Phantoms in the Brain: Probing the Mysteries of the Human Mind (37 page)

I find great irony in the fact that every time someone smiles at you she is in fact producing a half threat by flashing her canines. When Darwin published
On the Origin of Species
he delicately hinted in his last chapter that we too may have evolved from apelike ancestors. The English statesman Benjamin Disraeli was outraged by this and at a meeting held in Oxford he asked a famous rhetorical question: "Is man a beast or an angel?"

To answer this, he need only have looked at his wife's canines as she smiled at him, and he'd have realized that in this simple universal human gesture of friendliness lies concealed a grim reminder of our savage past.

As Darwin himself concluded in
The Descent of Man:

But we are not here concerned with hopes and fears, only with truth. We must acknowledge, as it seems to me, that man with all his noble qualities, with sympathy which he feels for the most debased, with benevolence which extends not only to other men but to the humblest creature, with his Godlike intellect which has penetrated into the movements and constitution of the solar system—with all these exalted powers—man still bears in his bodily frame the indelible stamp of his lowly origin.

"You Forgot to Deliver the Twin"

It is an old maxim of mine that when you have excluded the impossible, whatever remains, however
improbable, must be the truth.

—
Sherlock Holmes

Mary Knight, age thirty−two, bright red hair pinned neatly in a bun, walked into Dr. Monroe's office, sat down and grinned. She was nine months pregnant and so far everything seemed to be going well. This was a long−awaited, much desired pregnancy, but it was also her first visit to Dr. Monroe. The year was 1932 and money was tight. Mary's husband did not have steady work, and so Mary had only talked to a midwife down the street, on an informal basis.

But today was different. Mary had felt the baby kicking for some time and suspected that labor was about to begin. She wanted Dr. Monroe to check her over, to make sure that the baby was in the right position to coach her through this last stage of pregnancy. It was time to prepare for birth.

Dr. Monroe examined the young woman. Her abdomen was vasdy

enlarged and low, suggesting that the fetus had dropped. Her breasts were swollen, the nipples mottled.

But something was not right. The stethoscope was not picking up a clear fetal heartbeat. Maybe the baby was turned in a funny way, or perhaps it was in trouble, but, no, that wasn't it. Mary Knight's navel was all wrong.

One sure sign of pregnancy is an everted or pushed−out belly button. Mary's was inverted, in the normal 146

fashion. She had an "innie" rather than an "outie."

Dr. Monroe whistled softly. He'd learned about pseudocyesis or false pregnancy in medical school. Some women who desperately want to be pregnant—and occasionally some who deeply dread pregnancy—develop all the signs and symptoms of true pregnancy. Their abdomens swell to enormous proportions, aided by a sway back posture and the mysterious deposition of abdominal fat. Their nipples become pigmented, as happens in pregnant women. They stop menstruating, lactate, have morning sickness and sense fetal movements. Everything seems normal except for one thing: There is no baby.

Dr. Monroe knew that Mary Knight was suffering from pseudocyesis, but how would he tell her? How could he explain that it was all in her head, that the dramatic change in her body was caused by a delusion?

"Mary," he said softly, "the baby is coming now. It will be born this afternoon. I'm going to give you ether so that you won't be in pain. But labor has begun and we can proceed."

Mary was elated and submitted to the anesthesia. Ether was given routinely during labor and she'd expected it.

A little later, as Mary woke up, Dr. Monroe took her hand and stroked it gently. He gave her a few minutes to compose herself and then said, "Mary, I'm so sorry to have to tell you this. It's terrible news. The baby was stillborn. I did everything I could but it was no use. I'm so, so sorry."

Mary broke down crying, but she accepted Dr. Monroe's news. Right there, on the table, her abdomen began to subside. The baby was gone and she was devastated. She'd have to go home and tell her husband and mother. What a terrible disappointment this would be for the entire family.

A week passed. And then, to Dr. Monroe's astonishment, Mary burst into his office with her belly protruding, as huge as ever. "Doctor!" she shouted. "I've come back! You forgot to deliver the twin! I can feel him kicking in there!"1

About three years ago, I came across Mary Knight's story in a crumbling 1930s medical monograph. The report was by Dr. Silas Weir Mitchell, the same Philadelphia physician who coined the term "phantom limb."

Not surprisingly, he referred to Mary's condition as phantom pregnancy and coined the term "pseudocyesis"

(false swelling). Had the story come from almost any other person I might have dismissed it as rubbish, but Weir Mitchell was an astute clinical observer, and over the years I have learned to pay careful attention to his writings. I was struck especially by the relevance of his report to contemporary debates on how the mind influences the body, and vice versa.

Because I was born and raised in India, people often ask me whether I believe there are connections between the mind and body that Western cultures don't comprehend. How do yogis exert control over their blood pressure, heart rate and respiration? Is it true that the most skilled among them can reverse their peristalsis (leaving aside the question of why anyone would ever want to)? Does illness result from chronic stress? Will meditation make you live longer?

If you'd asked me those questions five years ago, I'd have conceded grudgingly, "Sure, obviously the mind can affect the body. A cheerful attitude might help accelerate your recovery from an illness by enhancing your immune system. There's also the so−called placebo effect we don't understand completely—merely believing in a therapy seems to improve one's well−being, if not actual physical health."

But as to notions of the mind curing the incurable, I've tended to be deeply skeptical. It's not just my training in Western medicine; I also find many of the empirical claims unconvincing. So what if breast cancer patients with more positive attitudes live, on average, two months longer than patients who deny their illness? To be 147

sure, two months is better than nothing, but compared to the effects of an antibiotic like penicillin in improving the survival rates of pneumonia patients, this is hardly anything to boast about. (I know it's not fashionable to praise antibiotics these days, but one only has to see a single child saved from pneumonia or diphtheria by a few shots of penicillin to be convinced that antibiotics really are wonder drugs.) But as a student I was also taught that a certain proportion of incurable cancers—a very tiny fraction, to be sure—disappear mysteriously without any treatment and that "many a patient with a tumor pronounced malignant has outlived his physician." I still remember my skep−

ticism when my professor explained to me that such occurrences were known as "spontaneous remissions."

For how can
any
phenomenon in science, which is all about cause and effect, occur
spontaneously
—especially something as dramatic as the dissolution of a malignant cancer?

When I raised this objection, I was reminded of the basic fact of "biological variability"—that cumulative effects of small individual differences can account for myriad, unexpected responses. But saying that tumor regression arises from variability is not saying a hell of a lot; it's hardly an explanation. Even if it is due to variability, surely we must ask the question, What is the critical variable that causes the regression in any particular patient? For if we could solve that, then we would have ipso facto discovered a cure for cancer! Of course, it may turn out that the remission is the result of a fortuitous combination of several variables, but that doesn't make the problem insoluble; it merely makes it more difficult. So why isn't much more attention being paid by the cancer establishment to these very cases, instead of regarding them as curiosities? Couldn't one study these rare survivors in detail, looking for clues that confer resistance to virulent agents or reapply the brakes to renegade tumor suppressor genes? This strategy has been applied successfully to acquired immunodeficiency syndrome (AIDS) research. The finding that some long−term survivors carry a gene mutation that prevents the virus from invading their immune cells is now being exploited in the clinic.

But now let us return to mind−body medicine. The observation that some cancers occasionally regress spontaneously doesn't necessarily prove that hypnosis or a positive attitude can induce such remissions. We must not commit the blunder of lumping all mysterious phenomena together simply because they are mysterious, for that may be all they have in common. What I need to be convinced is a single proven example of one's mind's directly influencing one's bodily processes, an example that is clear−cut and repeatable.

When I stumbled across the case of Mary Knight, it occurred to me that pseudocyesis or phantom pregnancy might be an example of the kind of connection I was looking for. If the human mind can conjure up something as complex as pregnancy, what else can the brain do to or for the body? What are the limits to mind−body interactions and what pathways mediate these strange phenomena?

Remarkably, the delusion of phantom pregnancy is associated with a whole gamut of physiological changes associated with pregnancy—cessation of menstruation, breast enlargement, nipple pigmentation, pica (the desire for strange foods), morning sickness and most remarkable of all—progressive abdominal enlargement and "quickening" culminating in actual labor pains! Sometimes, but not always, there is enlargement of the uterus and cervix, but the radiological signs are negative. As a medical student I learned that even experienced obstetricians can be fooled2 by the clinical picture unless they are careful and that in the past many a C−section was performed on a patient with pseudocyesis. As Dr. Monroe detected in Mary, the telltale diagnostic sign lies in the belly button.

Modern physicians who are familiar with pseudocyesis assume it results from a pituitary or ovarian tumor that causes hormones to be released, mimicking the signs of pregnancy. Tiny, clinically undetectable prolactin

−secreting tumors (adenomas) of the pituitary could suppress ovulation and menstruation and lead to the other symptoms. But if that were true, why is the condition sometimes reversible? What kind of tumor could 148

explain what happened to Mary Knight? She goes into "labor" and her abdomen shrinks. Then her abdomen gets big again because of the "twin." If a tumor could do all that, it would present an even greater mystery than pseudocyesis.

So what causes pseudocyesis? Cultural factors undoubtedly play a major role3 and may explain the decline of pseudocyesis from an incidence of one in two hundred in the late 1700s to about one in ten thousand pregnancies today. In the past, many women felt extreme social pressure to have a baby, and when they felt they were pregnant, there was no ultrasound to disprove the diagnosis. No one could say with certainty, "Look here, there's no fetus." Conversely, pregnant women today submit to round after round of evaluations leaving little room for ambiguity; confronting the patient with physical evidence of an ultrasound is usually sufficient to dispel the delusion and associated physical changes.

The influence of culture on the incidence of pseudocyesis cannot be denied, but what causes the actual physical changes? According to the few studies carried out on this curious affliction of mind and body, the abdominal swelling itself is usually caused by a combination of five factors: an accumulation of intestinal gas, a lowering of the diaphragm, a pushing forward of the pelvic portion of the spine, a dramatic growth of the greater omentum—a pendulous apron of fat that hangs loose in front of the intestines—and in rare cases an actual uterine enlargement. The hypothalamus—a part of the brain that regulates endocrine secretions— may also go awry, producing profound hormonal shifts that mimic nearly all the signs of pregnancy. Furthermore, it's a two−way street: The body's effects on the mind are just as profound as those of the mind on the body, giving rise to complex feedback loops involved in generating and maintaining false pregnancy. For instance, the abdominal distension produced by gas and the woman's "pregnant body posture" might be explained, in part, by classic operant conditioning. When Mary, who wants to be pregnant, sees her abdomen enlarge and feels her diaphragm fall, she learns unconsciously that the lower it falls, the more pregnant she looks. Likewise, a combination of air swallowing (aerophagia) and autonomic constriction of the gastrointestinal sphincters that would increase gas retention could also probably be learned unconsciously. In this manner, Mary's "baby" and its "missing twin" are literally conjured out of thin air through a process of unconscious learning.

So much for the abdominal swelling. But what about the breast, nipple and other changes? The most parsimonious explanation for the whole spectrum of clinical signs you see in pseudocyesis would be that the intense longing for a child and associated depression might reduce levels of dopamine and norepinephrine—the "joy transmitters" in the brain. This in turn could reduce the production of both follicle−stimulating hormone (FSH), which causes ovulation, and a substance called prolactin−inhibition factor.4 Low levels of these hormones would lead to a cessation of ovulation and menstruation and an elevation of the level of prolactin (the maternal hormone), which causes breast enlargement and lactation, nipple tingling and maternal behavior (although this has yet to be proved in humans), along with an increased production of estrogen and progesterone by the ovaries, contributing to the overall impression of pregnancy.

This notion is consistent with the well−known clinical observation that severe depression can stop menstruation—an evolutionary strategy for avoiding a waste of precious resources on ovulation and pregnancy when you are disabled and depressed.