregnancy? There have been cases of false pregnancy in men, but they are rare and have often been accompanied by a psychotic disorder.
I did find one documented case of false pregnancy in a man who was not mentally ill.118 According to the author of the 1988 paper, Deirdre Barrett, the man in question felt comfortable with the term “transsexual.” He had always felt he was a woman trapped in a man, but he only rarely dressed as a woman, had not sought surgery to alter his body, and did not use the pronoun “she.” He was still grieving for his male partner, who had died some months before, when he sought out a doctor for hypnosis. The man wanted to quit smoking. During the hypnotic session, the doctor asked his patient to imagine being the person he wanted to be, and he imagined himself pregnant. He had long had this fantasy, and although it isn’t mentioned in the report, it seems to me his wish had a sound dream logic.
After the death of his beloved partner, wouldn’t an imaginary pregnancy keep the deceased alive inside him? Isn’t it also a metaphor for his grief? Not long after the hypnotherapy, the man’s belly began to swell. He suffered nausea in the morning, noticed “watery secretions from his nipples,” and felt a rhythmic heartbeat in his abdomen. He sought medical help for what he himself identified as a “false pregnancy.” According to Barrett, the patient vacillated between knowing he was not pregnant and wondering whether he might actually be carrying a fetus. He inquired about a supposed case of genuine male pregnancy in France and brought up experiments on male mice to alter them for pregnancy. Hypnosis coupled with the wish seems to have produced the pseudocyesis.
Far more common among men is couvade syndrome: an expectant father develops some of the symptoms of pregnancy—nausea, cravings, cramps, bloating, irritability—a sympathetic (or envious) response to his partner’s changing physical reality, which his own body mimics, a kind of mysterious contagion from one body to another. In some cultures, male participation in pregnancy is ritualized and, among the men who enact these rituals, there are those who develop external signs of fetal growth. Pseudocyesis also occurs in animals. It is common in cats and has sometimes been linked to a female cat’s loss of her litter. Can a cat’s desire or loss be considered? Is pseudocyesis a form of bodily conditioning for pregnancy that includes the imagination or mental images in human beings? The endocrine system of glands through which hormones are secreted into the circulatory system is not well understood. Confident assertions about any single hormone’s relation to complex human psychology may be premature. Furthermore, the fact that hormonal levels and endogenous opioids are affected by one’s culture, by one’s beliefs and desires, should make any thoughtful person think carefully about how he frames the question of what we mean by “biology.”
How does a verbal suggestion or internal wish create mystifying changes in a person’s body? Ever since Franz Anton Mesmer scandalized the European medical community in the eighteenth century with his spectacular demonstrations of animal magnetism, science has had a queasy relation to hypnotic suggestion. It was briefly dignified by the great French neurologist Jean-Martin Charcot, who used it as a technique for demonstrating the nature of hysteria. Charcot wrongly believed that only hysterics could be hypnotized. The powers of suggestion, however, were widely regarded as a fact of human biological reality and were studied by Charcot’s younger colleague, the neurologist and philosopher Pierre Janet, and by Sigmund Freud and Josef Breuer, all of whom worked with hysterical patients.
Late in his career, Charcot said, “We now know without a doubt that, in certain circumstances a paralysis can be produced by an idea, and also that an idea can cause it to disappear.”119 According to this theory, hysterical symptoms were caused by an autosuggestion that took effect in the patient. Janet maintained that “ideas” had the power to alter neurobiology through a kind of disconnection or dissociation in the brain, an alienation of one system from another. Janet and Freud were both invested in
understanding a patient’s particular emotional history and how ideas connected to a traumatic event or events created a suggestion, which was then converted into symptoms. Janet is not a household name, but his writing about dissociation is highly sophisticated, and some contemporary scientists trying to understand conversion hysteria or conversion disorder have resurrected his work.120
Unlike pseudocyesis, cases of conversion are common. One would have to search high and low to find a neurologist or psychiatrist who has not seen numbers of patients suffering from the myriad inexplicable symptoms of hysteria, including blindness, deafness, paralyses, contractures, and seizures. After a surge of medical and popular interest in the late nineteenth and early twentieth centuries, hysteria became a medical embarrassment. Interest waned, but the patients kept coming. Many of them (if they are not combat veterans) are women, and all complaints that afflict more women than men have been and continue to be treated with a mixture of condescension and contempt by many members of the medical establishment.
Recently, brain scans have propped up hysteria as a condition of renewed medical interest because it is now possible to distinguish on an fMRI or PET scan between a hysterical and a feigned paralysis, for example. They do not look the same. In fact, a conversion paralysis resembles a paralysis induced under hypnosis by suggestion.121 Charcot and Janet appear to have been right. Hysteria may be a suggestion-induced symptom, although the suggestion may not be conscious. The right temporo-parietal junction is hypoactive (less active) in people with hysterical conversion seizures compared to people who pretend to have tremors.122 This is the same area that the wizard in the Daily Mail designated our “moral compass.” The conversion patient is really paralyzed. His paralysis, however, is different from another patient who sustains damage to her spine and loses the use of her legs. Hysteria creates the same philosophical problems as nocebo or false pregnancy. How do ideas, beliefs, wishes, and fears transform bodies? Is this mind over matter? Is this a case of psychological factors interacting with physiological factors? If one accepts the reality of ideas altering bodies, what does it mean for the mind-body problem?
A related mystery appears in cases of dissociative identity disorder (DID), or what used to be called multiple personality disorder, an illness also intensely studied in the late nineteenth and early twentieth centuries and one that fell under the broader rubric of hysteria. Almost always connected to childhood trauma, the disorder seemingly causes these patients to need more than one persona to adapt to an impossible reality. The fact that this disorder turned into an epidemic in the 1980s has often been read as a testimony to its “fake,” “manufactured,” or “unreal” character. No doubt there were frauds during the high contagions of multiple personality, but it seems more interesting to ask whether traumatized people are more vulnerable to some forms of suggestion. Research has confirmed that there are physiological differences between one personality and another in people with dissociative personality disorder. They include allergic sensitivities—one personality has hay fever; another doesn’t—differences in endocrine function, skin arousal, color vision, and varied responses to the same medicine.123 What is one to make of this in terms of mind and body—or several minds in one body in this case?
Every human being has various modes of being—the social self, the family self, the private self—but most of us in the West hold on to the idea that each one of us is singular and unified. I wonder if an actor caught up in playing a character unlike himself shows similar physiological changes or not. And what about a novelist who has spent five years writing in the first person as someone very different from herself? Does the imaginative movement into another persona or into a fictional character have a measurable effect on her physiology? As far as I know, there is no research one way or the other, probably because the current theoretical framework does not permit these questions to be asked, and if a question is not asked, it cannot be pursued.
A 2007 study tracked a traumatized DID patient who suffered from cortical blindness. After fifteen years of blindness, she gradually regained vision during psychotherapy. “At first,” the authors write, “only a few personality states regained vision, whereas others remained blind. This could be confirmed by electrophysiological measurement, in which visual evoked potentials (VEP) were absent in the blind personality states but were normal and stable in the seeing states.”124 In “The Neural Basis of the Dynamic Unconscious,” Heather Berlin comments on the 2007 paper: “This case shows that, in response to personality changes, the brain has the ability to prevent early visual processing at the cortical level.”125 The brain may be able to do this, but again, how are these personality changes induced to begin with? How is the brain responding to such changes and, if the statement is posed in such a way, doesn’t that suppose that personality and the brain are somehow different? Where do we locate personality?
David Morris, who has written eloquently about placebo, advises that we think about “human beings and complex human events like health and illness as constructed at the intersection of culture and biology.”126 The word “intersection,” like the word “interaction,” is an attempt to bring together what has been kept apart: the biological person of flesh and bone and the culture and its ideas, which are outside her. The philosophical problem is not solved, however, by Morris’s intersection. Exactly how does the intersection work? Conflating culture and biology is not a solution. One might ask, when and how does culture become biology? Or more radically, how is biology cultural? Or, perhaps better, how are ideas embodied? Hysteria, dissociation, pseudocyesis, placebo, and nocebo are fascinating because they force a reexamination of not one but several conventional concepts—those boxes into which scholars of all sorts pack up their knowledge and hope to God the contents don’t begin to stir and jump out at them in the middle of the night.
A Moment for Frog Sacrifice and Aristotle’s Biology
Almost every American high school biology student in my day dissected a frog. No one worried about the frog’s thoughts or if the creature had any when it was alive, and the dissection project didn’t include its former habitat either. Its biological body was confined to what the student could make of the recently expired carcass on the table before her and its various parts, many of which also belong to human beings. The word “biology” came into use in the eighteenth century, but the study of living systems is much older. What did the dead frog lack that the living one had? What is life? How did I know the frog was dead? What is the secret of being alive? The frog corpse was dead matter. It is not strange that for millennia an explanation was sought for a principle that once animated that long-legged carcass.
The word “soul” has been used in many ways. Plato’s tripartite soul consisted of reason, appetite, and spirit, but reason was meant to keep the other two in check. Plato’s soul is immortal and both predates a single life and carries on afterward in reincarnation. In Christianity, the soul is immaterial, but many theological arguments have turned on exactly how that works. Soul has also been used to describe animation, spirit, or aliveness in general. In Cavendish’s philosophy, life and soul appear to be interchangeable and to permeate all matter. “There is not any Creature or part of nature without this Life and Soul; and that not onely Animals, but also Vegetables, Minerals and Elements, and what more is in Nature, are endued with this Life and Soul, Sense and Reason: and because this Life and Soul is a corporeal Substance . . .”127 Cavendish is startlingly egalitarian in her distribution of soul. In one fell swoop, she banishes the philosophical hierarchies of man over animals and reason over appetite and passion.
Generation of Animals can be described as Aristotle’s biology. In it he makes astute and specific observations on plants, animals, and human beings in an attempt to locate life itself. How does it come about? He argues that all living things—plants, animals, and human beings—have souls. Plants have vegetative or nutritive souls only; all animals have both a vegetative soul and a sensitive soul. It is the latter that allows ani
mals to have appetites and feelings. Human beings possess the first two souls but also have rational souls. Reason sits at the top of the hierarchy of souls. Aristotle makes a further vital distinction between form and matter, which aren’t separable, but nevertheless each one makes a contribution to a plant, animal, or person. Aristotle’s “embryology” is complex, and although some have argued that for Aristotle semen is somehow immaterial, my reading of him suggests this is not the case.128 Nevertheless, both form and matter are needed for living organisms. Without form matter is inert.
Much has been written about the role of the male and female in Aristotelian procreation, but it is clear that both sexes contribute to the process. A number of feminist scholars have noted the philosopher’s polarities of form and matter and their effects on his view of women. Other scholars have mounted vigorous defenses of Aristotle.129 In Generation of Animals, Aristotle presents form and matter as principles identified with the two sexes.
Soul is better than body, and a thing with a Soul in it is better than one which has not, and the living having soul, is thereby better than the lifeless which has none, and being is better than not being, living than not living . . . But since the male and female are the first principles of these, they will exist in those things that possess them for the sake of generation. Again, as the first or efficient moving cause, to which belong the definition and the form, is better and more divine in nature than the material on which it works, it is better that the superior principle should be separated from the inferior. Therefore wherever it is possible, and so far as it is possible, the male is separated from the female. For the first principle of the movement, whereby that which comes into being is male, is better and more divine, and the female is the matter. The male, however, comes together and mingles with the female for the work of generation, because this is common to both.130
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