Amanda was a pretty girl but always rather shy.  She was 17 before she lost her virginity.  Her friends made fun of her; they had much more ‘experience’.  But Amanda said she wanted to wait until it felt right.  She knew that Richard was troubled and had a bit of reputation, but he was so clearly adored her.  She knew he would never let her down.  He did.  She was pregnant before she found out he had been seeing Rachel.  When she told him, he was scared and told to get rid of the baby.  She couldn’t.  She was a catholic and didn’t believe in abortion.  Besides, it was Rick’s baby.  If she couldn’t have him, at least she could have his baby.   


Her mother was horrified and angry.  She had married her father because she was pregnant.  They weren’t suited and the marriage soon failed.


Amanda didn’t take up her place at dental  school.  She left home, had the baby, found herself a flat in a tower block and earned some money working at the local florists. 


Her friends supported her for a while, but she was no fun to be with and they drifted away.  Jason, her baby, was fractious.  Amanda didn’t get a lot of sleep and was exhausted. Besides, she felt so ill.  She had pains in her back and abdomen, constipation and was so bloated at times, she looked like she was pregnant again.  She wasn’t.  She couldn’t bear to have a man anywhere near her. 


Her doctor ordered blood tests and scans of her abdomen, but they revealed nothing.   That was not surprising.  Mandy didn’t have a medical disease.  What she was suffering from was the shame of her pregnancy, the depletion of hope for the future, her concerns over being a bad mother for Jason and her guilt for letting her mother down.  She felt unloved and unlovable.  



Illnesses that have no clear medical explanation have become much more common in recent years.  About 50% of visits to the doctor are for illnesses that have no clear pathology, no obvious cause, but seem to be associated with the events that have occurred in their patients lives.  If you find that difficult to believe, look at how often bereavement, divorce, redundancy and relocation is followed by illness and how prisoners of war and uninjured victims of disasters can tend to suffer illnesses often years after the event.  It is only in recent years that we have tended to regard illnesses as the effect of damage to specific organs.  In the past, hysteria, hypochondria, the spleen, neurasthenia and melancholia were terms for bodily ailments related to life situations.  The social context of illnesses is well understood in other cultures.  For example, in he Punjab,  dir ghirda hai, the sinking heart, is associated with loss of honour experienced by men whose wives or daughters have brought shame on the family.  In Pakistan, jiryan, is the name given to the variety of bodily symptoms associated with the ‘shame’ of masturbation.  There are frequent examples in literature of how ‘the evil eye’, pointing the bone and witches’ curses may cause illness and even death by publicising the recipients guilt.    


The notion that bodily ailments represent what happens to us should not surprise us too much.  We are not divided at the neck. All the functions of all parts of the body are represented in the brain and are given meaning by the orbito-frontal cortex.  One  function of this part of the brain, which is situated in the mezzazine of the skull, behind the forehead and above the eyes, can be compared with that of a composer.  It uses the thoughts and memories that events and situations evoke to create a unique composition that is performed by the whole bodily orchestra with the sympathetic and parasympathetic nervous systems providing the major or minor key. 


So sad events can give us a lump in our throats or make us weep.  Things that annoy us can cause a tension in our muscles, a burning, throbbing sensation in our chest.  Events that make us anxious may give us a headache.  Usually, we know what has happened.  We can put our ‘feelings’ into context, create an emotion out of them and resolve the anger, sadness and anxiety by doing something.  But if what has happened has made us feel so bad that we can’t deal with it or even worse we can’t even gain access to the cause of our feelings, then the symptoms remain as an illness and have to be taken to the doctor.


The meaning of the individual torment so often seems to be played out in the spectrum of symptoms.  Amanda’s abdominal complaints remind her of the shame of her pregnancy that she can never get rid of.  Her back ache represents the burden, the tiredness the futility of her life.  There is no relief.  Certainly tablets, diet and even surgery won’t help.  Her internal persecutor has a whole body repertoire of tortures that could be deployed.      


Guilt and shame figure so prominently in unexplained illness.  Not only do they tend to remain secret, their meaning locked up in the body, they are corrosive.  They eat into a person’s self worth, eroding their self esteem, undermining their self confidence, abolishing hope and inducing a profound depletion of the spirit. ‘I have let myself down.  I have not behaved well.  I am not good enough. No wonder I feel ill. It’s my punishment.  I deserve to die.’   The criticisms go on and on,  demeaning, undermining,  driving their recipients into exile.  So if  the victims of this pernicious form of emotional abuse are not ostracised by society, they exile themselves.  They feel too ashamed, too depressed to talk to anybody, they become too nervous to approach people for fear of rejection.  It is the burden of the guilt coupled with an awful sense of abandonment  and melancholy that makes people ill.  If we thought of illness from a social perspective rather than a medical one, loneliness might be said to be the most common illness.       


We are social animals.  We need the love and support of other people; they give meaning to our lives. We need to talk, to touch, to hold, to laugh with people.  We need people to praise us when we do well and to hold us back when we might behave unwisely.  Without the companionship of other people, we, like other social species, become listless, apathetic and ill.  We may be able endure solitude better if we feel good about ourselves, but if our spirit is already undermined and our body exiled by shame and guilt, then this aggravated loneliness can be a most persistent and destructive pathogen.       



Illness always occurs at times of change,  when we are forced to review, often quite radically, the way we think and behave in order to adapt to new situations.  The rate of change has increased alarmingly over the last 50 years – faster than at any other stage of our history.   I am not just talking about changes in our social fabric, our mobility or even electronic communication – although these aspects have an important influence.  I want to emphasise more crucial factors; a decline in community, isolation, materialism and selfishness.  We have become a narcissistic society.  The watchword of the age seems to be ‘You’re worth it’.


Yes, of course, there were narcissists in the past, but perhaps they felt they had the birthright. Now, increased affluence and education means we can all feel entitled to behave as we wish and it’s every man and every woman for themselves.  There is less empathy, less altruism.  If we want something we can just go out and get it.  If we want to do something, we don’t need to ask. There are no brakes any more, no impulse control.  People don’t often think of the consequences of their actions before they act, and as the inevitable camp followers of the thrill of desire, lope guilt and shame.    


‘Why shouldn’t I have fun?’  ‘I’ve only got one life.’  ‘I need this so badly.’  ‘I deserve it.’  ‘I can get away with it.  She’ll never find out.’  These are all justifications for ill considered actions that can lead to a lifetime of pain and regret.  There are casualties to selfishness.  Other people get hurt – badly – and they may have to protect themselves by rejecting the person that hurt them.    



The tectonic shift towards materialism and selfishness has seriously disturbed the moral compass of society, altering attitudes to all important aspects of our social relationships.  The way young people think about sexuality, marriage, bringing up children, work, family, religion, drugs – even The Royal Family is so different to the way we used to think in the ‘swinging’ sixties.  Such changes in attitude separate parents from their children, children from their teachers, and all of us from the ways in which we grew up.  They generate moral conflicts.  Adrift in a rapidly changing  morality, the ways people try to resolve their dilemmas lacks cultural wisdom and may cause situations that entrap, isolate, shame and debilitate.    


Perhaps the greatest impact of narcissistic transformation is felt by children.  Despite notable exceptions,  the erosion of the family – single parents, absent fathers, working mothers, paid minders, must threaten their stability.  Children who feel rejected, punished or abandoned by their parents early in life, those bullied by siblings and friends can grow up thinking there is something wrong with them.  They develop the habit of shame early in life – a bit like original sin.  


Single parent families, working mothers, absent fathers, teenage pregnancy, drug abuse, binge drinking, violent crime, anonymous sex, marital breakdown, early retirement, parents that live longer and need to be cared for, family relocation are all features of our current society.  The prevalence of all of them has increased quite alarmingly throughout the last fifty years. They all bring their own varieties of guilt and shame.  They all contribute to the growing rate of illness. . 


But it’s not so much individuals that are sick, it is society.  And this type of sickness will not get better overnight through more regulations, tighter controls and harsher sentences.  Better policing just serves to enhance the guilt and shame that people feel.    By the same token, we can’t expect doctors to treat the problem successfully with large scale prescription of antidepressants.       



Amanda is not bad, although she feels dreadful.   She is a casualty of the age.  She might be criticised for being impulsive, careless, too trusting, maybe even a little stubborn – but she was young,  inexperienced in life, she received little guidance from her mother, none from her father and – she was unlucky.  Her friends were too influenced by their own romantic entanglements to be helpful and the soap operas she was addicted to just offer the most dysfunctional solutions.


In the past, Amanda’s behaviour might have been contained by the community.  There would have been other people to talk to, people that she and her mother knew, friends, other family members, the lady who works in the post office, the doctors wife,  the vicar, Rick’s mother.  They would have given support, held her back, provided shelter if she needed it.  The notion of community has loosened.  The doctor is gay, the vicar only comes once a month, Rick’s mother is in rehab and they have closed the post office.  About 35% of people living in the UK are living alone, often  in inner city apartments with just television and e-mail for company.  The official channels, the family planning clinic,  relationship counselling,  social services, are too much in demand.  Appointments are delayed and infrequent.   


I would be hopeful for Amanda.  She is still young, she is intelligent and she does her best for Jason.  She has not succumbed to the slide into poverty, drugs and prostitution.  There is help out there.  Maybe she should move out of the tower block, marshal her resources, become friends with other bright young single mums, share child care, get some time for herself, find a job and a training more suited to her abilities, join a dating agency, become reconciled to her mother.  She doesn’t need psychotherapy; she needs support and a strategy.  And she, like so many others, need to see her symptoms for what they are – the anguish and inertia brought about by bad luck and overwhelming feelings of guilt and shame.  First, identify your target! 



And what about the sickness in society?   Maybe we can learn from history.  Two hundred years ago, during the industrial revolution, there was a similar epidemic of unexplained illness.  Alternative and complementary therapists, derided then as Quacks and Mountebanks, were very busy.  Gradually, social structures were put in place, churches were built, clubs, trades unions.  A new sense of community was restored.  And now, swamped by the Third Wave of social change – the electronic revolution,  we need to restore that sense of community we began to lose in the nineteen fifties, but in a different way.  But people have to feel the need to do it.   Perhaps economic decline the impact of climate change will force us to pull together.  Perhaps it will go the other way.  During the 1888 cholera epidemic in Naples, the Swedish physician, Dr Axel Munthe observed that people were engaged in an orgy of sex, as if in the presence of death, there was a desperate urge for life.