E M BODI E D

christopher eccleston

EMBODIED
The psychology of physical sensation

1
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For Zoe
 ACKNOW LEDG MEN T S

M any people helped me find my way on this journey. Particular thanks go to those
who allowed me to peer into their lives and ask them questions about how they
live with their bodies and their sensory worlds. I am grateful to all of those striving to
push themselves to their limits. Hopefully their voices will speak for many people. In
the order they appear, thank you to Luna Othnin Girard, Debbie Hollingsworth, Luke
Rendell, Jeremy Clark, Emma Roy, Marni Elder, Sam Kirby, Ian Taylor, Kerry Sutton,
Sarah Prior, IIana and Crispin Wigfield, Rupert Fingest, James Reynolds, Neil Car-
rier, Alex Coode, Euphemia Graham, Jean Christophe Slowik, Tom Strawson, Arthur
Smith, and Connie Webber.
I am also grateful for the help of many colleagues and friends. Thank you to Anna
Broderick who invited me to the Central Ballet School in London. She has a won-
derful energy and enthusiasm for helping people achieve their dreams. Resmi Malko
allowed me to observe his dancers. His quiet authority and connection with their
movement was inspiring. Anna Hobson suggested I talk with Debbie Hollingsworth
and made the introductions. Richard Tite encouraged me to think about acrobatics
when thinking about movement, and introduced me to Luke Rendell. Jeremy is an
old friend. Amanda Williams suggested I talk with Sam Kirby as a fellow champion
freediver, and Mike Osborn and Jackie McCallum were very kind in introducing me
to the amazing Ian and Pat Taylor. Caro Taraskevics suggested I talk with Emma Roy,
and Isabelle Sully encouraged the remarkable Marni Elder that it might be fun to talk
to me. Zoe Eccleston suggested I talk to Kerry Sutton who trains in Bath and had just
completed her jungle run. Thank you to Anne Johnson from the Chronic Fatigue Ser-
vice at the Royal National Hospital for Rheumatic Diseases NHS Trust in Bath. Their
service is second-to-none internationally; their understanding of the needs of people
with chronic fatigue is remarkable. Mike Osborn suggested to the Wigfields that a
psychological approach to the marathon might add an interesting aspect. Rupert Fin-
gest I have known for a very long time. Thanks to Nicolette Craig from the education
department of the Cotswold Wildlife Park for being interested in the idea and suggest-
ing I talk to James Reynolds. And Janet Bultitude introduced me to Neil Carrier. I am
grateful to her for thinking so carefully about the book and who might be able to help.
Euphemia Graham is a family friend, and Will Hawking gave me the idea of forge
working that led to the fascinating Alex Coode. Dawn Hawking was kind in tracking
down Jean Christophe and for the ice-cream ideas. And I am very grateful to Emma
Fisher for persuading Tom Strawson that talking to a psychologist was not so weird a

vii
 ack now l e dgm e n ts

thing to do. Arthur Smith I cold-called. I am grateful he could not resist talking about
flatulence. And, finally, Sarah Dalrymple took me seriously when I wanted to talk
about vomiting and introduced me to Connie Webber.
Many other people made connections and suggestions, and so helped me ask
the right questions. From OUP, Charlotte Green, Martin Baum, and Matthias Butler
were patient with my bombarding them with drafts. There were many conversations
with friends and colleagues along the way, in particular Geert Crombez, Amanda
Williams, Nina Attridge, and Emma Fisher, who read unpolished versions. I am also
grateful for the individual chapter reviews from the busiest of experts: Andrea Evers,
Omer Van den Bergh, Kim Delbaere, Bob Hockey, and Martin Burton. I corresponded
with many of the authors of the papers referred to. I am repeatedly amazed at how
generous people are in sharing their work and discussing ideas within the papers.
It would not be possible without their primary research. Ulrike Bingel and Thomas
Tölle gave me invaluable advice in exploring the ideas of das unkörperliche.
Finally, thank you to Zoe for living with The Body, as it was known, for more than a
year, for journeying with these chapters, for the home experimentation, for editing,
and for staying positive as it emerged out of its shell.

viii
 CON TEN T S

List of Figures  xv
List of Tables  xvi
List of Boxes  xvii

1. The ten neglected senses  1

The big five senses  2
Methods of inquiry  4
Personal stories  5
The physical senses  5
References  6
2. Balance  8
Learning to stand on your own two feet  9
A psychology of falling  9
Deliberate falling  10
Fear of falling  11
Accidental falling  14
Achieving balance (equilibrium) 15
Natural balance awareness  16
Interview: Luna, the dancer: “when you are on balance you can
grow, almost out of the ground”  17
Losing balance (disequilibrium) 19
Dizziness  19
Vertigo  22
Interview: Debbie, living with vertigo: “your mind can play amazingly
cruel tricks on you”  23
Height intolerance  25
Height intolerance autoscopy  26
Summary  29
References  29
3. Movement  33
Proprioception  34
Developing movement control  34

ix
 con t e n ts

Embodied cognition  35
Clumsiness  36
Improving motor performance  37
Personal theory of movement  39
Interview: Luke, the acrobat: “it is more about focus than thinking”  40
Personal space  43
Posing and strutting  44
Disorders of movement  46
Anosognosia  47
Tremor  47
Start and stop  48
Fine motor control  48
Interview: Jeremy, recovering from stroke: “you take things for granted”  49
Summary51
Notes  51
References  51
4. Pressure  55
Flexibility  56
Stiffness  56
Flexibility-stiffness continuum  57
Interview: Emma, the Yoga teacher: “I am aware of my body all the time”  60
Strength  62
Weakness  62
Strength-weakness continuum  63
Heaviness  64
Lightness  66
Heaviness-lightness continuum  67
Swollen  68
Reduced  69
Swollen-reduced continuum  71
Interview: Marni, living with lupus: “it feels like every inch of your
body weighs too much” 72
Summary75
Notes  75
References  75
5. Breathing  79
Catching your breath  80
Taking control of breathing  81
Breathing to achieve  82
Breathing at height and depth  84

x
 con t e n ts

Interview: Sam, the freediver: “it is massively a mental game”  86

Respiratory awareness  88
Respiratory variability  89
A focus on rumination  90
Relearning to breathe  91
Panic  92
Dyspnea  95
Terror management  100
Interview: Ian, living with dyspnea: “it is about feeling vulnerable”  101
Summary103
Notes  103
References  103
6. Fatigue  107
Being tired  107
The fallacy of resource depletion  109
Fatigue as motivation to change  110
The urge to sleep  112
Vitality, energy, and perseverance  112
Brain training  113
Indefatigable  115
Interview: Kerry, the ultra runner: “when my body says
stop I won’t accept it”  116
Being tired all the time  118
Cognitive behavioral model  119
Attention to threat  120
Cognitive behavioral therapy  122
Interview: Sarah, living with fatigue: “everything is planned”  123
Summary125
Note  125
References  125
7. Pain  129
The problem of pain  130
Pain mechanisms  130
Motivated interruption  131
Religion  132
Rites of passage  134
Self-injury  134
Goal pursuit  135
Interview: The Wigfields, running a marathon together: “what I
often do is think ‘one more mile’ ”  137

xi
 con t e n ts

Paying attention to pain  139

Living in an analgesic culture  140
Pain that won’t go away  141
Trying to cope alone  141
Vigilance  142
Worry  143
Courageous engagement  144
Interview: Rupert, living with chronic pain: “I will always push
through if what I am doing is worth it”  145
Helping people to cope  146
Summary148
Notes  148
References  148
8. Itch  152
From itch to scratch  153
Function of itch  153
Grooming  154
Social contagion of itch and scratch  155
A hygiene paradox  157
On the pleasure of itch  158
Interview: James, working with itch: “it is the horrible looking
creatures that I see a beauty in”  159
Chronic itch  161
Attending to itch  162
If you have an itch, don’t scratch  163
Social emotions  164
Shame and disgust  165
Formication  168
Psychodermatology  169
Interview: Neil, living with itch: “it is hard for me to imagine
what it is like not to itch”  170
Summary172
Note  173
References  173
9. Temperature  176
Thermoregulation  177
Blowing hot and cold: judging others’ character  179
Please hold my coffee  179
Cold and lonely: a Bridget Jones effect  180
Protecting ourselves from the elements: secondary regulation  181

xii
 con t e n ts

Mad dogs and Englishmen  181

“The apparel oft proclaims the man”  182
Entering the extremes  183
Interview: Alex, the heritage blacksmith: “you have a holiday
from your body”  184
The paradox of sweating  186
Hot flushes  189
The psychological ambiguity of heat  189
Being cold  190
Raynaud’s phenomenon  191
Cold comfort  192
Interview: Euphemia, living with Reynaud’s: “I guess I am
learning all of the time”  194
Summary196
Notes  196
References  197
10. Appetite  201
Appetite regulation  201
Power  203
Setting priorities  204
The pleasures of desire  205
Eat your greens  206
Lipsmackinthirstquenchinacetastinmotivatingoodbuzzincool
talkinhighwalkinfastlivinevergivincoolfizzin Pepsi  208
What’s on the menu?  209
Interview: Jean Christophe, the restaurateur: “I love what we serve
and we serve what I love” 212
Personal responsibility  214
“I’m on a diet”  215
Hungry behavior  216
Craving217
Interview: Tom, the jockey: “the discipline comes
from an ambition to succeed”  220
Summary222
Notes  222
References  222
11. Expulsion  225
Human jets  226
“Coughs and sneezes spread diseases”  227
Common and public  227

xiii
 con t e n ts

Hiccup  229
Releasing gases  230
Burping  230
Farting  232
Why is farting funny?  234
Interview: Arthur, the comedian: “we are hardwired to laugh at farting”  234
Continence psychology  236
Toilet training  236
Managing incontinence  237
Emotion and incontinence  238
Vomiting  238
Voluntary vomiting  240
Interview: Connie, on modern vomiting: “we are putting more
alcohol in so we need to take it out.”  241
Reproductive removal  242
Ejaculation  244
Tell no one  245
Summary246
Notes  246
References  247
12. Embodied and embedded  251
Transitive and intransitive  252
Attending  252
Vigilance  253
Urge  254
Corporeal derealization  256
Aging  258
Hands up  259
A psychology of the body  260
References  260

Index  261

xiv
 LI S T OF FIGURE S

Figure 2.1: Cartoon of two extreme experimental conditions: well lit and walking
on the ground, and dimly lit and walking on an elevated platform.
Figure 3.1: Three sitting poses, two expansive and one constricted.
Figure 4.1: Shrinking waist and hips study. The design of the study and position of
the hands to the body.
Figure 5.1: The relationship between the pressure of inspired oxygen at different
altitudes.
Figure 5.2: Equipment for 24-hour monitoring of breathing and ambulation.
Figure 8.1: The distribution of scratching episodes in widespread (scattered) areas,
in patients with atopic dermatitis (AD) and healthy subjects. (Plate 1)
Figure 8.2: Stimuli used in the paired disgust sensitivity task. (Plate 2)
Figure 9.1: Average daily deaths and monthly temperatures in England and Wales
in 2012/13 and a five-year average. (Plate 3)
Figure 10.1: Rated characteristics of salmon-flavored food presented as either “ice-
cream” or “frozen savory mousse.”
Figure 10.2: Body modifications student and professional actors would undertake to
achieve their “dream job.”
Figure 11.1: Coughs and sneezes spread diseases. Circa 1960. (Plate 4)
Figure 11.2: Domains of Quality of Life judged by women with normal menstrual
bleeding and heavy menstrual bleeding (HMB).

xv
 LI S T OF TABL E S

Table 2.1: The phenomenology of four autoscopic illusions

Table 4.1: Yoga poses and descriptions used in clinical trial
Table 5.1: Language used to describe breathlessness by those with and without a
Chronic Obstructive Pulmonary Disorder
Table 7.1: The benefits of pain and associated processes
Table 12.1: The functions of physical senses

xvi
 LI S T OF BOX E S

Box 2.1. Luna, the dancer: “when you are on balance you can grow, almost out of the ground”
Box 2.2. Debbie, living with vertigo: “your mind can play amazingly cruel tricks on you”
Box 3.1. Luke, the acrobat: “it is more about focus than thinking”
Box 3.2. Jeremy, recovering from stroke: “you take things for granted”
Box 4.1. Emma, the yoga teacher: “I am aware of my body all the time”
Box 4.2. Marni, living with lupus: “it feels like every inch of your body weighs too much”
Box 5.1. Sam, the freediver: “it is massively a mental game”
Box 5.2. Ian, living with dyspnea: “it is about feeling vulnerable”
Box 6.1. Kerry, the ultra runner: “when my body says stop I won’t accept it”
Box 6.2. Sarah, living with fatigue: “everything is planned”
Box 7.1. The Wigfields, running a marathon together: “what I often do is think ‘one
more mile’”
Box 7.2. Rupert, living with chronic pain: “I will always push through if what I am doing
is worth it”
Box 8.1. James, working with itch: “it is the horrible looking creatures that I see a beauty in”
Box 8.2. Neil, living with itch: “it is hard for me to imagine what it is like not to itch”
Box 9.1. Alex, the heritage blacksmith: “you have a holiday from your body”
Box 9.2. Euphemia, living with Raynaud’s: “I guess I am learning all of the time”
Box 10.1 Jean Christophe, the restaurateur: “I love what we serve and we serve what I love”
Box 10.2. Tom, the jockey: “the discipline comes from an ambition to succeed”
Box 11.1. Arthur, the comedian: “we are hardwired to laugh at farting”
Box 11.2. Connie, on modern vomiting: “we are putting more alcohol in so we need to take
it out”

xvii
 5
3 Sites scratched
11
by healthy subjects
3 2

4 1 10

7 7

Sites scrached
by AD patients 2
8
1
6
4 9

Plate 1: The distribution of scratching episodes in widespread (scattered) areas, in patients

with atopic dermatitis (AD) and healthy subjects.
“The distribution of scratching episodes in widespread (scattered) areas, in patients with atopic
dermatitis (AD) and healthy subjects, reveals that patients with AD experienced an itch that
extended beyond the local itch induction site, becoming generalized, while they watched the itch
video (in red). Scratching beyond the local site in healthy participants was limited to the face, neck
and contralateral forearm (in blue). The areas scratched are shown in ranking order (by mean
duration) for an exposure to the itch video, when the local itch stimulus (histamine) was delivered
to the right forearm (i.e., scratching on the contralateral forearm is represented). Subjects with AD
scratched mostly their contralateral forearm (1), mid-back region (2), face (3), neck (4) and scalp
(5). Note that colored areas indicate in a figurative manner the location of scratching sites and are
not intended to depict to scale the extent of the skin surface scratched.”
Reproduced from Contagious itch in humans: a study of visual ‘transmission’ of itch in at-
opic dermatitis and healthy subjects, A.D.P. Papoiu, H. Wang, R.C. Coghill, Y-H. Chan, and G.
Yosipovitch, British Journal of Dermatology, 164 (6), pp. 1299–1303, Figure 4, doi: 10.1111/j.1365–
2133.2011.10318.x Copyright (c) 2011, John Wiley and Sons.
 pair disease irrelevant disease relevant

(a)

– –
x = 1.6 x = 2.6

(b)

x– = 1.5 x– = 3.1

(c)

x– = 1.2 x– = 2.0

(d)

x– = 1.6 –
x = 3.9

(e)

x– = 3.6 –
x = 4.6

(f)

–
x = 3.7 x– = 3.8

(g)

–
x = 2.8 x– = 3.5

Plate 2: Stimuli used in the paired disgust sensitivity task (xˉ-is the average disgust score out of
5 as the most disgusting).
Reproduced from Val Curtis, Robert Aunger, and Tamer Rabie, Evidence that disgust evolved to
protect from risk of disease, Proceedings of the Royal Society of London (1800–1905), 282 (1804),
S131–S133, Figure 1 © 2004, The Royal Society.
Mean daily °C
deaths
Deaths in 2012/13 Five-year average deaths
2,000 20
Mean monthly temperature Five-year average temperature
1,800 18
1,600 16
1,400 14
1,200 12
1,000 10
800 8
600 6
400 4
200 2
0 0
Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul
Plate 3: Average daily deaths and monthly temperatures in England and Wales in 2012/13 and
a five-year average.
Reproduced from Office of National Statistics, Excess Winter Mortality in England and Wales,
2012/13 (Provisional) and 2011/12 (Final), 2013, p. 5, Figure 2, http://www.ons.gov.uk/ons/
dcp171778_337459.pdf © Crown Copyright 2013. This figure is published under the terms of the
Open Government Licence (http://www.nationalarchives.gov.uk/doc/open-government-licence/
version/3/).
Plate 4: Coughs and Sneezes Spread Diseases. Circa 1960.
©The British Library Board, B.S.81/19.
 CHAPTER 1

THE TEN NEGLECTED SENSES

T his book is about how we experience our bodies and how our bodies experi-
ence the world; it is about physical sensation. For the most part the body has
been neglected and ignored in psychology, thought of merely as a taxi for the mind,
dwarfed by the study of observable behavior, action and agency, motivation and per-
formance, cognition and emotion. We take for granted the obvious truth that the
objects of our study (personality, motivation, emotion, cognition, and behavior) are
quite literally embodied. We are encased by flesh in a physical being that defines the
limits of our ability to act upon the world, and provides the medium by which the
world acts upon us.
All of the human sciences are interested in bodies, in their biological, physi-
ological, chemical, and biomechanical functions. The collective application of these
sciences as medicine is comprehensively invested in understanding the disordered
body and its effects on human function, including the opportunity for repair. The
experience of the bodily senses, and of having a body, is much less investigated. As
Rom Harré (1991) noted, being embodied means to be instantiated, to be definable,
observable, and accountable. Ultimately it also means to have one’s limits defined. It
is the limits that are partly of interest here. It is only when forced to our limits that we
come to understand the possibilities of being. And in each of the ten individual sense
chapters that follow, extreme physical experiences provide one important source of
evidence.
Psychology was not always uninterested in bodily sensations. At its birth, German
structural psychology, borne from physiology and philosophy, was greatly con-
cerned with the phenomenology of physical experience and with the close obser-
vation and detailed report of sensation. Much of Wilhelm Wundt’s early innovation
in laboratory science came in the form of improved instrumentation to measure the
speed of perception and the integration of sensory information (Rieber and Rob-
inson, 2001). Methods of close introspection were an early casualty of the turn to
observable behavior as the new subject of psychology (Danziger, 1990). How we actu-
ally experience our senses came to be seen with suspicion, often removed as a source
of experimental noise from otherwise perfect behavioral experiments (Leary, 1995).
Phenomenology was sent back to philosophy. In this book, however, the feel of one’s
own body is an important source of evidence for a psychology of physical sensation,
and is brought back out of the shadows.

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 t he t e n negl ec t e d se nse s

The big five senses

Open any general textbook of psychology and perception will be covered in detail.
However, much of it will be about the big five senses, the senses we grew up learning
about as children: sight, sound, smell, taste, and touch. The primacy of these sensa-
tions in our thinking and learning is reflected in their cultural dominance. The big five
dominate across cultures, religions, and histories, starting perhaps with Aristotle’s
conjecture in De anima that five senses were philosophically sufficient.
Vision, of course, is hugely important to the coherence of our behavior and to
learning and development. To a great extent we live in a world that reflects the dom-
inance of vision, with a built environment dependent upon and determined by vis-
ual capabilities. Culturally, vision also dominates and can be seen in our everyday
language with the use of visual metaphors and references—as I just did with “can
be seen” (Duncum, 2001). Psychologically, vision achieves quite astonishing compu-
tational challenges in returning coherence of experience from the physical barrage
of light energy. Perhaps the challenge of vision science is not to map the complexity
of what our visual system can achieve, but to address a fundamental conundrum of
consciousness. Simply put: how close to reality is our visual experience? What is real
to us as perception is largely an approximation, augmented by computational rules,
finessed to achieve efficiency and to infer a good-enough version of reality, one that
allows decision making and coherent behavior (Knill and Richards, 1996). What you
see is not what you get. Where the scientific study of vision goes we will just have to
“wait and see.”
Vision is fascinating but is a scientific sponge. It soaks up attention and resources.
Audition comes a close second in the perception popularity stakes. The science of
hearing is wide-ranging, from physics through engineering and mathematics, to
architecture and the social study of sound. Acoustic psychology is interested largely
in how perceptual rules govern heard experience, in particular how we achieve dis-
crimination in the amount, location, character, and quantity of sound, and how we
segment signals from noise. A major research interest is in how meaning is identi-
fied in otherwise disordered sound, in what distinguishes noise from music, or one
musical tone from another (Lotto and Holt, 2011). What distinguishes the distressed
cry from the contented gurgle of a child is hard to explain by reference to the signal
alone. Explaining the emotional content and the personal recognition of sound as
meaningful is where much of the interesting psychological investigation of auditory
perception lies.
The other two senses with biological organs front-loaded in the head also attract
some attention. Smell (olfaction) and taste (gustation) use different sensory appar-
atuses but operate around the same functions of exploring the properties of food
or potential food, and by providing critical information regarding toxicity or dan-
ger. For example, Daniel Kelly explores the evolutionarily quite ancient ability of our

2
 t he big f i v e se nse s

midbrain to use the sensory input from taste and smell to trigger an extreme affective
experience of disgust (Kelly, 2011). Smell, of course, provides the material for psycho-
logical functions that go beyond self-protection or the provision of food. Smell pro-
vides information on environmental danger, on health status, and on preferences.
Fragrance can affect everything from one’s judgments about liking (both people and
things) to one’s consumer choices, and even mate selection.
Taste, however, occupies an interesting cultural position in this battle for the hier-
archy of senses. There is a cultural ambiguity around taste, which is best understood
by the desire to rescue taste from base consumption; a desire that can be traced to the
sixth century (Jütte, 2005). To taste means to consume, but to “have taste” means to
be especially discriminating, to be able unfalteringly to identify quality, to be attuned
to fine differences, and of course to reject the ugly, the common, and the familiar.
Confusingly, taste is applied across the realm of aesthetic judgments: one can have
(or be lacking in) taste in music, visual art, dance, and, of course, in judgments about
food and drink. The sensory apparatus of taste allows discrimination and is com-
plexly organized around categories of experience, with a particular reference to emo-
tion and memory, but its discriminatory ability is minimal in comparison to vision
and audition. In the world of the big five senses, it should be more flattering to be
described as having sight or smell than it would to be described as having good taste.
The co-location of sensory apparatuses in the head to enable the four primary senses
of sight, sound, smell, and taste is no evolutionary accident. The head provides an effi-
cient guidance system enabling us to move at speed away from danger and toward
safety, comfort, and reward. In addition, having duplicated organs of detection allows
for location and motion detection. More than a simple system of detecting change, the
environment can now afford action specific to the needs of its context: a delicate play
of sense and context defining possible action (Gibson, 1979/1986; Stoffregen, 2003).
Sight, hearing, smell, and taste have also promoted social scientific debate. Lisa
Blackman argues for a hierarchy of civilized sensation: vision and sound are the pri-
mary civilized sensations, with smell and taste relegated to the animalistic, the base,
and the primal (Blackman, 2008). Sight and sound are senses primarily of discrimin-
ation, of discernment, of clarification, and of precision, both practically and cultur-
ally. The gustatory sensations of taste and smell are less precise and more personal.
Sight and sound can be achieved distally, and often covertly, whereas taste and smell
require proximity and intimacy. In other words, you can watch someone undiscov-
ered at a distance, but to smell and taste someone you need to be up close and per-
sonal. A primary feature of the passage to adulthood is the negotiation of the space
between senses in a socializing process. Children are encouraged that licking, biting,
spitting, and overtly smelling others are going to be unwelcome in public adult soci-
ety. Adolescent and adult transgressions of these rules are socially troublesome and
demand explanation, explanations that are often pathologically framed. Taste and
smell are the most private and intimate of the big five.

3
 t he t e n negl ec t e d se nse s

Finally, touch, like taste and smell, involves proximity because it requires contact
with what is outside the body in a way that leaves the integrity of the body intact,
its boundaries unbroken. Central to touch is a discrimination of what is inside and
outside. Touch is also the only one of the big five senses to have extended its sen-
sory apparatus away from the head. Sensory nerve endings capable of discriminating
change in their environment through contact with the outside world are distributed
throughout the skin and so around the entire body. They are the principal methods of
embodiment. Most of the touch apparatus however is digital: located in and referring
to fingers. To manipulate and explore the world through touch, and to extend per-
sonal space to the peripersonal arc of our physical reach is a critical part of defining
personal and embodied being (Patterson, 2007).
The big five senses of seeing, hearing, smelling, tasting, and touching are undoubt-
edly interesting and a major part of embodiment. But they are not everything. Perhaps
our fascination with these dominant senses has come at the cost of a lack of investiga-
tion of the neglected other ten bodily senses that form a core part of the intertwined
experiences of the body: being physically embodied and environmentally embedded
(Haugeland, 1998).

Methods of inquiry

I adopt a transdisciplinary approach for this investigation of the physical senses. Any
one source of evidence is not going to be enough. For each sense it will be important
to review the biological structure and function of each system, with enough anatomy
and physiology to understand when and why structural limits of experience arise.
Relevant also will be the sciences of medicine as they apply to each case. And equally
important are the cultural and humanity studies, especially of historicized personal
accounting of experience, and narrative representations of extreme cases.
Steve Brown and colleagues neatly summarize traditions of enquiry in embodi-
ment (Brown et al., 2011). Sociologists have been interested in how specific bodily
practices such as cosmetic or adornment rituals (e.g., tattooing) operate within cul-
tures, made more interesting by the modern challenges of robotics, miniaturization,
and the blurring between what is manufactured and what is natural in new bodies
(Crossley, 2005). But much social theory has also grappled with the body as a site of
contested power and governance, most notably in cultural methods of objectifica-
tion and display (Turner, 1992). Feminist theory has perhaps done most to traverse
disciplinary boundaries with a specific focus on the gendered experience of bodies
as a site of argumentation over identity, control, and possibility (Ussher, 1997). Also
relevant are philosophical investigations on embodied cognition, which promote
a cognitive version of direct perception. In its strongest form, embodied cognition
holds that bodies not only constrain cognition but also shape and regulate it. Bodies
create minds (Foglia and Wilson, 2013).

4
 t he ph ysic a l se nse s

The psychology of the physical senses I explore is strongly influenced by a trad-

ition of enquiry that can be broadly defined as functionalist, one that focuses on the
experience of behavior in context. However, I have tried to extend this functionalism
to make space for personal experience. Examining personal experience has roots in
phenomenology, in existential philosophy, and in the structuralism of early percep-
tual physiology. Existential psychology, as it was originally known in the German
tradition, focused on the precise description of the structure of private experience;
self-observation of that experience was the primary source of scientific evidence
(Titchener, 1912). Scattered across the subdisciplines of psychology, you can find calls
to return experience to its place at the center of psychological enquiry (Stenner, 2008).
I develop here, following Andy Clark, a form of extended functionalism (Clark, 2008).
Under investigation is environmentally embedded experience that is constrained and
made possible by both having and being a body. Missing for me from these analyses
is the empiricism of private experience, and in this sense I extend functionalism with
a phenomenological consideration of the personal.

Personal stories

For each of the ten physical senses I asked people to talk with me about their experience
of the sensation being investigated. There are twenty-one personal stories appearing
throughout. Their stories are idiosyncratic. They are not case summaries and are not
meant to be typical. They are specific. My aim is to exemplify, sometimes to investi-
gate, but always to humanize. Psychology can lose itself in method sometimes, and it
is important to come back to real people and their experiences with their bodies.
The stories are written as brief sections of interview. I don’t pretend to have cap-
tured the complexity of people’s lives. Reported are stripped-down versions of experi-
ence focused specifically on the sense being discussed. Importantly, they are edited.
Natural speech is less accessible when reproduced verbatim. In editing, though, I have
always attempted to keep the meanings intact. I also offered everyone the opportun-
ity to be anonymous. Some people took up that offer, so some of the names have been
changed. The people I met were, without exception, intriguing, beguiling, and, above
all, generous.

The physical senses

My choice of ten will be contentious to some. There has been no shortage of attempts
to draw a hierarchy of the senses (see Robert Jütte’s helpful 2005 history of the
senses). Some attempts focus on a philosophical distinction of felt experience. David
Armstrong, for example, argued for the importance of a difference between transitive
sensations, whose existence can occur without the sensing person, such as balance,

5
 t he t e n negl ec t e d se nse s

and intransitive senses, which can exist only in and of the person, such as itch (Arm-
strong, 1962). Others are pragmatic. For example, both Mark Patterson (2007) and
Mark Hollins (2010) extend touching to do the work of many interoceptive (bodily)
sensations. Although the philosophical arguments are instructive, and the biological
psychology of levels of perception and cognition interesting, the experience of each
sensory category is equal across the ten, and so their treatment here is equal. I am
deliberately attempting a complete psychology of the body.
Each chapter focuses on a neglected physical sense. They are not neglected in real
life. We are only too happy to talk about how our bodies feel. But they are neglected
from the point of view of serious psychological enquiry. Of course some are more
studied than others, but compared to the big five, the ten bodily senses have been
neglected for too long.
I start with balance and movement, the proprioceptive senses that position us in rela-
tion to space. Next, I investigate a category of experiences of working with force as
pressure senses. Within pressure I deliberately wanted to explore the common human
experiences of flexibility and stiffness, strength and weakness, heaviness and light-
ness, and the feelings of being swollen or in some way reduced. Breathing is given a
whole chapter because the perception of breathing and its absence are unique. Next
come three chapters on the interoceptive domains of fatigue, pain, and itch, which
are followed by chapter-length considerations of temperature and appetite. Finally,
I introduce perhaps the most neglected of all bodily senses, the physical experiences
that accompany the expulsion of matter from the body. They include, in the order in
which they are treated, the air-removal senses of sneeze, cough, hiccup, burp, and
fart; and the fluid-removal senses of defecation, urination, vomiting, menstruation,
and ejaculation.
Each of the ten senses is explored as if it were isolated. This is a deliberate methodo-
logical choice. It is so rare to have a focus on a specific physical sense that I tried to avoid
distraction. It might seem odd to explore appetite without taste, for example, or motion
without sight—but these senses deserve to be foregrounded, dragged into the spot-
light. In the final chapter I look across the physical senses for what is common, at what
we can learn for a more encompassing, more complete psychology of embodiment.

References

Armstrong, D.M. (1962). Bodily sensations. London: Routledge and Kegan Paul.
Blackman, L. (2008). The body. Oxford: Berg.
Brown, S.D., Cromby, J., Harper, D.J., Johnson, K. and Reavey, P. (2011). Researching “experi-
ence”: embodiment, methodology, process. Theory and Psychology, 21, 493–515.
Clark, A. (2008). Pressing the flesh: a tension in the study of the embodied, embedded mind.
Philosophy and Phenomenological Research, 76, 37–59.
Crossley, N. (2005). Mapping reflexive body techniques: on body modification and mainte-
nance. Body and Society, 11, 1–35.

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 t he ph ysic a l se nse s

Danziger, K. (1990). Constructing the subject: historical origins of psychological research.

Cambridge: Cambridge University Press.
Duncum, P. (2001). Visual culture: developments, definitions and directions for art education.
Studies in Art Education, 2001, 42, 103–112.
Foglia, L. and Wilson, R. (2013). Embodied cognition. WIREs Cognitive Science, 4, 319–325.
Gibson, J.J. (1986). The ecological approach to visual perception. New York: Taylor and Francis.
(Originally published 1979)
Harré, R. (1991). Physical being: a theory of corporeal psychology. Oxford: Blackwell Publishers.
Haugeland, J. (1998). Mind embodied and embedded. In J. Haugeland (Ed.), Having thought:
essays in the metaphysics of mind (pp. 207–240). Cambridge: Harvard University Press.
Hollins, M. (2010). Somesthetic senses. Annual Review of Psychology, 61, 243–271.
Jütte, R. (2005). A history of the senses: from antiquity to cyberspace. Cambridge: Polity Press.
Kelly, D. (2011). Yuck! the nature and moral significance of disgust. London: Bradford Press.
Knill, D.C. and Richards, W. (Eds.). (1996). Perception as Bayesian inference. Cambridge: Cam-
bridge University Press.
Leary, D. (Ed.). (1995). Metaphors in the history of psychology. Cambridge: Cambridge Univer-
sity Press.
Lotto, A. and Holt, R. (2011). Psychology of auditory perception. Wires Cognitive Science, 2,
479–489.
Patterson, M. (2007). The senses of touch: haptics, affects and technologies. New York: Berg.
Rieber, R.W. and Robinson, D.K. (Eds.). (2001). Wilhelm Wundt in history: the making of a
scientific psychology. New York: Kluwer.
Stenner, P. (2008). A.N. Whitehead and subjectivity. Subjectivity, 22, 90–109.
Stoffregen, T.A. (2003). Affordances as properties of the animal-environment system. Ecological
Psychology, 15, 115–134.
Titchener, E.B. (1912). Prolegomena to a study of introspection. American Journal of Psychology,
23, 427–448.
Turner, B.S. (1992). Regulating bodies: essays in medical sociology. London: Routledge.
Ussher, J. (Ed.). (1997). Body talk: material and discursive regulation of madness, politics and
reproduction. London: Routledge.

7
 CHAPTER 2

BALANCE

S taying upright is a remarkable feat of human biology that we rarely if ever con-
sider; until, that is, we are confronted with its failure. Adopting and maintaining
a stable position in a direct relationship with gravity is a basic requirement. Literally,
one must take a stand in relation to the world. The perception of imbalance and its
removal to create balance (also known as being in disequilibrium or equilibrium) is
achieved by the convergence of sensory input from the visual, vestibular, and proprio-
ceptive systems, and their cortical integration. I have chosen here to focus exclusively
on balance and imbalance. From a neuroanatomical point of view, balance is only
one specific function of integrated sensory systems controlling bodily position; it is
a core part of many physical experiences. Running, walking, jumping, and even lying
all involve balance. From a psychological perspective, however, the phenomenologi-
cal experiences of being in or out of balance have a unique character. We know what
being unbalanced feels like.
I am interested in the plasticity of balance perception, from the excitement of the
infant achieving standing unsupported to how balance can be trained, controlled,
or improved. I explore normal balance, with a focus on applied attempts to train
people to overcome or control the perception of imbalance in the context of skill
development and falls prevention. I then turn to a clinical focus on the disorders of
imbalance, both primary and those secondary to disease or injury. Finally, I offer a
functional view that places balance in a cognitive and motivational context, in which
one’s beliefs about how the world should be are perhaps as important as one’s per-
ception of the world.
Extreme experiences are an important source of evidence. There are people who
have trained and trained until they can achieve remarkable feats of balance, often for
public performance or just private pleasure. At the other extreme, there are many
people who live with one of the challenging disorders of balance; they are often hid-
den from public view, unable to stand without dizziness, vertigo, and a feeling of fall-
ing. I explore both of these extremes with the help of two people who live with the
experience of extreme balance or imbalance. I talked with Luna who is a classically
trained professional dancer; understanding balance during complex movements is
central to her art. And I met Debbie who has had vertigo for the last two years and is
learning to live with an impermanent physical world.

8
 a psychology of fa l l ing

Learning to stand on your own two feet

The human ear enables the perception of sound, balance, and positioning of the
head in concert with visual feedback. The vestibular system contains in each inner
ear three semicircular canals ending in ampullae, and two orthogonally positioned
otolithic organs, the saccule and the utricle. The latter contain areas of hair-shaped
cells (cilia) in membranous folds with, suspended above them in endolymphatic fluid,
crystals of calcium carbonate that add mass to allow movement of the cilia giving
critical positioning information (Van De Water, 2012). All sensory information passes
through the vestibular nuclei to the thalamus, to the cerebellum, and to various cor-
tical areas of the brain (Lopez and Blanke, 2011). This vestibular system works with
information from the visual system, from touch, from proprioceptive transducers
in muscle, joint, and skeleton, interoceptive feedback, and from memory, to produce
balance. Balance in this psychological sense refers to more than just equilibrium: bal-
ance is the stable gravitational position in relation to the world, an egocentric sense
of position within the world (where I am in relation to other objects), and a sense of
agency (control over that position).
The lack of specificity and failure to reliably identify a unique vestibular cortex
is part of the intriguing neuroscience of vestibular function. Its cortical projections
spread widely across the brain, and interact with other sensory systems, including
touch and pain (Ferrè et al., 2013). The primary function of the system in giving critical
information about the self in relation to the world is now thought to go beyond the
provision of information on agency, position, and object relations. Vestibular infor-
mation appears to contribute to body schemata in general (Lopez et al., 2012), and spe-
cifically to one’s sense of ownership over all or part of one’s body (Lopez et al., 2008).
We learn to stand by training our intact vestibular system through goal-directed
movement. It is because we are inherently curious that we need to quickly train our
sensory apparatus to help us explore. Unsupported bipedal postural control, or stand-
ing as we call it, is critical to the development of point and reach, which are themselves
critical determinants of social development in infants. We learn to stand, typically
at the end of the first year, partly because of physical maturation, and in part due
to the richness of the context we are learning to explore. Controlling postural sway
and reducing the randomness (or entropy) of that sway while positioning for point or
reach are helped by repeated reaching (Claxton et al., 2012). Even at ten years of age
children are adopting alternative balancing strategies to achieve a stable position to
allow reach and grasp (Haddad et al., 2012).

A psychology of falling

Balance, of course, relies on more than vestibular function; it involves contributory pos-
tural information from muscle and skeleton. Proprioception and movement perception

9
 ba l a nce

are explored in Chapter 3. But maintaining postural equilibrium—centering and main-

taining the body’s mass in relation to gravity—is a critical and automatic human sen-
sorimotor activity that goes on all the time, without us noticing. I propose a psychology
of falling. We can learn a lot from both deliberate and accidental falling. A relatively
modern human invention is the pursuit of safe deliberate falling: think about free-
running (parkour), parachuting, or the roller coaster ride. What can we learn from these
newly engineered experiences? I examine the experience of those attempting to master
and control balance: those who work or play at heights, or who take part in activities
that require high levels of balance control, such as gymnastics or ballet. Also interesting
are the trips, slips, and collapses of accidental falling. Finally, I focus on the disorders of
balance, in particular those suffering from dizziness, vertigo, and height intolerance.

Deliberate falling

Falling involves both the loss of equilibrium (imbalance) and a loss of control to gravity.
A fall can be of a short duration (e.g., collapse to the floor from standing) or a long dur-
ation (e.g., a parachute jump). Deliberate falling is associated with the momentary sacri-
fice of control to gravity. But this sacrifice is only partial. Those who engage in deliberate
falling trust in a set of control procedures, tactics, equipment, or agents that limit any
damage from the fall, such as the parachute, a bungee rope, or the fairground engineer.
One might think that extreme sports people are likely to be risk takers, but the
opposite appears to be true. For example, in a large sample of free-runners, worry and
anxiety about action were related to risk taking but were mediated by self-control and
self-ability beliefs (Merrit and Tharp, 2013). In other words, believing you are in con-
trol when planning to lose control seems to be an important part of the experience
of deliberate falling. Further, the pursuit of freedom to live as you choose, expressed
in extreme and unusual sport, is paradoxically characterized by high levels of com-
mitment, discipline, and skills development. For example, Eric Brymer and Robert
Schweitzer interviewed 15 extreme athletes, including base jumpers, waterfall kayak-
ers, and big wave surfers. The athletes they found “revealed a consciousness of choos-
ing a way of being-in-the-world in which predictability was subjugated in preference
to letting go of control.” They noted also that there was

a paradox to participants’ experience in that they develop skills to engage in activities “at
the extreme” and develop the skill and flexibility to experience some degree of control
and mastery of the techniques which enable them to engage in the activities. (Brymer
and Schweitzer, 2013, p. 871)

They were interested in fear and motivations. All reported fear but judged this as healthy
and necessary. Mastering fear was a prime motivation (Brymer and Schweitzer, 2012).

10
 f e a r of fa l l ing

A less extreme example of the transformative power of overcoming fear is the

fairground ride. Many roller coaster rides include a fall or a drop. The drop rides are
marketed to youth and are relatively common (Gothelf et al., 2010). They provide a
modern cultural mechanism for the safe exploration of fear. Imagine that before the
advent of mechanized safe fear it was impossible to experience the long-duration
fall and live to explain the feeling. Kathryn Woodcock (2007) gives us an intriguing
glimpse into the world of those attempting to improve the safety of fairground rides,
when by their nature people are seeking to experience the illusion of serious risk.
Posting warnings, for example, are unlikely to be effective. She observed over 5,000
journeys on 103 different rides, at three carnivals in Canada. She recognized that rais-
ing awareness to situational danger was difficult to achieve:

Situation awareness is an unusual challenge in this domain. During the ride, the rider
will be immersed in the illusory physical sensation contrived by the ride designer, be
it unpredictable changes of direction, flying, or free falling or the illusion of a ride nar-
rative, such as travelling to distant lands or other worlds. To the investigator, the real-
world limits are apparent, thus the rider’s behaviour may be interpreted as a loss of
situation awareness, in the failure to be aware of the danger of an action, or a mode
error, where the action taken is appropriate in another mode but not the current one.
Unlike most other human error circumstances, in this domain the requisite conscious-
ness of the real-world situation would cause failure to achieve the ride’s other mission,
which requires immersion in the illusory world. (Woodcock, 2007, pp. 394–395)

This is perhaps why people put themselves at risk by attempting to increase the thrill
(e.g., standing out of harness).
The context of the deliberate fall is crucially important. Whether it is in pursuit of
a hedonic thrill, the safe testing of fear, or an experience narrated as transformative,
the meaning of the fall is important. We know that when standing on a precipice, fear
of falling over the edge is directly related to one’s perception of height (Proffitt, 2006;
Teachman et al., 2008). What is missing from this literature is any phenomenological
sampling of the experience during the fall.
Deliberate falling is a modern invention. Exposure to terror with new technology
like the bungee rope or the fairground drop provides novel opportunities to sample
the perception of prolonged imbalance. Just as visual illusions and altered mirrors
taught us much about visual perception, so perhaps the mechanisms of deliberate
falling used to thrill could teach us about balance perception.

Fear of falling

Some researchers have asked people what it is like to fall. I could find no studies of
people reporting the experience of deliberate falling, no speak-aloud studies during

11
 ba l a nce

an actual fall: that would be interesting. But we know that the meaning of the fall, how
it came about and its consequences, are what matters. To older people the meaning
of falling is the challenge to independence, a possible signal of a new stage of decline,
and a threat to one’s identity as competent (Dollard et al., 2012). A common feature
of accidental falling is the experience of shock. For example, in one interview with
27 older people who had fallen suddenly, finding oneself on the floor emerged as the
most disturbing aspect of falling. One participant, for example, said:

Well, it came as a shock. It’s a shock to me, very much. I really didn’t think anything
like this would ever happen to me. Nothing ever has of all the years . . . and it came as a
terrible shock. (Roe et al., 2008, p. 592).

As with deliberate falling in the sportsperson, accidental falling in the older per-
son can also be a transformative experience, but the transformation is to a life of
everyday fear. Falling as an older person is not useful or edifying; it is unpleasant and
disruptive. Unplanned and unwelcome falling is experienced as a loss of autonomy
and control over a basic human function (staying upright): it is immediate discomfort
along with a more reflexive fearful concern of an altered future. When one has had a
fall, one becomes vigilant for possible future falls. A primary goal for assistive devices
and treatments is not only to stop the fall, but also to reduce the burden of feeling
constantly vigilant to the possibility of a fall (Williams et al., 2013).
Fear of further falling is a common consequence of a fall, and in an extreme form
is sometimes referred to as a post-fall syndrome. More than just a further source of
distress, fear of falling has emerged as a predictor of future falling. For example, in an
interesting longitudinal study of over 2,000 people, “fear of falling at baseline was an
independent predictor of being a faller at follow-up” (Friedman et al., 2002, p. 1333). Is
it likely that adjusting one’s sense of risk, typically through activity restrictions and
over-cautiousness, paradoxically increases the likelihood of falling? Perhaps being
cautious becomes self-fulfilling, confirming an unhelpful belief in personal vulner-
ability and frailty.
Thomas Hadjistavropoulos and colleagues have argued for a re-examination of this
popular view of avoidance. They do not doubt that people are fearful following a fall,
and that this can lead to avoidance of activity associated with the fall, but the cause
may be due to the effect of anxiety on balance perception (Hadjistavropoulos et al.,
2011). Kim Delbaere is one of the few scientists to explore fear of falling with experi-
mental paradigms that offer closer examination of the interplay of physiological and
psychological factors in balance adjustment. For example, in a walking study she and
her colleagues used an elevated walkway and measured the physical changes pro-
duced by increased fear of falling (Delbaere et al., 2009). They asked their participants
to walk in two different light intensities (dim and bright) and at two different heights

12
 f e a r of fa l l ing

60 cm
A B

Fig. 2.1. Cartoon of two extreme experimental conditions: well lit and walking on the ground,
and dimly lit and walking on an elevated platform.
Reproduced from Kim Delbaere, Daina L. Sturnieks, Geert Crombez, and Stephen R. Lord, Con-
cern about falls elicits changes in gait parameters in conditions of postural threat in older people.
Journal of Gerontology A: Biological Sciences and Medical Sciences, 64(2), pp. 237–242, Figure 1 © 2009,
­Oxford University Press.

(ground and elevated). Figure 2.1 depicts their apparatus. They found evidence for
a paradoxical effect of fear on balance, increasing a risk of postural instability. We
might think that being concerned or fearful makes us more careful which should
decrease the risk of falling. The opposite was true in this experiment: the greater the
concern of falling the larger the alterations in speed and type of walking. A fear of
falling may paradoxically increase the risk of falling.
Fear of falling may arise due to largely unconscious sensorimotor adjustments
leading to overcompensation and hence a sensation of frailty, which in turn can
exacerbate a belief in poor balance control and increase fear of falling. Perhaps para-
doxically, fear following a growing belief in lack of balance can increase the risk
of postural instability, and an overall self-confirming belief of increasing frailty,
inevitable decline, and the surrender of control. Undermining this surrender of
control and the belief in the inevitability of falling is at the heart of falls prevention
strategies.
These modern interpretations of the psychology of falling are just making their
way into treatments, (e.g., the iStoppFalls program funded in Europe; http://www.
istoppfalls.eu/). However, we don’t know how to interpret patients’ initial reports of
frailty and fear of falling. If we rush too soon to a primarily behavioral treatment of
fear we might miss its potential role as a useful early warning system. More investi-
gation is needed into the possibly primary role of aging sensory and motor systems
in falling, the emergence of a fear of falling, and falls efficacy interventions (Pasma
et al., 2014).

13
 ba l a nce

Accidental falling

Falling when it is not one’s choice, through roll, trip, slip, or collapse, is common, with
the incidence peaking at both ends of the age spectrum. We tend to think of falling as
a problem of old age but falling is also the primary cause of injury in infants attending
the emergency room, either through being dropped or rolling off beds and furniture
(Pickett et al., 2003). Older children’s falling is typically associated with play or sport.
For example, Glenn Keays and Robin Skinner compared injury from falling between
home and public play equipment from a database of over 39,000 children, ages three
to eleven. Eighty-four percent of all falls occurred in public, outside of the home, but
severe injury was more likely to occur with home equipment; for example, falling from
a garden slide onto a hard yard surface (Keays and Skinner, 2012). Also common are
falls from sports, either sports at height (e.g., rock climbing) or sports in which balance
can be compromised—for example, the barge in basketball or soccer, a trip running to
field a cricket ball, or the poor control of the novice snowboarder. Most of these falls are
from a short height. Falling from buildings (windows, balconies, roofs, fire escapes),
high trees, or walls also occurs (Keogh et al., 1996), and is a particular issue of growing
urbanization, high-rise building, and multigenerational dwelling (Pressley and Barlow,
2005). The epidemiology of childhood falling comes largely from the study of injury
and its prevention, caused either through trauma from the fall, or often from attempts
to minimize the effects of a fall through reaching, causing shoulder, arm, or hand
injury. We know very little about the everyday, clinically uninteresting falls, as children
stumble and bounce their way into adulthood, learning about gravity as they go along.
Nonclinical information on adult falling is available from occupational settings. In
young adults, falling arises from slips or trips when there are unexpected changes in
ground surface, from poor or impaired hazard perception, or from distraction (Nenonen,
2014). Although falling is associated with working at heights, in truth accidental falling is
possible anywhere and everywhere, in fact wherever there are trip hazards, or wherever
we bring distractions with us, such as mobile phones (Schabrun et al., 2014), or increase
risks, as with the destabilizing effects of fashionable footwear (Kilby and Newell, 2012).
Perhaps the largest concern with falling is at the other end of the age spectrum. Falling
is a common feature of older age, although its incidence in many countries is in decline
(Finland; Korhonen et al., 2012). In the elderly, the likelihood of falling is greatly increased
by multimorbidity, by the experiences of illness and treatment, and by general physical
frailty with specific regard to musculoskeletal dysfunction. Alan Morrison and col-
leagues looked at the incidence of fracture from falls. In the United States they found that

1.4% of the community-dwelling elderly experience a fracture annually due to a low-

impact fall. . . . Extrapolating to the 39 million US population ≥ 65 years living outside
of skilled nursing facilities in 2010 yields a total of 0.53 million such fractures per year.
(Morrison et al., 2013, p. 15)

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 achie v ing ba l a nce (equ il ibr i u m)

In a comprehensive systematic review of 22 studies of falling and its consequences,

in China, Hong Kong, Macau, Singapore, and Taiwan, the “reported annual rate of falls
in older Chinese community-dwelling people ranged from 11% to 34% in retrospect-
ive studies and 15% to 26% in prospective studies” (Kwan et al., 2011, p. 537). However,
what was particularly interesting in this study was the high incidence of fear of falling
as a direct consequence of a fall: “Fear of falling [reported in four studies] as a result of
a fall ranged from 42% to 70%” (Kwan et al., 2011, p. 540). Fear of falling is emerging as
a crucial feature of the experience of falling, suggesting that it is one characterized by
feelings of being out of control and of being at high risk of future danger.

Achieving balance (equilibrium)

The clinical literature on balance is focused on people’s belief that they cannot main-
tain their balance and so must be cautious. But belief in one’s ability to be balanced is
not always associated with fear. Context matters.
Consider the world of the ballet dancer. When standing, one is swaying and cor-
recting movements unconsciously within a fixed perimeter. The size of the area of
acceptable sway is determined in part by the base of support one has. Ballet dancers
often reduce that base of support to the smallest possible amount; for example, when
standing en pointe. In an intriguing study, Roger Simmons from San Diego investi-
gated professional dancers’ neuromuscular control, and found “a superior postural
control mechanism in trained dancers [which] may explain the ability of dancers to
maintain static balances over a small base of support” (Simmons, 2005, p. 1193). A
recent review of the balance abilities of ballet dancers found it likely that they have
increased postural control. However, these authors argued the opposite to Simmons:
namely, that when highly experienced dancers compromise vestibular and proprio-
ceptive feedback, in the dance, they instead rely heavily on visual cues (Silva da Sil-
veira Costa et al., 2013).
Visual feedback is certainly used in dance training, with a reliance on mirrors and
techniques of distancing and anchoring to fixed points in space. Kimberley Hutt and
Emma Redding explored a novel method of training that relies on nonvisual informa-
tion. Working with 18 elite ballet dancers, they compared an eyes-closed group with
a standard group on a training intervention over four weeks. The dancers who put
more reliance on vestibular and proprioceptive adjustments were much better on a
range of objective balance tests (Hutt and Redding, 2014). Training with eyes closed is
one technique for improving balance. Another might be training in complex environ-
ments, with an understanding of the multiple and interacting demands on balance.
In normal life balance is rarely a sole goal; it is normally just part of what we are
trying to do (Huxham et al., 2001). Elite sports, however, often require greater balance
control and so greater training and awareness. Equestrian sports are particularly inter-
esting in regard to the study of recreational and nonclinical balance. Comparatively

15
 ba l a nce

little is known about the biomechanical performance of rider and horse working
together, although there is evidence that expertise is predicted by better balance control
(Douglas et al., 2012). Balance in this context is not always about postural adjustments
in response to the horse changing position, but is about merging movements into a
singular flow of rider and horse. In dressage riding, for example, maintaining balance
and constant contact with the horse not only through the use of reins and legs, but also
principally with the pelvis, is important. In a study of 20 novice and professional rid-
ers, all wearing accelerometers to measure the movement of their pelvis, professional
riders were more adept at making micro-adjustments in the pelvis, micro-adjustments
that could be the difference between winning and losing (Münz, et al., 2014).

Natural balance awareness

The biomechanical and physiological study of normal balance and balance in elite
activities are relatively well studied in comparison to the study of people’s awareness of
their balance abilities. In specific communities, be it ballet, riding, gymnastics, or judo,
there is a narrative of balance as part of performance and training. But there are very few
studies taking as their point of interest people’s beliefs about their balance performance.
In our dressage example, pre-performance fear is a well-documented challenge for
riders. In a small study of riders before a competition, the experienced and elite riders
showed more vigor and clarity or purpose than novice riders, who were more con-
fused. The authors interpreted this confusion as a sign of low rider confidence (Wolf-
ramm et al., 2010). Although speculative, we can transfer learning from the study
of balance in older age. We do not know whether the lack of confidence displayed
by athletes before competition can profitably be framed as performance anxiety, or
whether it is a sign of skill insufficiency: overconfidence is being corrected with infor-
mation about lack of precision.
There is one area of human activity in which an awareness of and learning about
balance is a requirement: high-wire walking (funambulism). Perhaps the most famous
example was the spectacle of Philippe Petit walking a high wire, and lying on it, and
bouncing on it; the wire was suspended between the almost-built twin towers of the
World Trade Center in New York, in 1974. This performance was more than a simple
high-wire act. It is explored now in a range of texts as the ultimate form of social trans-
gression. It crosses the boundaries of entertainment and danger, of spectacle and hor-
ror, and of order and disorder. Chloe Johnston explores the added poignancy of that act
of defiance and art in the context of the now-destroyed twin towers (Johnston, 2013).
Philippe Petit has talked about his experience. In his book, first called To Reach the
Clouds and later, after the success of the film, reissued as Man on a Wire, he explains the
planning and execution of the feat in some detail (Petit, 2003). He is particularly forth-
coming about how he understands the physical challenge. As with athletes of extreme
sports involving a deliberate fall, acrobatic athletes who are working hard not to fall

16
 nat u r a l ba l a nce awa r e ne ss

are planful, self-disciplined, organized, and extremely aware of what they are doing
and its risks. On stepping out onto the 400-meter high tower for the first time, to test
the conditions, Petit recalls the inner battle he had with feeling drawn into the depths,
struggling with a natural vertigo. The small steps are important as one seeks to tame
the challenge, to fight the urge to control. After six years of planning and training for
this event he finally makes it onto the wire. It is here that the training is tested. We wit-
ness the mind of the athlete who knows that true mastery of this balancing involves
not control but the surrender of control, and a trust in one’s body—a body trained for
the task. For Petit, the path to success is very clear: the funambulist has to be expert in
not fighting, he has to abandon his desire to take charge of every step and observe his
trained feet finding their own way. In part, for Petite, this is an aesthetic and sensual
experience; he talks of allowing the beauty of movement to be unencumbered by a
clumsy body, and an even clumsier mind. There is a necessary abandonment.
Achieving more than the normal level of skill in balance, in whatever sphere of life,
requires training of the vestibular and sensorimotor system over hours of repeated practice.
In addition, letting go of the urge to control, not attending to vestibular and proprioceptive
information, but trusting in the training, appear to be important for elite performance.
Natural balance awareness may be crucial to the acquisition of balance, but at some level
natural balance ignorance appears to be important to its expert performance.
To explore these ideas of being in balance further, I talked to Luna Othnin Girard
(see Box 2.1).

Box 2.1. Luna, the dancer: “when you are on balance you can grow, almost out of the ground”
Luna is eighteen, comes from France, but lives and works in the UK. She describes her-
self as “a passionate fighter.” We talked about the work and discipline involved in achiev-
ing the mix of being an athlete, an artist, and a work of art, all at the same time. We also
discussed what it means to be in balance, or as dancers call it, being on your leg.

______________________________________

Chris: What is it like to be on your leg?

Luna: For balance it is weird. There are days when you feel that you are just on balance.
You don’t have to think about it. Your body just puts you in the right place. But there are
days when you are more tired, when you have to fight for the balance. When you take bal-
ance at the bar you wouldn’t find it. It wouldn’t be quite right. So you have to start again.
And again. Until you find your balance. There are days when you really need to fight
because it is hard. The more you find your balance everyday, the more reliable you are.
I know that when I am not on my leg, it can be someone else’s good day on their leg. When

(Continued)

17
 ba l a nce

Box 2.1. Continued

you get tired and you have to stay on balance, it is your muscle memory that will put you
on your leg rather than just luck. It is really training to find your center all the time.
Chris: What does it feel like? Do you have a sense of being perfectly balanced?
Luna: You know when you are not on it. There is always a time when you feel perfectly on
balance, but those times are so rare. You will need adrenalin to feel exquisitely on your
leg. You would feel it because the whole combination of steps would work as perfectly as
your whole body can manage. The feeling of that is incredible. But when you are training
every day you are not going to be able to have that.
When you do a movement and you put feeling into it, it works. But in everyday life we
need to work on the technical aspects. So one day I will focus on my turn-out. Another
week I will work on my upper body, and will think that my arms need to be placed right
every time. When you are on balance you grow and you can expand onto that axis but
when you are not on it you work around it. When you are on balance you can grow,
almost out of the ground through the axis.
Chris: Is it a search for the perfect balance so you avoid imbalance?
Luna: No, it is not avoiding it. It’s working to get it perfect every time. So being off-balance
is going to happen. Every day there is going to be a point where I know it didn’t work.
But then it’s the way you work within that that’s going to make you more consistent in
getting toward that point of balance.
Chris: As a dancer are you in balance or are you always moving toward and away from it?
Luna: It is more moving through my balance. Because dancing is movement, movement
is not static, therefore we can’t be on balance all the time. What makes us on balance
or not is how we move to get to the balance—moving through the balance out onto
another movement. We would work, using our balance, to be on our legs all the time; to
be able to hit the balance; to carry on without wobbling.
Dancing is about plié-ing, stretching, and movement from one leg to the other. So it is
about being up and down and all the way around. Moving. And that gets more compli-
cated when you use different levels. In contemporary dance you use the ground a lot. It
is not the same axis you would find when you are on your feet. But you still have to move
through. Sometimes you are on your back and do a backward roll, then the axis is in the
middle of your body rather than just your feet. It becomes a 360-degree middle, so not
just one spot. It moves with you.
What is great about contemporary dance is that you use your axis and being off-balance
to make your movements even bigger. Because you can be low to the ground you can
really move from one side through yourself—up from being off-balance to catch your-
self again and then fall and catch it again.
Chris: Does confidence in the move matter?
Luna: It changes the movement itself. If you believe you can do it you are halfway to
doing it. If you believe you are never going to make it, it is never going to happen. It just

18
 dizzine ss

Box 2.1. Continued

won’t happen. If you think there might be a chance and you are going to go for it, you are
already halfway to doing it right.
Chris: And what is the experience like when it works as you wish?
Luna: When you let go, your body will just do the steps. You will feel your body moving
but your mind will be free; sometimes it is not on the physical part but on the emotional
part.
You feel light. It feels like it is part of you. When you do a step that you know you can
do, nearly 100 percent of the time, good every time, it is really fluid when it comes out.
It brings you happiness. It is quite amazing when you know you can do that one thing
and when it works when you are on stage. It makes the hours of training worthwhile.

______________________________________

For Luna balance has come to mean something specific to her dance. It is not the
stout planting of feet we do on the subway to avoid falling, or to pick up a box. It is
a perfect moment, captured fleetingly, in passing from one position to another. It is
a celebration. Being out of balance is also different. It is not the lack of control that
we might feel in falling, but a controlled and artful imbalance that is always moving
one toward balance. Confidence in disequilibrium, a sense of one’s body in space as
potentially beautiful, and hours of training, can tame imbalance into an artful path
to balance.

Losing balance (disequilibrium)

For many people, working to achieve and sustain balance is a struggle fought not in
the context of artistic improvement but in a context of fear of damage. For those liv-
ing with a balance disorder the most basic of human biomechanical functions such as
standing can be challenging. There are many causes of balance disorder—infection,
trauma, or disease. Whatever the cause, the main symptoms of the balance disorders
are similar, and include postural instability, increased risk of falling, dizziness, and
vertigo.

Dizziness

Feeling light-headed when standing (orthostatic dizziness) is a common complaint

and comes with a risk of fainting (syncope). For some, dizziness it is a constant men-
ace. Jacquelien Dros and colleagues call it a geriatric “giant” because it is a common

19
 ba l a nce

and debilitating symptom experienced in older age. In a large study of people attend-
ing primary care, they explored the impact that dizziness has on people’s lives. They
defined dizziness as “a giddy or rotational sensation, a feeling of imbalance, light-
headedness, and/or a sensation of impending faint” (Dros et al., 2011, p. 2), and found
that “almost 60% of dizzy older primary care patients experience moderate or severe
impact on everyday life due to dizziness” (p. 6).
That dizziness is disabling is not surprising, but patients with chronic dizziness
experience great distress. Strangely, the distress of dizziness is often talked about in
the clinical literature as an abnormal and puzzling presentation. A small thought
experiment, imagining the experience, might be enough to convince one of how
easily it can unsettle and threaten. Consider the potential loss of function, social
restriction, and health anxiety. Sarah Kirby and Lucy Yardley, who have done much to
explore the meaning of dizziness to patients, and how to improve function, reviewed
the studies on psychological distress for those with Ménière’s disease (Kirby and
Yardley, 2008). Dizziness is only one symptom of Ménière’s disease, which includes
tinnitus and hearing loss, but it is associated with anxiety about health; in particular,
worry about the future and uncertainty over both diagnosis and cause.
Qualitative studies of living with chronic dizziness reveal confusion over cause
and diagnosis, uncertainty over course, and worry about the future. In a qualitative
study, one could see the lack of understanding of the biology of balance. One patient,
for example, said:

The Ear-doctor did nothing but a hearing test. Finally, to me, this seems absurd, very
absurd. . . . If I have different arguments, this has nothing to do with hearing, and I have
always said, hearing is not the problem. (Kruschinski et al., 2010, p. 8)

Confusion and the need for clearer communication are at the heart of the experiences
of people with dizziness.
As we will see with both pain and itch, and with fatigue, the chronic experience
and complaint of some sensory experiences attract confusion and fear. This fear is
exacerbated by diagnostic uncertainty and the stigmatizing implication of an implied
psychosomatic cause (Yardley, 1994). Much of the psychology of dizziness is mired
in an unhelpful language of patient psychopathology. Patients are often described
as expressing inappropriately high anxiety, symptom reporting, or a psychosomatic
disease (Orji, 2014). There seems to have been a collapse of theory or knowledge
translation in this field. Lucy Yardley’s early theoretically rich direction has not been
built upon.
An extended functionalist account of dizziness requires an understanding of the
phenomenology of the experience, of its social meaning, and of its function in pri-
oritizing behavior. Disequilibrium, or the threat that one is about to lose control of

20
 dizzine ss

one’s gravitational position, is a threat to coherence and to complete action. Feeling

light-headed and expecting to faint is a threat that is hard to ignore. Attending to that
threat may be relevant in chronic dizziness (Asmundson et al., 2000). Older people
worried about falling are often preoccupied with perceived risks of further falling.
It is a reasonable hypothesis that those with chronic dizziness may also show a bias
of attention to possible cues of dizziness, an increase in behaviors (often ineffective)
that patients think will postpone the onset or exacerbation of dizziness, and altered
behavioral patterns of postural adjustment.
Gerhard Andersson and colleagues reported a rare experimental study of patients
with dizziness. They compared 20 patients, all of whom met the criteria for vestibular
disorder (including ten with Ménière’s disease), with 20 people free from such prob-
lems. The study required everyone to close their eyes while they received vibration
delivered to the calf, a procedure designed to induce a cue of impending postural
instability: it feels like you are going to fall. This all happened while participants were
standing on a force platform measuring body sway. People were also asked about
their perceptions of body sway and their perception of risk of losing balance, both
before and after stimulation. This unique experimental setup was to test an intri-
guing hypothesis of the function of beliefs about balance. They predicted, first, that
patients would overestimate the threat of the vibratory stimulation, thinking it more
damaging than it was. Second, they thought that these fears would be resistant to
correction through experience, so that overestimation and anxiety would be main-
tained. The opposite of what was expected occurred: “Contrary to what we expected
the control group overpredicted sway to a greater extent than the patients did.” Fur-
ther, “regarding the predictions of ‘risk of losing balance,’ rather similar results were
obtained with the difference that the groups did not differ significantly across trials”
(Andersson et al., 2008, p. 180).
Putting the behavior of patients with dizziness in the context of threat shows
that attempting to control balance, and vigilance for signs of imbalance, is to be
expected. A normal psychology of balance would expect patients to attend to the
threat of imbalance, attend quickly to that threat, and adjust posture to maintain
balance.
The patient with vestibular dysfunction might usefully be compared to the ballet
dancer. They both inhabit an environment of persistent challenge to balance. They
are both trained to recognize, and are continually training to recognize, the cues for
threat to balance so as to adjust efficiently to that threat. Unlike the patients at risk of
fall who may be accurately reflecting their physical frailty in their avoidance behavior,
the person with Ménière’s disease might usefully be thought of as an expert in achiev-
ing equilibrium. Andersson and colleagues hint at this idea when they say, “One inter-
esting possibility, following the findings of this study, is the notion that dizzy patients
are more correct than incorrect in monitoring their balance.” (Andersson et al., 2008,
p. 181).

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 ba l a nce

From a treatment perspective, the extent to which people with chronic dizziness
are accurate in their perceptions of threat to equilibrium is crucially important.
If inaccurate—given to overestimating threat, leading to avoidance—one might
adopt a cognitive behavioral approach to improving balance confidence, correcting
inaccurate beliefs (Schmid et al., 2011). If accurate, one might encourage vestibular
rehabilitation with the repeated practice of movements or the training of position-
ing (Hillier and McDonnell, 2011). Perhaps when it comes to disorders of balance
perception, training (and yet more training) of perception is more important than
altering belief.
If psychology is going to be relevant in helping people balance, it will be in devising
methods to motivate and encourage persistent engagement with repetitive physical
therapy, or inventing more accessible ways to deliver treatments to patients, such
as community education or the use of virtual reality (Yardley and Kirby, 2006). Of
course beliefs and the content of fear matter, but understanding those beliefs as
rational and sensible in the context of dizziness will be important when considered
in rehabilitation (Staab, 2011).

Vertigo

Vertigo was recently defined by consensus as “the sensation of self-motion when

no self-motion is occurring or the sensation of distorted self-motion during an
otherwise normal head movement” (Bisdorff et al., 2009, p. 1). The different types
of vertigo are classified largely by presumed cause, starting with a distinction
of spontaneous versus triggered vertigo; the symptoms of vertigo are described
in terms of their specific phenomenological quality. For example, a distinction
is made between ­vestibulo-visual symptoms, such as the feeling that the world
is oscillating (oscillopsia), and visual lag, in which the perceived environment
lags behind real movement. Similarly, a distinction is made between postural
symptoms, such as a near-fall steadied with an outstretched hand or lean, and
unsteadiness.
The phenomenological focus of vertigo in diagnostic discourse is on a perception
of a body moving (or being moved) out of one’s control, and it overlaps with experi-
ences of dizziness, as they often occur together. What is common across different
presentations of vertigo is the experience of spatial impermanence and the threat
to balance. In one sense the fundamental belief in a physically stable world is chal-
lenged, often without warning. Indeed, the very earth beneath one’s feet appears to
be moving.
To learn more about the experience of vertigo, of living in an unstable imperman-
ent world, I talked to Debbie Hollingsworth (see Box 2.2).

22
 v e rt igo

Box 2.2. Debbie, living with vertigo: “your mind can play amazingly cruel tricks on you”
Debbie is a support worker for a charity helping those in housing crises. She
describes herself as “an activist,” someone who is engaged in social justice and
equality campaigns. She likes to challenge both herself and the status quo. For the
last three years she has had episodes of spasmodic episodic vertigo. She can spend
months without an episode but has had some weeks where the symptoms were
daily. I was interested to learn what feeling unbalanced was like, and how she made
sense of it.

______________________________________

Chris: When did you first know something was wrong?

Debbie: About two years ago. It came on quite suddenly and the doctor did not really
know what kick-started it. But I just kept getting this sensation that I wasn’t comfortable
with. And then you start imagining all sorts of things like blood clots and things like
that on your brain. Your mind can play amazingly cruel tricks on you. You can imagine
all sorts of things going wrong. And I think it is the unknown that is more frightening.
Once you have a diagnosis you can deal with it.
Chris: What are the feelings like when you have an attack?
Debbie: Your head is just swimming. That is the only way of explaining it. It just swims.
It feels as though you are going backward and forward but you are not actually moving.
And it doesn’t matter if you are lying flat or sitting up or if you are moving quickly or
slowly, it is just this continual swimming, and it comes in waves in your head. It is mainly
your head. It is just the sensation that your head is swimming inside. It is also a feeling
of going left to right. So you can lie down and at first you think that will sort it out, but
your head keeps going left to right. It is like a crescendo; it goes up and down and back
up again. It just makes you feel really sick. Yes, very nauseous. And if you are standing
up you are likely to stagger.
Chris: Is it just your head or do the room and floor move also?
Debbie: There are times when the whole room is orbiting. And there are times when you
are stuck in places. I have had that a handful of times. Not often. But that is when you are
more likely to lose your balance. It is the two. It is your head and your environment that
are moving against each other. It is just very disorientating. Your head is going one way
and the room is moving around but it won’t just spin but it will be a disjointed moving
backward and toward you. So you get a sensation that the wall is just much closer than
it actually is. Or it is further away. So you start to lose perception of your surroundings,
and that can be quite frightening. And that is when I am more likely to lose my balance
and I will have to grab something to right myself.
Chris: Do you ever feel like your body is being left behind?

(Continued)

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Box 2.2. Continued

Debbie: I have woken up sometimes and moved over, and my head feels like it is com-
ing after me. It is like a delayed reaction of your head catching up: your insides catch-
ing up with your physical head. That is quite strange as well. It is like a different feeling
altogether of everything catching up after you. But that only happens when you are lying
down. That has never happened when I am standing up.
Chris: Have you ever felt that the world is starting to control you rather than you con-
trol it?
Debbie: No. I have not had that. That would be frightening. The closest I have had is
that things are not where they should be. When everything is moving around you,
you can never be sure that the table you reach for is still there. Because you can’t
always judge whether you have moved. You can’t be sure whether you have moved
away because everything is moving. Your legs do feel a bit weird. If I have been stand-
ing I am not sure if my legs have moved somewhat or if I am standing still. I am not
sure if my body has moved or I am standing still. It is hard to judge. You are not quite
sure because the floor could be feeling like it is moving as well, and is it the floor or
is it you?
Chris: Is there anything pleasant or intriguing about these feelings?
Debbie: No. There is nothing pleasurable. It is unpleasant. That is the word. You can’t say
it is painful; it is just unpleasant. Not nice. And the longer it goes on, then that is when
you start feeling more nauseous. And that in itself is uncomfortable.
Chris: When does it start to become frightening?
Debbie: It is just that you don’t know what is going to happen. If you are at the top of
stairs and it goes, there is the instant thought of falling so you just grab whatever is there
to steady yourself. The fear comes afterward. If you have ever had a near collision in a
car where you have almost knocked into something and afterward you get butterflies,
anxiety in your stomach, and your heart is racing. It is that sort of near-miss feeling when
you realize that you are OK. For me it is afterward. I don’t worry about it in advance, it
comes afterward.
Chris: Do you plan differently now?
Debbie: No. You can’t. I can’t just sit at home waiting for it to happen. I need to earn
a living. I think I am a fairly positive person anyway and you just get on with things.
It if happens it happens. There is not much I can do. I think it is not worth stressing
or worrying over something I can’t control. I have no control over it so I might as
well just get on with life. When it happens I think it is not going to go on forever. It
will stop at some point. I suppose I look at it that there are people far worse off than
me, so it is something you put up with. It is better than having a lot of other things
wrong with you.

______________________________________

24
 he igh t in tol e r a nce

Box 2.2. Continued

Debbie captures perfectly the extent to which imbalance and the fear of falling are risks,
but they are not what dominate her story. The altered reality, the loss of control, the
confusion, and the challenge of how to respond are core parts of vertigo. In the same
way that Luna experienced near-perfect balance and control over the relative position of
her body in space, so Debbie describes having to experience being in a world in which
the physical certainties have been altered, the coordinates have been scrambled: keeping
you own body coherent and attempting to act on the world takes effort.

Height intolerance

One form of vertigo is particularly interesting in terms of its prevalence and the
experience of a changed physical reality. Vertigo often occurs in those with a fear
of heights (acrophobia), with visual height intolerance, and is a common symptom
of panic disorders. Thomas Brandt has worked hard to separate height intolerance
and subsequent vertigo from a psychiatric discourse in which the expressed fear of
heights is used to identify a primary anxiety disorder (Brandt et al., 2012). Almost 30
percent of us report height intolerance, which includes the distortion of perception of
body and space, postural sway, a perception of postural instability, and a fear of fall-
ing. In essence, height vertigo can usefully be considered a primary balance disorder.
In an acute attack, typically occurring when climbing a tower, crossing a bridge,
or mountain hiking, people are often able to discuss their experiences. Doreen
Huppert and colleagues report that as many as 50 percent of people report fre-
quent avoidance of actions (e.g., climbing a ladder) that will induce height ver-
tigo, and as many as a quarter engage in avoidance or help-seeking when an attack
begins (Huppert et al., 2013). In an interesting qualitative study, this same research
group interviewed 18 adult members of the German Alpine Association living in
Munich who had identified themselves as experiencing height intolerance to the
extent that they had sought help (Schäffler et al., 2014). In addition to the experi-
ence of vertigo, participants were forthcoming about the experiences of falling,
fear of falling, physical arrest, and of being drawn to an edge. One participant
described actually falling: “And then you could really look down five floors verti-
cally into the lobby. And then I fell over. Actually it was really the case . . . that my
knees turned to jelly” (p. 704).
Another described not a real fall but a fear of falling:

During height intolerance I have the additional feeling that I could fall down some-
where, into a, for me, bottomless abyss, even if it’s only 50 cm deep, that is still for me at
the time into a bottomless abyss. (p. 704)

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 ba l a nce

Another described the unusual phenomenon of physical arrest or paralysis, of an

inability to move. This is beyond a fear of falling, as people describe almost being an
observer of their body, ignoring or denying instructions to move: “Yeah and when it
gets really bad, then I can’t even lift my foot. It’s like my feet are glued to the ground.
I’d probably remain standing there forever, for I can’t move my legs” (p. 702). Going
beyond the perception of physical disobedience, in which agency is intact but one is
fixed to the ground, is the report of being drawn: “The funny thing is that whenever
I look down anywhere, I automatically feel this pulling sensation, as if I had almost
already fallen down” (p. 702).
Disturbance in the sense of body ownership, witnessed here in the failure of agency
in not being able to move, and a separation of agency in the feeling of being controlled,
is similar to those described by Yen Pik Sang and colleagues who described experi-
ences of derealization and depersonalization in a matched sample of 50 patients
with a primary vestibular disease (Sang et al., 2006). They found that after dizziness,
imbalance, and difficulty attending, a “feeling of not being in control of oneself”
(p. 762, Table 3) was the most common symptom. They argue:

Derealisation occurs in vestibular patients because their distorted vestibular signals

create a misleading frame of spatial reference which mismatches with the other senses,
giving rise to illusory, “unreal” perceptions of the patient’s transactions with the phys-
ical world. (Sang et al., 2006, pp. 765–766).

Feeling paralyzed, helpless, and incapable of action—or feeling drawn toward an

undesirable and dangerous act, exactly toward the danger one rationally wants to avoid—
brings the sensation of balance into the realm of strong belief, urge, and autoscopic phe-
nomena. Depersonalization in observing one’s body collapsing, loss of agency in being
able to move (rooted to the spot), together with the feeling of being urged or drawn to
danger, could usefully be considered a form of autoscopic illusion. Autoscopic illusions
range from the out-of-body phenomenon of experiencing yourself as separate, typically
floating above your supine body, to a heautoscopic illusion of seeing yourself and being
seen by yourself, to a vague feeling of a presence (Lopez et al., 2008). Olaf Blanke and
colleagues, for example, in their case studies of brain-injured patients reporting out-of-
body experiences, report their first patient who “felt as if she would be elevated vertically
and effortlessly from her actual position associated with vertigo and fear” (Blanke et al.,
2004, p. 245). Table 2.1 summarizes well the different possible autoscopic illusions.

Height intolerance autoscopy

What makes this form of autoscopic illusion different to those from a known neuro-
logical trauma is its high prevalence. It may be a common feature of height intolerance,

26
Table 2.1: The phenomenology of four autoscopic illusions

out-of-body autoscopic feeling-of-a-

heautoscopy room tilt illusion
experience hallucination presence

Phenomenology

Vestibular
disturbance +++ ++ - + +++
Disintegration in
personal space +++ +++ +++ +++ -
Disintegration
between personal and +++ ++ - + +++
extrapersonal space
embodiment embodiment
Disorder
body ownership body ownership - body ownership -

occipito- posterior
parietal/ premotor
Brain mechanisms right TPJ left TPJ parietal PIVC
TPJ

(Continued )
 Table 2.1 (Continued )
“Phenomenology and physiopathology of the autoscopic phenomena and the room tilt illusion. For each paroxysmal illusion, the actual position of the
patient’s body is schematically represented by black lines and that of the parasomatic body by dashed lines. The direction of the visuospatial perspective
is indicated by an arrow pointing away from the location where the patient has the impression he is located. The patient has the impression to see the
environment from the physical body in the case of autoscopic hallucination, feeling-of-a-presence and room tilt illusion, alternatively from the physic-
al and the parasomatic body in the case of heautoscopy, and from the parasomatic body in the case of out-of-body experience. The paroxysmal illusions
are characterized by a different pattern of vestibular disturbance and of disintegration in personal space and between personal and extrapersonal space.
The lower part represents the hypothetical involvement of the different multisensory vestibular regions in the different form of paroxysmal illusion (TPJ:
temporoparietal junction; PIVC: parieto-insular vestibular cortex).” Reproduced from Clinical Neuropsychology, 38 (3), C. Lopez, P. Halje, and O. Blanke,
Body ownership and embodiment: Vestibular and multisensory mechanisms, p. 151, doi:10.1016/j.neucli.2007.12.006 Copyright (2008), with permission
from Elsevier.
Reproduced from Clinical Neurophysiology, 38(3), C. Lopez, P. Halje, and O. Blanke, Body ownership and embodiment: Vestibular and multisensory mechan-
isms, pp. 149–161, Figure 1, doi:10.1016/j.neucli.2007.12.006 Copyright (2008), with permission from Elsevier.
 su m m a ry

although its incidence is unknown. Height intolerance autoscopy, if discussed at all, is

discussed only in the context of derealization that occurs in panic. However, under-
standing it as a feature of a primary balance disorder may help to both normalize the
frightening illusory experience and direct research into treatments for height intoler-
ance that do not rely solely on challenging beliefs during exposure. There has been
no research on this specific form of autoscopy. If it exists in any stable form, it should
have two primary features: first, the loss of agency, or paralysis, of part or all of one’s
body; and second, the perception of being under the control of an external force in
being drawn toward danger. Extending the boundaries of study away from the idea of
an intact agent experiencing confusing perception, to an altered agent out of control
of perception is necessary. Height intolerance may be less about an altered perception
of heights and more about an altered perception of self.

Summary

Balance is a prerequisite for action. From birth we train our balance system by the
force of creativity, reaching for the world and learning about the consequences of
instability. Intriguingly, it seems that the allure of falling, the curious thrill of “the
drop” never goes away. Now it is possible to explore it safely, and so the deliberate fall
is used as a form of entertainment. I argue that technologies of the deliberate fall offer
possibilities for research that have yet to be exploited. At the extremes of balance,
there are those who have trained repeatedly in the micro-adjustment of posture, as
with the dressage rider, or in the art of falling away from and returning through bal-
ance in the flow of dance. But at the other extreme are people suffering with the fear
of falling, with dizziness, with vertigo, and with height intolerance. Their experience
shows how a disorder of imbalance is much more than falling: it can challenge one’s
perception of reality and of agency, whether you can act independently in the world.

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 CHAPTER 3

MOVEMENT

E ngaging with the world requires more than balance. We are constantly in motion,
moving toward or away from objects in a shared environment. To act upon the
world we need to know where we are in space relative to everything else. Knowing
the position of one’s body in space is achieved through the integration of information
from the vestibular system, from muscles and joints, from touch, and from vision. As
I write this, I can see now my fingers moving in my peripheral vision, feel the touch
of the keys as I type, but I also know that my whole body is in gravitational equilib-
rium, and the joints and muscles of my fingers are giving detailed information about
specific position and about movement. Thankfully, all of this goes on without my
knowing, largely out of awareness.
I am interested in these experiences of moving bodies. What does it feel like to
move through space? To be totally aware of your own body in space would perhaps
be distracting, at least if you attempted it all of the time. But an acute or momentary
awareness of the moving body is common. This experience of bodily awareness is
most commonly discussed either in the context of learning or relearning a motor skill
(e.g., juggling or playing an instrument), or in rehabilitation after injury or disease
(e.g., physical therapy). We know how it feels to be clumsy, when reach and grasp start
to fail, and we know what precision can feel like, when a finessed movement you have
practiced so many times runs exactly as planned.
I begin at the beginning, with infants learning to move, and then explore the experi-
ence of fine motor control and its failure as clumsiness. The opposite of clumsiness is
also interesting, especially about what matters when we come to talk of someone
as an expert. I then examine the role of peripersonal space; in particular, one’s per-
ception of personal boundary maintenance: where I end and another person begins,
and the acceptable space between. Finally, I examine the experiences of those with
far-reaching disorders of proprioception and movement for what they teach us about
bodily perception.
Two people offered to share their experiences of proprioception at its limits. Luke
is an acrobat. He works with a human circus in Las Vegas. Precision movement is
crucial to the success of his art and to his survival. I also talked with Jeremy just
after he experienced a stroke. He struggles both to initiate and conclude movement,
and describes himself as “frustrated,” having lost precision control of his limbs and
his body.

33
 mov e m e n t

Proprioception

Proprioception was a term introduced by Charles Sherrington in his published lecture

series The Integrative Action of the Nervous System; it refers to the position of the body
in space and the limbs of the body in relation to the rest of the body (Sherrington,
1906). Mechano-receptors are found in skin, skeleton, muscle, and connective tissue,
which, in concert with vestibular information, inform the central nervous system
of movement. Of course, input from the periphery does not occur in isolation. The
central nervous system is constantly modulating and adapting local sensory envir-
onments with top-down interactive control. Motor control involves multiple brain
structures, not only the cerebellum and the motor cortex. Felt experience typically
emerges from a mismatch between what is expected and what occurs. But this mis-
match rarely occurs between expected and real limb position, making a sudden
awareness of proprioception unusual (Proske and Gandevia, 2012). The general
idea—that proprioception functions largely out of awareness—is intriguing. As we
saw with balance in Chapter 2 and will see for breathing in Chapter 5 and tempera-
ture in Chapter 9, knowing when and when not to attend to bodily information is
crucial to embodied action.

Developing movement control

Humans are not born with intact proprioceptive abilities. Unlike species able to
immediately self-propel, as with the standing foal or calf, controlled human move-
ment takes time to develop. As Esther Thelen said:

Human infants are born with very little control over their bodies. Yet within a year or
so, they are able to sit, stand, walk, reach, manipulate objects, feed themselves, gesture,
and even speak a few words. A year later, toddlers are adept at running, climbing, scrib-
bling, riding a tricycle, and talking in simple sentences.1

The developmental study of movement has focused on postural control, the direct
shaping of perception and cognition by the environment, and on the adoption and
mastery of specific motor skills.
At birth, humans have intact basic movement reflexes, but learned movements
quickly overtake them. Francesco Lacquaniti and colleagues neatly summarized the
development of postnatal movement, showing how very young children explore
their environment with everything that is available to them, using all limbs:

Toddlers often place a foot on the obstacle or on the edges of the stairs, presumably
as part of an exploratory strategy of the environment. . . . Most toddlers spontaneous-
ly carry objects while walking, combining locomotor and manual skills. Despite the

34
 e m bodie d cogni t ion

additional biomechanical constraints, carrying an object is actually associated with

improved upright balance, as demonstrated by smaller probabilities of falling with the
object than without.2

Here, the authors refer to an intriguing naturalistic study of 13-month-old children

in their home environments. In a similar study of spontaneous carrying behaviors,
26 infants who were crawling and 24 who were walking were observed. The prevail-
ing view is that carrying behavior occurs only after movement control is established,
but the opposite was found: infants appear to spontaneously carry as a way of self-
training their movement control (Karasik et al., 2012).
What emerges from the contemporary study of postural control and motor devel-
opment is the idea of the infant as an active participant in the self-development of
locomotion. Many of the carrying episodes observed appeared to be without obvious
motivational purpose: “with no apparent object-related or mother-related destina-
tion” (Karasik et al., 2012, p. 394). Pushing or carrying objects in hand, under one’s
arm, or in one’s mouth, for no purpose might appear biomechanically inefficient, but
may actually be part of locomotor self-training. Even before walking or crawling, we
are feet-reaching toward intrinsically attractive objects, using the environment for
locomotor development (Galloway and Thelen, 2012). From the very beginning of
rudimentary motor control, we are driven to engage with the environment.

Embodied cognition

This functional view of human movement extends beyond motor learning. For
example, a popular movement in cognitive science, which has come to be known as
embodied cognition, views movement as central not only to the development of pro-
prioception, but also for cognition. In its purest form, this view is of all cognition as
situated: of movement that is always of and for action. Rather than viewing the body
as simply a receptacle for the mind, as a means of moving a thinking machine around,
the mind is a product of physical being in interaction with the world. In 2002, Mar-
garet Wilson recognized the popularity of this emerging set of ideas and mapped out
six versions of it as she saw them developing. She is troubled by the most extreme of
these ideas, which essentially positions the mind as one enmeshed part of a continu-
ous, highly integrated information flow (Wilson, 2002). For a deeper analysis of this
position it is worth visiting Thomas Stoffregren and Benoît Bardy’s important discus-
sion piece, “On Specification and the Senses” (Stoffregren and Benoît, 2001).
Movement creates the possibilities for thought. It is only in exploration that intelli-
gence can emerge. Another way of thinking about this comes from computer science.
How do we train an artificial intelligence? In “Six Lessons from Babies,” Linda Smith and
Michael Gasser asked what we can learn about embodied cognition from the develop-
ing child. For our purposes, lesson four is the most important: “Babies explore—they

35
 mov e m e n t

move and act in highly variable and playful ways that are not goal-oriented and are
seemingly random. In doing so, they discover new problems and new solutions. Explor-
ation makes intelligence open-ended and inventive.”3 Smith and Gasser conclude:

Young mammals, including children, spend a lot of time in behavior with no apparent
goal. They move, they jiggle, they run around, they bounce things and throw them,
and generally abuse them in ways that seem, to mature minds, to have no good use.
However, this behavior, commonly called play, is essential to building inventive forms
of intelligence that are open to new solutions.4

Exploring space, and exploring one’s manipulation of space, functions to train

proprioception, and through that training create the possibilities of cognitive
development.
This training of and by locomotion continues throughout infancy into adoles-
cence. Walking patterns are still in development well into adolescence. Movement
skills are crucially important to master in childhood because competency at walking,
hopping, throwing, and catching are associated with a lower risk of obesity and the
associated health benefits that accrue from exercise, potentially across the lifespan
(Lubans et al., 2010). The finding that low competency in fundamental motor skills is
associated with low physical activity is not unusual (Hardy et al., 2012) and perhaps to
be expected, interrelated as they are.
Only now emerging, however, is information to suggest that lower competence
in fundamental motor skills increases the risk of obesity and exercise avoidance. For
example, in one study of 5- to 13-year-olds, poor motor control, measured objectively
with tasks such as walking backward on a narrowing beam and one-legged hopping
over an obstacle, significantly predict an increase in body mass index two years later
(D’Hont et al., 2014). It is too soon to tell whether difficulty in catching and throwing
in childhood can be used as an indicator of increased risk of morbidity. If the lessons
of babies are true for adolescents, then we might expect that any reduction in oppor-
tunities for exploratory play or movement in the world will limit proprioceptive
development and possibly cognitive development.

Clumsiness

How good are you at throwing and catching a ball? When Mark LeGear and his col-
leagues asked 260 children in kindergarten (aged about five years old) this question,
the average answer was very positive. In fact, it was a lot more positive than their
actual abilities, which were quite poor. Girls were more positive than boys (LeGear
et al., 2012). So what happens to this confident start on our view of our own motor
abilities? Unfortunately, it does not last very long. Jacqueline Eccles and colleagues

36
 im prov ing motor pe r for m a nce

show that older children are more accurate, or perhaps more pessimistic, in their
perception of how competent they are at throwing (Eccles et al., 1993). In a synthesis
of 22 meta-analyses of studies assessing people’s perception of their own abilities,
it becomes quite clear that we are pretty bad at judging our own abilities (Zell and
Krizan, 2014). We witness our abilities all of the time, but somehow still have a biased
perception of them. This perception failure is an interesting puzzle. For example, it is
not clear whether the biases in our self-perception are general across domains (from
mathematics to throwing and catching) or whether they are domain-specific. Also
unclear is how stable or open to influence these biases are.
Daniela Rigoli and her colleagues have argued that this self-perception is more than
just an abstract puzzle. A sample of 93 adolescents with poor motor coordination
showed elevated emotional problems, principally anxiety. However, this study had a
measure of self-perception of ability. The relationship between motor coordination
and emotional state was mediated by the self-perception of poor ability. In other words,
believing you have poor motor control is what makes it possible for poor motor per-
formance to be linked to anxiety (Rigoli et al., 2012).
Some people have motor problems that are severe enough to attract a label of
dyspraxia, also described as a motor coordination disorder. Although commonly
thought of as a developmental disorder, many people continue to have problems into
adulthood. Amanda Kirby and colleagues found that adult coordination problems
were characterized by items such as “have difficulty playing team games, such as foot-
ball, volleyball, catching or throwing balls accurately” (p. 135), with 75.5 percent of the
sample agreeing that this was usual. Fine motor movements such as writing, captured
with the item “have difficulty writing neatly when having to write fast” (p. 136), were
endorsed as usual by 71.4 percent (Kirby et al., 2010).
Part of Kirby and colleagues’ interest in adult motor control problems was the
extent to which one is able to compensate for and work around coordination prob-
lems. They found that avoidance of group activities, such as team sports and social-
izing (when it included dancing), was common, as were difficulties in the mastery of
social skills such as driving, reading, self-care, and financial management. Although
such motor disorders are common, there is little research into people’s perceptions
of their motor abilities, except in diagnostic interviews or in accounts of a specific
experience of dyspraxia resulting from developmental disorder or brain injury. Casey
Edmonds argues that for children, at least, this lack of research into their experience
leaves them at risk of poor education and social exclusion (Edmonds, 2013).

Improving motor performance

Psychology has long been interested in the improvement of motor performance; in

particular, as it relates to skill development. Most of us, even as adults, are visited by
the idea of learning a new skill, such as playing a musical instrument or improving

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 mov e m e n t

performance in a sport: in my case, learning piano as an adult novice and trying to

run a faster marathon.
We have seen already that perhaps more than any other sensory system, propriocep-
tion needs training. Interaction through locomotion, play, or object manipulation is how
one learns about the world and how one sharpens sensory systems to allow learning
about the world. Specific skills, however, require repetition of movement. Whether one
is learning to shape a ceramic pot (Gandon et al., 2013), returning a beach volleyball serve
(Cañal-Bruland et al., 2011), or mastering the Chopin’s Ballade No.1 in G Minor (Rus-
bridger, 2013), skill acquisition is dependent on repetition. Practice is undeniably crucial.
Anders Ericsson has busily worked on expert performance and the psychology of
experts for over 20 years. He introduced the idea that skills take at least ten years of
effortful practice. This seems to be true of academic, physical, sporting, and musical
expertise. The idea is now more commonly accepted, but it is worth reflecting that
he and his colleagues were presenting these ideas against a backdrop of the lingering
Victorian belief in the inheritability of limits to ability. Of course, many people work
away at physical skills for more than ten years and appear to plateau or go backward.
In their authoritative summary, Ericsson and his colleagues Ralf Krampe and Clem-
ens Tesch-Römer addressed the important question of what we mean by practice.
They were particularly interested in deliberate, goal-directed practice. In two studies,
one of violinists and one of pianists, they conclude:

People believe that because expert performance is qualitatively different from normal
performance the expert performer must be endowed with characteristics qualitative-
ly different from those of normal adults. This view has discouraged scientists from
systematically examining expert performers and accounting for their performance
in terms of the laws and principles of general psychology. We agree that expert per-
formance is qualitatively different from normal performance and even that expert per-
formers have characteristics and abilities that are qualitatively different from or at least
outside the range of those of normal adults. However, we deny that these differences are
immutable, that is, due to innate talent.5

They also make an intriguing suggestion for future research that has not been well
developed; namely, that we should view experts not only as expert in their skills, but
also experts at practice, experts at summoning and maintaining motivation to prac-
tice, and experts at resisting distraction.
In some ways the idea that one can, with enough grit and determination, and with
ten years, or over 10,000 hours of deliberate practice, achieve expertise is now as
popular as the biological determinism Ericsson and colleagues were reacting against.
David Hambrick and colleagues comment that this idea has been popularized in
journalism, most prominently in Malcom Gladwell’s book Outliers (Gladwell, 2008),
and they describe the ideas as a popular myth. They argue:

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 pe r sona l t heory of mov e m e n t

Deliberate practice does not explain all, nearly all, or even most of the variance in perform-
ance in chess and music, the two most widely studied domains in expertise research. Put
another way, deliberate practice explains a considerable amount of the variance in per-
formance in these domains, but leaves a much larger amount of the variance unexplained.6

The extent of expertise is, however, to some extent a personal value judgment.
Anders Ericsson has made the point repeatedly that what counts as success in skilled
movement changes each year, whether it is Olympic records being re-made or once
famously unplayable musical pieces like the Chopin Ballade now in the repertoire of
the amateur. The 10,000 hours is a contextual idea—it is about the time invested in
adjusting to environmental restrictions. But when we come to look at the experience
of the expert, there are two aspects that are not commonly discussed, but are pertin-
ent to our functional exploration of the physical senses. The first extends Ericsson and
colleagues’ interesting idea that perhaps as important to understand as the amount
of practice undertaken is its psychology. Is practice more than just movement repeti-
tion? The second relates to the experience of experts in the act of their expertise. What
is the role of awareness in relation to limb and body position, or bodily movement
and locomotion, during skilled performance?
The acquisition of motor skills is typically thought to happen without awareness
or central monitoring. But practice in the pursuit of skills acquisition is at least delib-
erate in its initiation: we decide to practice a task. But are one’s beliefs about practice
and its effects relevant to performance? In one study, 45 male Gaelic football players
were asked to make two kicks toward goalposts, one from their hands and one from
the ground. The footballers were either experts or at an intermediate level. In addition
to measuring performance at different stages of practice, the researchers investigated
the footballers’ subjective physical exertion, mental effort, and enjoyment of phys-
ical activity. The results were that the expert group “invested greater physical effort,
greater mental effort, and rated practice activity as being less enjoyable than did the
intermediate group” (Coughlan et al., 2014, p. 457).
At one level this is perhaps not surprising. That could be a good summary of what
makes an expert. But what is surprising is the self-report. Developing Ericsson’s idea,
what may be as important as practice for motor performance is a personal theory of
movement, a reflexive account of what one is engaging in, why, and exactly how.

Personal theory of movement

There are two schools of thought when it comes to the idea of a personal theory of
movement, which are opposed. The first can be called mindful. A number of authors
have argued, as with Coughlan and colleagues and their Gaelic football players, that
if you ask people directly they will tell you about their bodies in motion. Perhaps it is

39
 mov e m e n t

just that psychology has not traditionally been a part of the study of motor perform-
ance, which is dominated by interests in physiology, biomechanics, and the applied
practice of training. We don’t have a research habit of investigating experience, and
seem to avoid self-report data. Rebecca Lewthwaite and Gabriele Wulf have argued
that a grand challenge in movement science will be to embrace a broader cognitive
and emotional perspective (Lewthwaite and Wulf, 2010).
The second school of thought can be called mindless, not meant pejoratively. Gun-
ner Breivik calls the state of lack of awareness of motor control “zombie-like” (Breivik,
2013). The extreme form of a mindless view is that highly automatized expert behavior
does not need conscious control; in fact close attention to expert skills might actually
be disastrous to performance. If I ask the concert pianist to think carefully and in detail
about where she places her fingers on the keys and their touch and feel, such executive
control of action will slow performance. Andrew Greeves and colleagues reported an
analysis including interviews with expert concert musicians who were emphatically of
this opinion (Greeves et al., 2014). Not everyone agrees, of course, and there is a move-
ment for exploring what mindful playing could add to performance (Montero, 2010).
Skill and practice awareness are likely to be individual to the context of the skill, but
there is an intriguing gap in our knowledge. The developmental model suggests that
children engage in a great deal of self-exploration. When an infant sits and watches
her hands manipulating an object, she is actively creating connections across motion
sensing systems; it is neurological development in action. When the expert pianist
makes decisions about whether to practice more, and what to practice, she is apply-
ing a theory of what needs to improve, based in part on proprioceptive feedback.
An acrobat planning to fly through the air to catch a moving swing would not do it
without first planning and practicing the required moves. But as to whether individ-
uals in the very act of performance are partially or wholly controlling actions, or are
relegated to the status of observer of those actions, we do not know.
To explore these ideas further, I talked with Luke Rendell (see Box 3.1).

Box 3.1. Luke, the acrobat: “it is more about focus than thinking”
Luke is an acrobat with Cirque du Soleil. He competed as an athlete in trampoline with
the Great Britain team. He also trained in dance. When we talked he was on a break from
performing ten shows a week in the Michael Jackson One extravaganza. Luke described
himself, and his fellow athletes, as adrenalin connoisseurs. He is someone who enjoys
being expert, and admires people who can transfer expertise and excel across domains.
I was particularly interested in his experience of precision and flight, of understanding
a body in motion.

______________________________________

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 pe r sona l t heory of mov e m e n t

Box 3.1. Continued

Chris: Do you know with any precision your position in the air as you fly?

Luke: Yes, I do. It comes from training. It is just like catching a ball. If you are somersault-
ing and you are short of rotation or you’ve travelled a little bit, you know exactly where
you are because you have done it so many times. The trouble is that these skills are not
in normal walks of life.
Chris: What does it mean to be aware of your body in flight?

Luke: You do learn aerial awareness and where you are in space when you are somer-
saulting or twisting, and you learn what is around you, but then you do get the odd
talented person who can get in trouble in the air but know where she is and can get out
of it and land on her feet, like a cat. These people have an extra talent. What you do in
the air is such an unnatural thing. If you think you are going to mess it up, you will. You
need to think more basically. People are extremely spatially aware and very quick on
reactions. They will get lost and then find themselves again, in a split second. Transfer
that from sport into an acrobatic act: you have ten people, three trampolines, people
jumping over and under you, or running up the wall with someone at the top of the wall
there to catch you. You have to learn this extra awareness. You have to be able to know
your way around so well, and for it to be automatic. Your friends need to be “on it” also,
because if he messes up I am in trouble, or if I mess up he is in trouble. You are dealing
with life-or-death situations. You are 25 feet above the ground and you have to know
exactly where you are.

Chris: How can one be aware, but at the same time not think too much?

Luke: It is an optimum thing. When you are on a trampoline you are thinking about
parts of a skill, or you go into meditation. If you think about it too much it will mess up.
However, when you are doing the move, you get into that zone of automaticity and you
don’t think—you just do it. When you mess it up it is like a blank part of your mind, the
world collapses almost and then you think: “Oh no, I am in trouble now: I don’t know
how to get out of this.” So when you are training hard you have to be in a balanced mind.
You can’t be concentrating too much on the skill and you can’t be not concentrating.
You have to be calm and ready to go. It is more about focus than thinking.

Chris: But does this awareness extend to personal space? Being aware of others’ position
in space relative to you?

Luke: It happens naturally. You find in a lifetime of trampolining that you start to know
whether people are about to fall and whether you need to catch them, so transferring this
to the circus, you know when you need to follow and what is safe. It is automatic. You
have a sixth sense of being safe or unsafe, distance-wise—as long as you are not going
to hit me in the face and knock me out, then you are good. Some, like trapeze artists,
are catching less than a foot away. When they come round from a triple and reach for
their catcher, his arms may have to be bent. Not catching is not an option, it is black or

(Continued)

41
 mov e m e n t

Box 3.1. Continued

white. You have to catch— you have to know that you are going to save that man and he
is going to save you.
Chris: Do you need to give verbal instructions or is it unspoken?
Luke: Any extra sound distracts some members, and they worry. Sometimes you com-
municate to motivate. I might say, “I have you” or “Watch out.” We try not to commu-
nicate with new artists, but when you know people well you know when to speak and
when not to speak. Sometimes they say, “Shut up: don’t say anything to me. I know
when I am in trouble.” It is a pride thing.
Chris: You mention worry. Is there fear when you are flying high up?
Luke: It is situational. If you are standing in a cage that someone says is safe, even if it is 60
feet up, it is safe. Take away that cage and put a solid platform there. Stand on the edge
of that and look down—you will get vertigo. I would have done that before Cirque. But
you go into that environment and you train and train, and it becomes automatic. Then
you add a handloop. Hang from that. Now I am 60 feet up and relying on just my grip. It
becomes even more dangerous. Then you rely on yourself and your own anxiety. If you
get too anxious, too nervous, it could go the other way. This is what I have learned. Don’t
concentrate too hard, but concentrate; don’t get too nervous, but nerves are good. You
have to have both and you have to make sure it is at its peak. We need to have explosive
power to get where we want to be, but can’t be too anxious because then the nerves and
the adrenalin go too far.
Chris: Is peak performance about a balance of fear and attention?
Luke: I know what I am going to do before I have done it. I know what will happen before
it happens. In my mind I am watching myself, and watching myself through my eyes.

______________________________________

Luke expresses beautifully the tension between awareness and automaticity. He has a
complex personal theory of movement that does not fit the simplistic dualism of mind-
ful or mindless. Knowing exactly where you and others are in shared space, being scared
but not too scared, aware but not too aware, and ultimately being able to act and observe
oneself at the same time, are all unusual perceptual achievements. Luke shows how the
self-report of expert behavior can enrich psychology and be a useful theoretical tool.
We need to develop a language for these experiences of the expert, because our current
concepts are inadequate to the task of explanation.

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 pe r sona l space

Personal space

You know when someone is in your space. We don’t own the space around us, but
it feels like we do. How uncomfortable do you feel when strangers enter that space?
Biological psychology has defined this as peripersonal space, the reachable distance
immediately outside of the space you occupy. This definition, although a useful
summary, has been expanded to account for some anomalies. For example, you
can extend your space by tool use: if you carry a bag this is now in your space. We
have found that that space is not dependent on intact limbs; it remains in place after
loss of limb. Interestingly, although one cannot reach very far with one’s head or
by extending your tongue, peripersonal space around the head is much larger than
one’s reach. And, finally, this space is fundamentally malleable, dependent on a var-
iety of environmental and interpersonal factors (Cardinali et al., 2009). Your percep-
tion of being and moving in space is dynamic, action-oriented, and environmentally
contingent. For a good summary, Dorothée Legrand and her colleagues argue that
what we make possible relates constantly to our fixed location as perceivers, and that
multisensory input about personal space is integrated to allow us to act on the world
(Legrand et al., 2007).
Often this peripersonal space is described as an invisible bubble that defines the
limits of reach and of comfort. When two bubbles of egocentric interpersonal space
approach each other, or collide, how we move to re-establish acceptable distance
becomes an interesting focus of study. The management of interpersonal space, or of
the maintenance of your own peripersonal space, is known as the study of proxemics;
that is, the study of what is proximal (Bruno and Muzzolini, 2013). Proxemic con-
trol or awareness is variable and dependent upon gender, age, status, attraction, and
environmental influences such as light.
Marco Costa, from the University of Bologna in Italy, recognized that most stud-
ies of proxemics have been undertaken with only static stimuli. He decided to study
how people manage their interpersonal space when they are moving. He observed
1,002 groups (of between two and five people) walking in the daytime in an urban
setting. He found that women are more likely to walk abreast, whereas groups of
men will more often adopt a forward and backward position. Costa interprets
this to be a consequence of social dominance effects. He also found that groups
of three most often walk in a “<” formation with the central person receded. This
may be only an acoustically efficient strategy to facilitate communication, but is
more likely a specific effect of ensuring that one’s personal space, even in a group, is
maintained for all members (Costa, 2010). Taking this idea further, personal prox-
imity may also predict walking speed and changes in direction: the more crowded
a space is, the more one jostles (speeds up and changes direction) to maintain one’s
space (Frohnwieser et al., 2013).

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 mov e m e n t

Posing and strutting

What happens when one deliberately takes control of posture and movement? Can
we reverse the influence of social factors? Can we influence other people and their
perceptions of us by deliberately adopting different positions in space (posing) and
deliberately adopting different gait patterns (strutting)?
The first of these questions was examined experimentally with a focus on space-
taking expansive postures and space-limiting constricted postures. In one experiment,
93 young people engaged with actors who were secret confederates in the experi-
ment. These confederates adopted one of three postures: expansive, neutral, and
constricted. The postures adopted by the participants in response were recorded
and analyzed. The interest was in whether adopting expansive postures would
evoke mimicry in observers or whether it would evoke a complementary, opposite
response. There was no evidence for mimicry. In fact,

When the confederate displayed a dominant or submissive posture, participants were

likely to respond with the opposite kind of display. Dominance appears to invite sub-
missiveness and submissiveness appears to invite dominance. Dominant and submis-
sive behaviors do not just affect perceptions of the actor, as has been shown in previous
research, but also the behavior of people around that actor.7

In a second study, Tiedens and Fragale explored people’s sense of comfort and their
awareness of the posture they had adopted in response. Did they know they were
doing it? They did not. It seems that we are generally unaware of the posture we adopt,
which, given what we know about proprioception, is not surprising. More surprising
was the finding of this study that people report being more comfortable when adopt-
ing a complementary posture. In other words, we seem to like a vertical social order
to be observed, and posture is an immediate, nonverbal, and easy to communicate
means of establishing that order.
There is an emerging view that the social dominance encoded in postures may
be universal, and biologically mediated (Carney et al., 2010). But Lora Park and col-
leagues have argued that dominance postures are culturally constructed. They
examined three expansive sitting postures and compared them to a constricted sit-
ting posture. Figure 3.1 shows the postures. They compared student perceptions of
those born in the United States, and those born in East Asia, on these three different
power poses, using a variety of methods. Contrary to their general hypotheses, they
found evidence that expansive postures do indeed seem to communicate power and
dominance across cultures. However, more specific dominant poses, such as one that
involved putting one’s feet on the desk and displaying the soles of one’s shoes, vary
across cultures (Park et al., 2013). This shoe effect is perhaps unsurprising, as the dis-
play of shoes and feet vary in meaning across cultures. In Middle Eastern cultures,

44
 Expansive-Upright-Sitting-Pose Expansive-Hands-Spread-on-Desk-Pose

Constricted-Sitting-Pose
Expansive-Feet-on-Desk-Pose

Fig. 3.1. Three sitting poses, two expansive and one constricted.
Reprinted from Journal of Experimental Social Psychology, 49 (6), Lora E. Park, Lindsey Streamer, Li
Huang, and Adam D. Galinsky, Stand tall, but don’t put your feet up: Universal and culturally-
specific effects of expansive postures on power, pp. 965–971, Appendix A, doi:10.1016/j.
jesp.2013.06.001 Copyright (2013), with permission from Elsevier.
 mov e m e n t

for example, shoes are unwelcome or banned in religious building (Ibrahim, 2009,
p. 219). Being sensitive to the local cultural meaning of posture is important, but
nonetheless it appears that using more of your peripersonal space—seeking to fill it
rather than reduce it—could have far-reaching effects on both your own experience
of feeling empowered and your influence on others.
If some postures are universally constructed as dominant, are some gait pat-
terns also encoded differently to others? There is interest in whether emotion
is communicated in the way people walk, in their gait and posture (Gross et al.,
2010). In particular, there is a growing applied interest in whether we can identify
furtive, aggressive, or threatening behavior through observation alone; research
driven by a concern with security and threat identification. Unfortunately, there
is no mature research interest in how gait might shape the behavior of others,
either in proxemic control or in approach or avoidance of activity. One might
start with an approach similar to Lora Park and colleagues, and try to identify
emotional or intentional states universally encoded in bodily movement, such as
pain, aggression, or love.

Disorders of movement

There are many neurological disorders that alter one’s perception of position in
space. Incoherence from conflicting sensory input can cause perceptual illusion,
inaction, or compulsion, all of which invoke cognitive involvement in the form
of attention and executive control of action. Simply put, when proprioception
and kinesthesia fail to deliver the expected action, then the control of that action
becomes a task. There are acute movement and spatial awareness problems, such
as motion sickness; there are primary movement disorders that arise from ner-
vous system disease, such as Parkinson’s disease; and there are movement dis-
orders arising from brain injury, such as cerebrovascular insult, or stroke. From a
functional psychological perspective, I am interested in the experience of move-
ment disorders, grossly defined, not from within their biological categories but
from their phenomenological categories. Christine Klein defines movement dis-
orders as a

clinically, pathologically and genetically heterogeneous group of neurological condi-

tions. Despite this variability, there is considerable overlap between different forms of
movement disorders, as they all share the common features of impaired planning, con-
trol or execution of movement. (Klein, 2005, p. 426).

Three broad categories of altered experience can be explored across different condi-
tions: tremor, start and stop, and fine motor control. However, there is one extreme
case that is interesting because it involves a failure in belief rather than perception.

46
 t r e mor

Anosognosia

Anosognosia is a disorder characterized by a denial of a deficit (Coslett, 2005). It is

a useful concept that is rarely used because of its breadth and confusion with over-
lapping constructs, such as denial. But in spatial awareness anosognosia can be
described as a form of neglect with or without extinction. Typically the patient with
neglect will, as the name suggests, neglect information placed in the contralateral
side of the brain damage. Hence a right hemisphere stroke might induce a distortion
of perception in the left side of one’s personal space. This can be true for information
in any perceptual domain, although it is most commonly identified in visual-spatial
tasks. Extinction, a subtler observation, can occur in all perceptual systems “whereby
patients can detect a single stimulus in either hemispace, but fail when another iden-
tical stimulus is presented simultaneously in the other hemispace” (Cocchini et al.,
1999, p. 286). These symptoms are not of movement but of spatial awareness and
belief. The co-occurrence of a neglect of all information in a particular quadrant or
location in our peripersonal space—together with a strong, often emotionally dom-
inant belief that one is not ignoring that space: the ignored stimuli cannot possibly
exist—show how perception and belief can co-occur.
The case of brain injury is often quite specific and allows for the observation of a
disorder, but there is less interest and exploration in anosognosia in the broader cat-
egory of normal movement disorders. For example, there may be interest in extend-
ing the findings reviewed above on the common bias to a misjudgment of perception
of action, to a natural case of denial of action (Zell and Kirzan, 2014). Todd Feinberg
considers anosognosia as a part of a wider family of disorders of self (Feinberg,
2011). There is much to learn about how we come to deny experience in the space
we occupy (as in denying the existence or loss of a limb), how we deny experience in
our peripersonal space (as in neglect), and how we come to deny the existence in our
extrapersonal space (as in the case of attentional blindness). By definition, however,
any attempt to explore the phenomenology of denial will be brief.

Tremor

Tremor (trembling or rhythmic shaking) is a common experience of locomotor dis-

orders and occurs either as the primary presenting problem in essential tremor or
as a symptom, as in Parkinson’s disease (Grimaldi and Manto, 2013). There are some
studies of the experience of tremor, but they are focused largely on the disability
associated with disease or the lack of awareness and understanding among commu-
nities of the disease. For example, Gerry Mshana and colleagues reported a study of
people’s experience of Parkinson’s disease in rural Tanzania and the general lack of
understanding that dominates. One 65-year-old woman said “I get tired . . . the tremor

47
 mov e m e n t

is not only on the hands . . . the whole body tremors . . . even the intestines tremor . . .
and at night I get tired . . . I become unhappy” (Mshana et al., 2011, p. 4).
Although in some ways it is difficult to disentangle one particular symptom from
another in terms of its effects, the experience of tremor has not been adequately
described or understood. The effects of tremor on quality of life, and the indirect
effect on activities of daily living, are well mapped; but what it feels like to shake, and
the role of beliefs about the cause, consequence, and controllability of the experience
has hardly been explored. Given how close belief and perception can be, the absence
of any understanding of the personal meaning of tremor is concerning. There is the
beginning of a recognition of the importance of beliefs in movement disorders (Hurt
et al., 2015), and it will be interesting to see whether it can extend to a neuroscientific
study of the experience of tremor.

Start and stop

The specific experience of delay in the initiation of a behavior, freezing, or the inabil-
ity to control the stopping of a behavior, is particularly challenging for patients with
Parkinson’s disease or dystonia. The regulation of desire and will and the obedience of
our bodies in response to instruction are for many people distressing experiences. Con-
sider the experience of musculoskeletal injury, such as fracture, that biomechanically
denies movements, or of the experience of attempting to walk while dreaming. Typically
one experiences the sending of an instruction and confusion over the delay or lack of
response. As with tremor, there is no mature body of knowledge on the experience of
having a disobedient body or of experiencing a delay in motor control. There are hints
of concern. For example, Taku Hatano and colleagues interviewed patients and carers
with Parkinson’s disease and found that both patients and carers expressed a common
concern of not being able to keep pace with the patient’s movements, making the man-
agement of movement in peripersonal space an issue to address (Hatano et al., 2009). It
is not clear the extent to which people with motion delay or freezing develop a pattern of
excessive control in attending toward instruction, or whether further guided attempts at
executive control of action could improve the coherence of motor experience.

Fine motor control

In movement disorders that affect global planning and delivery, such as Parkinson’s
disease or cerebral palsy, the combination of motor and nonmotor symptoms affect
all aspects of function. But for some focal dystonias, especially peripheral dystonias,
they are often related to a specific activity, making their psychology different. Often
dystonias are specific to an occupation, such as arising from being a writer, a pian-
ist, a golfer, or a hairdresser. The psychology of peripheral dystonias is one strangely

48
 f ine motor con t rol

dominated by old-fashioned ideas of psychologically generated disability, with inves-

tigations of psychological characteristics in samples of patients presenting with pain,
anxiety, disability, and a threat to livelihood or career (Enders et al., 2011).
However, this old fashioned dualism of physical and psychological should be dis-
carded because it is both irrelevant and unhelpful. At face value patients often do
present anxiously, but the extent to which this anxiety reflects a premorbid tendency
to anxiety is normally unexamined. Alternative nonpathologizing explanations may
lie in the complexity of the environment of skilled performers, artists, or craft work-
ers, in movement repetition and the demands of their production. For one example
of this approach, Eckart Altenmüller and his colleagues explored the experience of
591 musicians with musician’s cramp. They explored the relationship between demands
for spatiotemporal precision from different instruments and showed that behavioral
triggers were important to the onset of the dystonia (Altenmüller et al., 2012), in par-
ticular the demands of individual instruments on particular dystonias.
The psychology of movement disorders is struggling to move away from a clin-
ical habit of framing patient experience as psychopathological. What is needed in
the psychology of movement is an understanding of felt experience as an expression
of a perceptual system driven to deliver phenomenological and behavioral coher-
ence. Missing is the voice of the person struggling to make sense of changes in their
embodied cognition.
To explore these ideas further I talked with Jeremy Clark (Box 3.2).

Box 3.2. Jeremy, recovering from stroke: “you take things for granted”
Jeremy had a stroke only 20 days before we talked. He had a right-sided cerebral infarct,
leaving him with left-sided loss of sensation and motor control. He also had a right
carotid endarterectomy to remove the offending plaque. He was active in early rehabili-
tation. We did not talk for long because he was easily fatigued, but he was keen to talk
about his experience of movement and movement effort.

______________________________________

Chris: How sudden was the experience of stroke?

Jeremy: My feeling about a stroke before I had one was that it was something very
dramatic. And instant. To me, although the end result was quite dramatic, the actual
event itself didn’t seem to be dramatic. It develops. There is constant monitoring as it
is going on.
Chris: How would you describe the dominant feelings now?

(Continued)

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 mov e m e n t

Box 3.2. Continued

Jeremy: Absolute frustration. Very fatigued. Tired all the time. And I am constantly aware of
an area of pain in the legs on the left hand side. Frustration is the biggest thing I am dealing
with at the moment: of not being able to do simple things. You take things for granted. You
put your hand on the table and the physical therapist says, “Tuck your fingers in,” and you
try and do it and it does not happen, and you don’t know how to do it. It is so frustrating.
Chris: It must be hard when your body does not obey.
Jeremy: Yes. You then worry it is never going to. If movement does not happen when in a
relaxed situation, will it ever? I will get there. You just have to believe that really.
Chris: Does it feel like you are sending messages that are not being received?
Jeremy: I suppose that is my problem. Technically I don’t know how to send that message.
When you think about it, it is rather amazing that the brain sends these messages. I am
not aware of sending them, and in some instances I am not sending them. It is amazing
that today my index finger is moving. How I am doing that I have no idea.
Chris: What are the major concerns now?
Jeremy: Where I go from here really. If I can get back to near where I was before the stroke
I will be happy. It is the loss of mobility and independence that you take for granted with-
out a stroke. Being able to get up and go somewhere, being able to drive. Even walking the
dog. That is a fear. Getting back to some form of normality, to the same position as before.
Chris: Is this the focus of the treatment?
Jeremy: They have me up standing and walking which gives a sense of progress, because
you can still have an element of control over that when you are doing it. You can still
sense that you are doing things that affect the outcome. It is going through the mech-
anics of moving. How your feet fall in walking, putting your legs and feet in the right
position. Quite intriguing really; I have never thought that much about walking. That is
what you take for granted. When you walk somewhere you don’t think about where to
put your feet, you just do it. Hence the frustration.
Chris: Does belief that you can move matter?
Jeremy: You have to believe you can do it, be convinced, and trust in the professional. The
longer I am being encouraged, and the more I practice and rethink everything about
moving, the better the signs are. I believe it will come.

______________________________________

The simplest of movements become frustratingly difficult. The experience of movement

disorders are of a disobedient body. But, as Jeremy discusses, the lack of control, of try-
ing to experience the sending of messages, is more than a simple on/off switch. Belief in
movement, practice, exploring the sensation of wanting and wishing to move, is part of
the rehabilitation, or working to new limits.

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 su m m a ry

Summary

We take our motor performance for granted. It is only when a child, when we are try-
ing to learn or perfect a skill, or when we suffer disease or injury, that we come to
appreciate the astonishing achievements of how our bodies move in space. Psychology
has been relatively slow to embrace movement as perception, despite a growing inter-
est in embodied cognition. A strong version of movement psychology is needed that
embraces the phenomenology of position in space and how who we are can change
through movement. Important will be to know how far practice is really important in
skill development, not just for the expert, but for us all. Important will be to develop
our concepts beyond the simple dichotomies of awareness. Alterations in movement
perception are not simple biomechanical degrees of freedom. Movement is central to
ego development, to intelligence, and to shaping the behavior of others.

Notes

1. Reproduced from International Journal of Behavioral Development, 24 (4), Esther Thelen,

Motor development as foundation and future of developmental psychology, p. 385
doi:10.1080/016502500750037937 Copyright (2000), with permission from SAGE.
2. Reproduced from Current Opinion in Neurobiology, 22 (5), Francesco Lacquaniti, Yuri P
Ivanenko, and Myrka Zago, Development of human locomotion, p. 825, doi:10.1016/j.
conb.2012.03.012 Copyright (2012), with permission from Elsevier.
3. Reproduced from Linda Smith and Michael Gasser, The Development of Embodied Cog-
nition: Six Lessons from Babies, Artificial Life, 11 (1–2), p. 13, doi:10.1162/1064546053278973
Copyright © 2005, Massachusetts Institute of Technology.
4. Reproduced from Linda Smith and Michael Gasser, The Development of Embodied Cog-
nition: Six Lessons from Babies, Artificial Life, 11 (1–2), p. 13, doi:10.1162/1064546053278973
Copyright © 2005, Massachusetts Institute of Technology.
5. Reproduced from Anders K. Ericsson, Ralf T. Krampe, and Clemens Tesch-Römer, The role
of deliberate practice in the acquisition of expert performance, Psychological Review, 100 (3),
p. 400, doi:10.1037/0033-295X.100.3.363 © 1993, American Psychological Association.
6. Reprinted from Intelligence, 45, David Z. Hambrick, Frederick L. Oswald, Erik M. Altmann,
Elizabeth J. Meinz, Fernand Gobet, and Guillermo Campitelli, Deliberate practice: Is that all
it takes to become an expert?, p. 41, doi:10.1016/j.intell.2013.04.001, Copyright (2014), with
permission from Elsevier.
7. Reproduced from Larissa Z. Tiedens and Alison R. Fragale, Power moves: Complementarity
in dominant and submissive nonverbal behavior, Journal of Personality and Social Psychology, 84
(3), pp. 563–564, doi:10.1037/0022–3514.84.3.558 © 2003, American Psychological Association.

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 CHAPTER 4

PRESSURE

T here is a class of experience that comes when forces are applied to our bodies,
when we attempt to move the whole body or parts of our bodies, or when the
outside world resists force. I call these senses, the senses of pressure. I am interested in
those experiences that we often discuss as the action of a braking system that allows or
restricts movement. Pressure is not the most exact noun, but it is the closest in English I
could find. It captures the sense of force against resistance. There are eight sensations
of pressure narrated as four sets of opposing pairs. I am interested in the experiences
of being flexible or stiff, strong or weak, heavy or light, and swollen or reduced.
Action is limited by a number of interrelated physical, biomechanical, and sensori-
motor features. The simplest perhaps is the case of a physical barrier caused by an
enlarged limb or organ denying free range of motion. Imagine an arm so swollen that
you cannot move it freely without it colliding with one’s chest, or a stomach and chest
so large that an arm is restricted in its range of motion. Mechanoreceptors are distrib-
uted throughout peripheral structures and are in some ways the most complex of all
sensory receptors (Delmas et al., 2011). The cortical fate of position and force informa-
tion is partly dependent on the origin and function of the sensory information. The
perception of pressure is broadly represented across multiple cortical, subcortical,
and brainstem structures.
Emerging is an architectural idea of a tensegral living system of interrelated, often
opposing, pressures—a perfect interdependent system in which live physical struc-
tures operate with and against each other to produce a unified system. The structures
are in part elastic, and can change their elasticity in response to force. In the language
of ecological perception, the environment affords the perception of pressure through
the medium of interacting muscle, skeletal, and connective tissues that envelop us
(Turvey and Finseca, 2014).
Many people could have helped me in exploring these pressure sensations. But
two had particularly relevant experience of working with or against their brakes.
First, I interviewed Emma. Emma is a yoga teacher. Every day she works to extend
her limbs into full stretch. Freedom of movement is important to her; removing
restrictions to the extent and fluidity of movement are key to the practice of yoga.
Second, I interviewed Marni, who was diagnosed with lupus in 2008. Feeling
restricted in her movement because of stiffness, swollen joints, and heaviness are
all part of her life.

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Flexibility

How flexible you are is normally defined by a test of your range of motion on a par-
ticular movement. But as anyone who has ever attempted to take part in an organized
sport will know, there is a popular view that stretching—extending a movement to
the extent of the range of motion and holding it—has beneficial effects, either imme-
diately in extending range as part of a pre-exertion, warming-up exercise aimed at
improving performance, or in reducing the risk of injury (Behm and Chaouachi, 2011).
Changing the range of motion of joints before exertion seems like a good idea.
However, the idea that static stretching—the short-term extension and hold of a
­position—is beneficial has been hotly debated. Indeed, some studies have found no
benefit at all. Katie Small and her colleagues reported an early meta-analysis of the
effects of static stretching as part of warming up but found no real benefit (Small et al.,
2008); a finding repeated by Mari Leppänen and her colleagues (2014).
Perhaps as important as whether stretching is effective, is whether people believe it
to be effective (Beckett et al., 2009). In one study, Sandra O’Brien Cousins surveyed
143 women aged over 70 about what they thought the likely benefits or risks might
be of different exercises. She included six categories: walking, cycling, water exercise,
arm curls, push-ups, and stretching. Two thirds of the women believed that stretching
would likely be of benefit. However, of all of the exercises suggested, including push-
ups, the largest number of responses about fear of risk came for stretching. Twenty
percent of the women expressed a concern that it would “hurt my neck/back”; 8 per-
cent said simply that they did not believe they could do it (O’Brien Cousins, 2000).
Often conversations and instructions to exercise as a way to increase flexibility imply
that static stretching is a relatively low-level, easy, and simple method of warming
up. However, what little data there are give the opposite impression: the experience
of stretching is, for some at least, unwelcome or feared, and is believed to be injury-
inducing, not injury-preventing.

Stiffness

Avoiding stretching for fear of injury or because it is judged unpleasant raises the
question as to how the opposite state is experienced: what it feels like to be stiff, either
in terms of a limited range of motion or a lack of fluidity of movement. Stiffness is a
symptom common to many diseases, but it has probably been most studied in rheu-
matology. Stiffness, especially morning stiffness, is part of the diagnostic criteria for
various rheumatologic conditions, such as rheumatoid arthritis, fibromyalgia, and
ankylosing spondylitis. Even so, it has traditionally been less investigated than the
other major symptoms of pain and fatigue.
Rheumatology has led the way in the quiet revolution in medicine of promoting
a greater understanding and prominence of patient experience, and measuring that

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 f l e x ibil i t y- st if f ne ss con t in u u m

experience as part of the outcome of treatments. If asked, patients report that stiffness
is a major source of concern. But you have to ask them. In one study, for example,
severe morning stiffness was a prominent reason for early retirement in a large sample
of German patients with early onset rheumatoid arthritis, although it has not trad-
itionally been discussed as a risk factor of occupational change (Westhoff et al., 2008).
In another study, stiffness was reported as part of the hard-to-manage flare in symp-
toms often experienced as uncontrollable (Hewlett et al., 2012; Flurey et al., 2014).
Ana-Maria Orbai was interested in what stiffness meant to different people who
were living with the condition. She and her colleagues ran four focus groups with
20 adults, and asked them in some detail about their experiences. Patients discussed
their experiences of stiffness as highly variable and thought that stiffness was related
to other symptoms of pain and swelling. They discussed the factors that exacerbate it,
including weather and inactivity, and activities that might relieve it. They also shared
their thoughts on when and where it was most likely to occur, and the limitations that
stiffness causes. One specific theme they identified as particularly interesting. They
labeled this theme individual context and meaning. Routinely, people rely on mechanical
metaphors to describe what it feels like to be stiff. For example:

In 2 groups . . . the experience of stiffness was described using imagery of the “Tin Man”
from L. Frank Baum’s The Wonderful Wizard of Oz. This description was spontaneously
produced in each group and elicited considerable acknowledgement from other group
members. In a third group a participant similarly described the effect of warm water on
the joints, as “greasing the joints . . . oiling what needs to be oiled”.1

Similar were the comments from Sarah Hewlett’s study. One patient said, “I feel I am
stuck together with superglue, everything is so stiff and won’t move”; another said,
“I’m locked in a box” (Hewlett et al., 2012, p. 71). Being restricted, held, fixed, or stuck
is at the center of this experience, but it is a feeling of restriction from within. It is not
about being held back by an external force, but a feeling of the whole machine—your
whole body—seizing up.

Flexibility-stiffness continuum

If we ask people about the experience of being either flexible or stiff, they can elo-
quently describe the sensations and their meaning as part of their lives. However, I
have presented them here as unique states. They are perhaps better represented as
part of a continuum: as one becomes more flexible, one feels less stiff, and vice versa.
Flexibility is something one is constantly moving toward or away from in time.
This temporal aspect is not often discussed in the scientific or medical literature, but is an
intrinsic part of how we approach managing the demands of pressure on joint structures.

57
 pr e ssu r e

To flex or not to flex, that is the question. Professional dancers, for example, have a
good understanding that flexibility is not a state to be achieved once, but something
to repeatedly work toward. Ballet training involves long periods of warming up with
and without a bar, and dancers have few rest periods (Twitchett, 2010). Professional
dancers have a sense of flexibility as inherently temporary, something to be achieved
and lost every day.
Yoga offers an interesting case. The general belief about yoga is that it is good for
flexibility. For example, the Beliefs About Yoga Scale has as an item that practicing
yoga means “I would become more flexible” (Sohl et al., 2011, p. 91). People who may
never have tried yoga believed it to have properties that improve flexibility. Further,
people practicing yoga often report that they do feel more flexible, and that this feel-
ing is welcome. For example, in a study of 42 older adults taking part in a clinical trial
of yoga, flexibility was high on their list of benefits:

Participants noted an improved capacity for stretching and renewed flexibility. As one
participant described, practicing yoga was instrumental in “learning how to stretch
properly.” For others, yoga practice restored function or enhanced baseline physical
fitness. One participant wrote, “I enjoyed the flexibility that had returned to my body. I
have noticed the difference.”2

Despite the perhaps anecdotal evidence about the real or perceived benefits of yoga in
improving flexibility there is little research. Research on this core part of the experi-
ence has not developed (Field, 2011).
Yoga is used in a range of different clinical areas, from primary mental health prob-
lems such as depression, to disease prevention, and to rehabilitation for many chronic
problems. In part the problem of the study of yoga is that it means different things to
different people. To some it is a whole approach to life; to others it is a set of specific
practices involving both mental and physical repetition with physical postures that
are achieved slowly and held. In the context of an investigation of flexibility, the nar-
rower consideration of yoga—a set of postures that extend one’s normal range of
motion—is relevant. For example, Zahra Rakhshaee conducted a study of just three
specific postures: the cobra, the cat, and the fish (see Table 4.1).
All three postures involve trunk movement. She was interested primarily in the anal-
gesic effects of these postures for adolescents with dysmenorrhea, but unfortunately
did not measure other outcomes, such as flexibility or strength, or beliefs about the
effectiveness of the postures. Although limited, this study does show how it might
be possible to focus on specific aspects of the practice of yoga for specific outcomes
(Rakhshaee, 2011). Other researchers are following this approach of working on spe-
cific postures by mapping their mechanical demands, with a view to advising how
one can become more specific in their application for specific problems (Wang et al.,
2013). I suspect that the next generation of studies of yoga, at least as applied in clinical
medicine and rehabilitation, will adopt this focused approach.

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 f l e x ibil i t y- st if f ne ss con t in u u m

Table 4.1: Yoga poses and descriptions used in clinical trial

Poses Performing Descriptions

1. Lie down with your legs together and your hands palms
down under your shoulders. Rest your forehead on the floor.

2. Inhaling, bring your head up, brushing first your nose, then
Cobra
your chin against the floor. Now lift up your hands and use your
back muscles to raise your chest as high as possible. Hold for a
few deep breaths then. Exhaling, slowly return to position 1,
keeping your chin up until last.

3. Inhaling, come up as before, but this time use your hands to

push the trunk up. Continue up until you are bending from the
middle of the spine. Hold for two or three deep breaths, then
exhale and come slowly down.

4. Inhaling,raise the trunk as before, but this time continue up

and back until you can feel your back bending all the way
down from the neck to the base of the spine. Breathe normally.
Hold the position for as long as you feel comfortable, then slowly
come down and relax.

1. Start on your hands and knees. Position your hands directly

beneath your shoulders and your knees directly beneath the hips.
Make your back horizontal and flat. Your spine will be at full
extension, with both the front and back sides equally long.
Cat

2. When you are ready to begin, breathe in deeply. Do this

by gently pulling the abdominal muscles backward toward
the spine, tucking the tailbone (coccyx) down and under, and
gently contracting the buttocks. Press firmly downward with your
hands in order to stay lifted out of the shoulders, and press the
middle of your back toward the ceiling, rounding your spine
upward. Curl your head inward. Gaze at the floor between your
knees.

1. Lie down on your back with your legs straight and your
feet together. Place your hands, palms down, underneath
your thighs.

Fish 2. Pressing down on your elbows, inhale and arch your back.
Drop your head back so that the top of your head is on the floor,
but your weight should rest on your elbows. Exhale. Breathe
deeply while in the position, keeping your legs and lower torso
relaxed. To come out of the pose, first lift your head and place it
gently back down, then release the arms.

Reprinted from Journal of Pediatric and Adolescent Gynecology, 24 (4), Zahra Rakhshaee, Effect of Three
Yoga Poses (Cobra, Cat and Fish Poses) in Women with Primary Dysmenorrhea: A Randomized
Clinical Trial, pp. 192–96, doi:10.1016/j.jpag.2011.01.059 Copyright (2011), with permission from
Elsevier.

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 pr e ssu r e

Yoga is typically undertaken as an activity in and of itself. In its Westernized forms, at

least, yoga is seen as a lifestyle intervention: a personal exercise and health choice. It often
involves a narrative of personal growth and development. In this context it is different
from the invitation to consider stretching as part of a seniors’ exercise class, as a part of
warm-up routine, or as a way to respond to morning stiffness from rheumatoid arthritis.
Perhaps the meaning of stiffness and flexibility is different for those who choose
to live some of every day at the extremes of their joint ranges of motion. What does
flexibility and stiffness mean to the dancer or the yoga teacher?
To explore the idea of the flexibility-stiffness continuum further I talked to Emma
Roy (Box 4.1).

Box 4.1. Emma, the yoga teacher: “I am aware of my body all the time”
Emma lives in Wiltshire. After many years running a successful restaurant, she turned
to yoga, first for herself and then as a teacher. She describes herself as highly sensitive to
her environment and aware of herself in relation to the environment. I asked her to help
me understand what being flexible can feel like.

______________________________________

Chris: What does flexibility feel like? Is it just the absence of stiffness?
Emma: When I first started, there were many things I could not do. The feeling of being flex-
ible is fluidity, it is flow, it feels like there is nothing there to hinder. It feels like open space.
So just as I can sweep my hand in front of me, that is how it feels on the inside and so then
I can choose where I am going to move. It is actually something I am working more with
now: allowing the body to move me, allowing my body to move where it wants to move.
If my arm wants to move to a certain position it moves and it feels right. Then it is right.
Chris: So the feeling of fluid movement is important.
Emma: It is about not jerking. Because if you move quickly it will feel tight, but when you
move with gentleness, the body is being allowed to investigate and go where it wants in
its own way. And I think this is where taking the mind out of it is important. I will often
talk about playing with not being in control. I will work with a movement. Often it is how
people have already decided to think about a movement, and when they try it and they
can do it, it is a surprise to them. Then it opens the mind to thinking of things as possible.
For me, when I want to play with something I go into an inquisitive approach. I will deal
with whatever comes. It is about being willing to investigate, to play the game, to have a go.
Chris: Does having a heightened awareness matter—what is often called mindfulness?
Emma: I think what others call mindfulness I would call creative awareness. We take so
much for granted. We don’t think about our physical movements. Creating an aware-
ness of movement, of feeling, of the emotions that might be attached to the movements:

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 f l e x ibil i t y- st if f ne ss con t in u u m

Box 4.1. Continued

for some people sometimes it can be very shocking. I remember reaching one move-
ment I did not think possible and I had an explosion of emotion that I did not understand
and just accepted. I think mindfulness is the kindergarten, the first stage of reaching a
level of creative awareness.
Chris: For many people that level of creative awareness might be frightening at first.
Emma: Yes, it is scary. First you feel a fool. Second, the brain has worked out what move-
ments do what. So if you do something different and bizarre with a movement, that is going
into the unknown. For me, it is going into a place of inquiry. When you allow the body to
be in charge rather than the head, then you have a completely different experience of life.
Chris: Do you think people can gain from adopting the yoga postures just as postures?
Emma: Well, I am sure you can do that. But without being encouraged to move into other
aspects of the experience, it feels a bit flat. But when you look at it in relation to grav-
ity and the feeling of the movement, it is massively different. When you come out of a
posture, what happens next? The counterposture is needed to relieve the body of the
movement. It is a kind of dance, but a structured dance. But within that structure you
can find your own personal experience—when you are given the opportunity, when
you are safe to explore your body.
Chris: It sounds so very positive. Are there any negative aspects to the experience?
Emma: At the beginning perhaps. Yes. I used to be the kind of person who pushed myself
to the absolute limit. And that included flexibility. An example of how flexibility can
play against you is from when I had been in my yoga class with my first teacher and we
were doing a position that is seated with feet flat together and knees spread to the floor
bending forward. It puts a lot of pressure on the abductor muscles. I am working away,
really going for it. Of course, that is not the way to do yoga, and I felt them go ping. It took
three years for them to recover: they just felt really tight. A lot of the time it was because
I was allowing my flexibility to go beyond its safe range because there was this feeling I
had of wanting to do more. Now I understand that it is OK to stay within my safe limit.
Chris: And now? Are you aware of your limits now?
Emma: Yes, but now I am also aware of my body all the time. My feeling of being com-
plete is all the time. As I sit here now, I am very aware of how my bottom is feeling on
the cushions. I am very aware of what I am seeing and how I am feeling. It is going on all
the time. It is tiring sometimes, I will admit that, but the growth that has come from it
is phenomenal.
______________________________________
Emma lives on this flexibility-stiffness continuum. She has trained over many years to
understand the limits of what is possible, of how far she can go before being stopped. But
her experience shows that the overcoming the limits is effortful and requires investment
in a whole understanding of how to live. These are not exercises but a choice to gain and
sustain an awareness of being embodied, and so living within and against, physical limits.

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Strength

How strong are you? Or, in other words: how much weight can you bear, and for how
long? These are complex judgments that inevitably involve the interplay and inte-
gration of other interoceptive sensations, such as fatigue and pain. However, as with
our other neglected senses, there is a language of strength. When we refer to feeling
strong it has both a physiological reference and a cultural relevance.
In many societies, feeling and appearing to be strong are highly valued. Doug McCreary
and Doris Sasse recognized early that the once-marginalized idea of building muscle was
transferring into mainstream culture. They established a measure of what they called a
drive to muscularity that included items about satisfaction with body shape and size, and
behaviors people adopt that will change muscle mass, but it also included beliefs about
physical strength, such as “I think I would feel stronger if I gained a little more muscle
mass” (McCreary and Sasse, 2000, p. 299). Although this aspect of a drive to muscularity
is more prominent in men than women (McCreary et al., 2004), being muscular is also dis-
cussed by women, and in some specific cultures, such as women’s bodybuilding, muscle
definition is constructed as core to their feminine ideal. In this subculture, however, feel-
ing physically strong is often exactly what is at stake in bodybuilding (Grogan et al., 2004).
There is a view emerging in the social science literature that the building of mus-
cle through exercise or through food supplements is driven by a concern, especially
by men, to match a stereotypical body image (Daniel and Bridges, 2010). Although
body image is part of the reason to build muscle, much less investigated is a concern
with strength. For many people, strength does not equate with muscle mass. Feeling
strong is particularly important for many practices such as yoga, dance, or acrobatics:
strength is valued highly but the appearance of muscle bulk is not.
There is little direct perceptual research on what the experience of strength is like.
Tim Henwood and colleagues explored older adults’ perceptions of a resistance train-
ing program. In a qualitative study with 18 seniors, they identified the now-common
themes of benefits to body image and health, and the social aspects of engaging in a
program (Henwood et al., 2011). Missing, however, is a concern for the felt experience.
Do people enjoy resistance training? There is evidence that training for strength has a
positive effect on anxiety (Asmundson et al., 2013), but there is no study of a possibly
positive psychological effect of feeling competent in returning resistance to physical
force. What is needed is an exploration of the experience of being and feeling strong
in general and in specific situations.

Weakness

Feeling weak, however, is more discussed in the study of adjustment to physically debili-
tating illness, and in rehabilitation. Weakness is typically thought of as the failure to
carry or endure load, the inability to match a previously possible requirement (“I used to

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be able to carry this”), or the inability to match one’s own or others’ expectations (“I/we
thought I was strong enough to lift this”). Of course, weakness is also closely tied to the
judgment of external force, such that one might complain equally of being weak or of the
force being too great. Weakness can be specific and temporary, sometimes associated
with injury, or can be discussed in narratives of age or illness-related decline as frailty.
Often weakness is closely related to fatigue as the judgment of tiredness (see Chapter 6);
failure to recruit energy to counter force may be discussed as performance loss.
Weakness is a common complaint of known neurological and muscular disor-
ders, of malignant disease, and from iatrogenic complications of treatments such
as radiation therapy. Rehabilitation focuses on strength and conditioning, largely
with a goal of return to occupational activity. Qualitative studies tend to stay at the
important but relatively macro-analytic level of identity, quality of life, relationships,
and loss (Salter et al., 2008). There is little interest in the specific experience of being
unable to meet force with resistance. These micro experiences are, however, poten-
tially important. How one comes to judge whether one is too weak to open a door or
take the lid from a jar could be a crucial part of everyday life.
In an interesting natural observation study of how humans manage in their built
environment, Chang and Drury (2007) recorded 1,600 “human/door interactions” with
a focus on hand position and the recruitment of whole-body force (e.g., leaning into or
pivoting away from a door). That most common of human devices, the door, affords
information to the operator on how heavy one might expect it to be, and so what force
to match to it, by the position of handles and door mechanisms. Whether we are likely
to feel weak in attempting to open a door is signaled far in advance of operating the door.
Susan Rodiek in Texas made the study of doors more real to the experience of the
people behind them. Simply put, doors have multiple functions. They provide safety,
protection from the elements, definition of boundaries, and access points between
spaces. However, depending on their properties, they can also function as barriers.
Rodiek and her colleagues assessed the properties of doors in different senior living
facilities in the United States, and ran focus groups discussing these properties with
residents. Lurking among the various features was a concern with forces. One par-
ticipant said of the doors in the residential home, “I mean, it’s hard. I have learned, but
then sometimes I have to go through the living room because these doors are heavy.”
Another agreed: “You’re right. I have trouble with my shoulder to open, push, and
pull the doors. I find that I have difficulties going through the doors.”3
Understanding the psychology of weakness, therefore, is not trivial. How we make
decisions about force and about what we are capable of has real practical concerns.

Strength-weakness continuum

As with flexibility and strength, strength and weakness lie on a continuum. They
are opposing features of the same physical experience and move together. When

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the perception of strength increases, the perception of weakness subsides, and vice
versa. Knowing when to improve one’s strength, perhaps by a program of exercise, or
whether one should reduce the environmental pressure, perhaps by altering the task
demand, is an interesting design question. When one is designing a task that requires
force, one needs a sense of what is a reasonable requirement in lifting, carrying, push-
ing, and pulling (Garg et al., 2014). Outside of the world that can be controlled via
design, when one is trying to encourage participation in the often immutable outside
world, how much strength can one encourage people to achieve in order to promote
participation? For example, a self-closing gate needs to be sprung to close automati-
cally, and at the same time it needs to be able to be opened with human strength.
The extremes are easy to understand. If a door is so heavy that it is beyond the
ability of 99 percent of people, then there is a strong argument for redesign. Similarly,
if 1 percent of people cannot open it due to reversible muscle weakness, then there is
a good argument for strengthening exercises. The problems come when these two
ideas meet in the gray middle. As we age, how much should we work on building
and maintaining strength? Or should we accept weakness as a consequence of aging
and adjust our homes and environment accordingly? These are, of course, questions
without easy answers. One might be tempted to argue that all strengthening exercise
is good exercise; however, the data on both effectiveness and possible adverse effects
are at worst unclear (Latham et al., 2004), and at best partial (Peterson et al., 2010).
The picture becomes even more complex when we remember that, like all subject-
ive judgments, the decision of what is possible—how much force one can extend in
manipulating the objective world—is sensitive to one’s belief in one’s ability to change
the world, and its ability to be changed. Understanding the biases in our perception
of personal strength and weakness is going to be important if we are to understand
how people behave when faced with physical resistance. To date, there is no guidance
on how to incorporate people’s perception of their weakness or strength into either
the design of strength training or the design of the built environment. That does not
mean, of course, that architects, designers, ergonomists, and various therapists are
not making such considerations. Experts make decisions. But there is an opportun-
ity for the development of a more scientifically informed psychology of physical
strength to contribute to decisions on what is possible and desirable to change.

Heaviness

Most studies of weight perception in psychology are concerned with the question of
how we judge the weight of external objects or people. There is also a large literature
on the self-perception of being large; in particular, of being overweight and its psy-
chological causes and consequences. Here I am interested simply in the basic ques-
tion of what does it feel like to be heavy; to experience the weight of your own body
or of a body part; to be both a body that experiences and is experienced.

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Heaviness is often discussed only in specific contexts. For example, the experi-
ence of heavy legs is common to post-exercise fatigue and to wearing high-heeled
shoes. It is also commonly reported in venous insufficiency, often occupationally
related, or emerges as “restless legs”, or is hidden behind a more dominant sensation
of pain (Jawein, 2009). Such vascular involvement in the judgment of heavy legs gave
Emmanuele Varlet-Marie and her colleagues the idea of exploring cardiorespiratory
function—in particular, blood flow—among athletes who had overtrained. They
studied 37 French national-level football, volleyball, and basketball players, as well
as triathletes. Fourteen reported being overtrained. The researchers found that com-
pared to athletes matched for age and body mass index, the overtrained group had
higher plasma viscosity; moreover, their red cells aggregated faster (Varlet-Marie
et al., 2003, pp. 154–155). It was argued that overtraining leads to higher blood viscos-
ity, which in turn causes circulatory slowness. Investigating venous return highlights
the importance of cardiovascular function in general when one is making a judgment
about heaviness in limbs.
In this study of athletes, changes in blood viscosity emerged as a marker of over-
training, probably caused by local inflammation and general dehydration. But it is
interesting that heavy legs are discussed as a cardiovascular phenomenon—a specific
sensation, before fatigue or pain sets in. People who have suffered a cardiovascular
accident or injury also report this sense of heaviness. For example, in their analysis of
transition from hospital to home following a stroke, the expression of a “heavy” body
often appears. In an interview study, one woman said: “My body feels so heavy. Have
I been like this all the time or have I become worse?” (Eilertsen et al., 2010, p. 2009).
This almost ethereal sense of distancing from a body is part of the experience of
heaviness. It is not clear whether in stroke the experience of heaviness is mediated
by aspects of cardiac and vascular function, or if it reflects a more central process of
personal weight perception.
Radically life-altering changes in physical health status caused by neurological disease
or accident, such as stroke, do bring with them a new vigilance for how one’s body feels.
Carla Ruis and her colleagues, in establishing norms for a commonly used questionnaire
about psychological symptoms, the Symptom Checklist 90, found that the subscale
somatic symptoms (which includes the item “heavy feelings in your arms”) is highly ele-
vated compared to those without disorder (Ruis et al., 2014). Attention to all aspects of
physical being, including the perception of heaviness, is often invoked in illness.
Normal changes in body weight also cause changes in the perception of heaviness.
For example, pregnant women can discuss the experience of being heavier than nor-
mal, and there is a language of feeling heavy in the literature on obesity and weight
management. However, the discussion of heaviness is largely lost in these literatures
in the much broader and less exact discussion of “feeling fat” and its social conse-
quences. For example, in one qualitative study of 76 women and their experience of
trying to lose weight, one participant said:

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The amazing thing is, in the past if I’d been 9 and a half stone I’d be disgusted with my-
self, I’d be really heavy, and now I was jubilant because I felt I was really light. It’s all
relative. (Byrne et al., 2003, p. 958).

In this example, the perception of heaviness may be specific or simply a general

marker of weight-related changes in both perception and self-perception.

Lightness

Susan Byrne’s just-mentioned qualitative study showed that people when dieting can
make judgments about feeling heavy and also about feeling light. Feeling light in this
case is a pleasant experience of weight loss achieved. But again, is the report of light-
ness a specific sensation, or is it a general term for freedom of movement or lack of
fatigue—or a composite of both? What do people mean when they report feeling
light?
An artificial method of creating weightlessness is to propel a body into zero gravity
in space, or create a microgravity environment on earth. The effects of long-term
weightlessness can be debilitating. Our musculoskeletal, respiratory, and motion
systems are shaped under pressure, exist in their shape largely in response to that
pressure. To remove it completely leaves those pressure-sensitive systems unsup-
ported. The long-term effects are typically discussed as deconditioning, but, really, they
are caused by a locomotion and physical control system cut loose from its context
and all its dependencies: it is perhaps better thought of as decontextualized. Elizabeth
Blaber and her colleagues have summarized the effects of changes to the body under
prolonged zero or altered gravity. They conclude that the changes in muscle function
on exposure to weightlessness is the principal physiological barrier to a successful
Mars landing (Blaber et al., 2010). Given the many challenges of space flight and the
extreme demands of this peculiar working and living environment, a concern for the
felt experience of lightness is not high on anyone’s agenda, although, paradoxically,
heaviness after re-entry often is.
Unwanted lightness after loss of body mass is, however, discussed more frequently
in specific discourses, often of illness or older age. For example, a common occurrence
in advanced cancer is cachexia, a form of generalized metabolic dysfunction (Fearon
et al., 2011). The primary feature of cachexia is marked weight loss and the inabil-
ity to maintain or increase weight. It is normally associated with other symptoms,
such as weakness, loss of appetite, and fatigue, and is experienced often with extreme
distress by both patients and carers. Joanna Reid believes it to be one of the most
distressing symptoms of the cancer experience. In Belfast, Reid and her colleagues
interviewed 15 patients with advanced and incurable cancer and cachexia. There were
interesting themes in these interviews, many of which revolved around strategies for
dealing with weight loss, such as coping through distraction, as well as strategies for

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increasing weight (Reid et al., 2009). However, the felt experience of weight loss in
the context of end of life is rarely discussed. Instead, it is a signal of a larger source of
distress in the collective fear of imminent death, expressed as denial of weight loss or
conflict over appetite, food, and social control (Oberholzer et al., 2013).

Heaviness-lightness continuum

There is, across multiple literatures, and in different fields of study, a lack of inves-
tigation into the experience of feeling heavy, and even less on the direct experience
of feeling light or lighter. As discussed in previous chapters with the sensations of
balance and motion, to attend to somatic sensations and make complex judgments
about one’s body weight, without the aid of a set of scales, is perhaps too clumsy, dif-
ficult, and, frankly, unnecessary. It perhaps has no function. Unless one is faced with
an unusual technical challenge, such as propelling the weightless body into space,
maybe there is simply no advantage to self-weight perception.
Or is there? Nicholas Edwards and his colleagues in Minnesota reported an inter-
esting finding concerning the biased judgment of adolescents. Using a representative
longitudinal survey of over 14,000 adolescents, they were able to compare adolescent
absolute weight at different time points with a self-perception measure of how they
would describe their weight. Approximately 30 percent of youth underestimated their
bodyweight. This misperception would be just interesting if it were only a guess-my-
weight parlor game. But what also emerged from this study was the role of mispercep-
tion on subsequent behavior. The more accurate young people were in estimating their
own weight, the more likely they were to eat less and exercise more (Edwards et al.,
2010, p. 456). It seems that the advantage of accuracy in deciding whether one is over- or
underweight is that it is more likely to come with adaptive attempts to manage weight.
In the context of Western nations reporting high and rising levels of overweight and
obese populations, the ability to make an accurate judgment about a crucial aspect of
identity and embodiment may be exactly the advantage one needs to develop.
How you decide if you are heavy or light, and under what circumstances, are not
often investigated. In summary, it appears that we rarely make the judgment of how
heavy or light we are. But we can do it if asked. However, when we do, we are not
particularly good at making such judgments, typically underestimating rather than
overestimating. To develop these ideas further, we need a better understanding of
what it feels like to be heavy or light,
In addition, we need to better understand the feelings of heaviness and lightness in
relation to feelings of pain, strength, and fatigue, and as judgments of external load. Is
there a bias toward not judging (ignoring) or underrepresenting (diminishing) one’s
own weight? If so, does the relative ignorance of one’s own weight allow for a bet-
ter judgment of the weight of an external object lifted or carried? Can we learn to
accurately perceive bodyweight through training, as we do strength and flexibility?

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And, finally, is there any phenomenologically distinct character to judgments on the

heaviness-lightness continuum?
Developing a psychology of the perception of bodyweight may help us achieve a bet-
ter understanding of when and how we act to change body shape and body size, regard-
less of whether the context is cosmetic, astronautical, illness preventive, or palliative.

Swollen

The final pressure sensation that is closely related to the senses of flexibility, weight,
and strength is the sense of being physically extended in a limb, head, or torso, or of
being systemically swollen. There are multiple causes of swelling. The most common
are vascular, either in normal erectile tissue, from a failure in lymphatic carriage of
interstitial fluid normally removed from tissue, or from the arrival of fluid to tissue as
part of an inflammatory response to injury. The feeling of being swollen or extended
can also come from the over-filling, or failing to void, body spaces such as bladder,
colon, stomach, or lungs.
Like balance, the sensation of pressure is largely unattended to—until it reaches a
salience. How that salience is interpreted is interesting, and is in part dependent upon
the functional context of what is swollen, when, and for what purpose (if any). The
pressure of overeating after a meal, for example, has a totally different meaning to the
unwanted bloating from opioid-induced constipation as an adverse effect of a treat-
ment for cancer. Two specific cases of feeling swollen can help to exemplify this effect
of context: the first is breast surgery, which causes lymphedema in approximately 5
percent of patients. The second is of constipation, which is both a common nuisance
for some and a severe problem for others.
Over three million women in the United States are living with a diagnosis of breast
cancer, and 232, 670 further women were diagnosed in 2014 (DeSantis et al., 2014).
Approximately 38 percent will undergo a partial or total mastectomy (Mahmood
et al., 2013). Of these, approximately 5 percent will go on to suffer lymphedema. By
conservative estimates, this means that each year in the United States alone, 45,000
women will start on a post-cancer survivorship trajectory, one dominated by living
with edema.
There are many unwelcome changes from such a challenging intervention, includ-
ing how to manage a broad array of symptoms. But a swollen limb brings significant
problems of its own. Women often report emotional challenges such as embarrass-
ment or shame, and practical problems with clothing, especially in warm weather,
which can increase the edema (Taghian et al., 2014)
Mei Fu and Mary Rosedale attempted to understand the symptom experience of
women with lymphedema following breast surgery. They interviewed 34 women and
deliberately went beyond the broader experiences of changes in body image, con-
fidence, and fractured life course, with an attempt to capture the felt experience of

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being or feeling swollen. Women do talk about unpredictability, the fear of cancer
recurrence, and handicap, but they also use interesting language about the actual
experience of distension or swelling as a pressure building to capacity. One said,
“Whenever I take a look at my ugly arm, it’s just like a giant bomb to me” (Fu and
Rosedale, 2009, p. 853). Another reported that her boss described it as “bursting.”
Although there are many aversive sensations (pain, fatigue, weakness, inflexibility)
that accompany postsurgical lymphedema, the experience of pressure and a limb
close to bursting is one that deserves further investigation.
Patients who are constipated also report this unique sensation of potential
explosion. Claire Ervin and her colleagues, who are working to highlight a con-
sideration of patient-reported outcomes as a worthwhile primary goal of clin-
ical trials in constipation, found this concern raised frequently. In their study of
28 participants, interviewed to augment a larger survey of trial reports, people
typically reported two feelings. One was of general discomfort; the other was of
abdominal distention: “huge . . . about to pop,” and “about six-months pregnant”
(Ervin et al., 2014, p. 195). Feeling swollen, distended, full, bloated, or tumescent
comes with many sensations, but perhaps unique to them is the experience of
being close to bursting.

Reduced

Less common is the experience of being in some way reduced, diminished, smaller,
slighter, or of being empty. Being under normal pressure, or the return to normal size
following pressure, does not have any specific phenomenological quality, other than
a sense of returning to normal or an awareness of pressure lifting. However, there is
one sense in which people discuss a more abstract idea of being physically reduced
or physically less.
In a large observational study, a sample of 8,610 women was tested. The average age
was 71. Their height was measured and on average the women had lost 4.5 centimeters
since their recorded tallest height. It is true that we become literally less as we age. In
this study, however, the investigators went one step further and asked the women
to estimate their own height. They found that women routinely underestimated this
height loss as much as by two centimeters (Briot et al., 2010). Such bias in estimation
is perhaps not unusual, but it raises the question of whether there is any perception of
being reduced, or of being physically less. Aside from the visual inspection of weight
loss or change in body shape, and the proprioceptive changes in feeling lighter, is
there any sense of being shrunken or reduced?
Clearly changes in mass take time. Those changes usually fall outside of perception,
and the norm can fail to be updated. But there is some direct evidence that a percep-
tion of sudden change might be possible. For example, in neurology it is possible to
induce somatosensory cortical changes through visual-tactile illusions and produce

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 A

Fig. 4.1. Shrinking waist and hips study. The design of the study and position of the hands to
the body.
When the palms of the hands were in contact with the body, the vibration of the two wrists elicited
the illusion that the wrists were passively flexing and the waist and hips were shrinking (A, lower
right). When the hands were not in contact with the body, the vibration of the wrists only elicited
the illusion that the hands were flexing (A, top right). In two additional conditions, we vibrated
the skin over the styloid bone beside the tendon, which does not elicit any illusions (A, top left
and lower left). The neural effect of the shrinking-body illusion can be modeled as the interaction
term between hand position and site of vibration in a 2×3×2 factorial design (see [B], [TENDON
CONTACT—­SKIN CONTACT]—[TENDON FREE—SKIN FREE]).
Reprinted from Ehrsson HH, Kito T, Sadato N, Passingham RE, Naito E, Neural Substrate of
Body Size: Illusory Feeling of Shrinking of the Waist, PLoS Biol, 3(12): e412. doi:10.1371/journal.
pbio.0030412, © 2005 Ehrsson et al. This figure is licensed under the terms of the Creative Com-
mons Attribution License.
 s wol l e n - r e duce d con t in u u m

B Site of vibration
Skin (bone) Tendon

No body contact
SKIN TENDON
Position of hands FREE FREE

Body contact

SKIN TENDON
CONTACT CONTACT

Fig. 4.1. Continued

a noticeable change in body schema. One can manufacture altered positioning, size,
and number of limbs. But also possible is the peripheral manufacture of the illusion
of reduction, as in, for example, the “shrinking waist illusion” (Ehrsson et al., 2005).
In this study the researchers were actually able to induce the experience of both hips
and waist getting slimmer. Figure 4.1 shows the procedure in which a vibration device
is fixed to the wrist with contact points extending to the palms of the hand. This pro-
duces a sensation of a shrinking waist.
And, perhaps equally bizarre, is one naturally occurring abnormal example. In
cultural psychiatry there are reports—although they have yet to be independently
corroborated—of localized outbreaks of an epidemic of genital shrinking. In West
Africa and South East Asia, men have reported the sudden loss (or theft) of their geni-
tals. Vivian Dzokoto and Glenn Adams report epidemics of genital theft as a form of
culture-bound mass psychogenesis (Dzokoto and Adams, 2005).
Perhaps the idea of being reduced or shrunk is both socially rare, and neurologic-
ally indistinct, such that it will be difficult to explore it in isolation. It is always experi-
enced in the immediate context of what is lost or reduced, and in the broader social
context of the meaning of that loss.

Swollen-reduced continuum

Perception abhors a vacuum. More than any other of the pairs of pressure senses,
being swollen dominates. Being less, or experiencing the loss of mass, is rare. It is
possible to produce artificially in the laboratory, and when isolated it is experienced

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as vivid, but when spontaneously discussed it is vague and often no more than a gen-
eral background phenomenon open to psychological and cultural influence, and dis-
cussed in the broadest of terms. At its other extreme, when a full stomach becomes
swollen, or an arthritic joint becomes inflamed, or a postsurgical edema feels ready to
explode, then the action of pressure is felt acutely; then it functions, as do many other
of the hidden senses, to alarm and to motivate.
From a functionalist perspective, however, being swollen offers an unusual
challenge. Like pain and fatigue, it can function as a low-level alarm giving critical
information about one’s state that one can address (e.g., stop eating now, or visit the
toilet). But it also has the capacity to function as a high-level alarm, imposing an
immediate priority on a system. Like our other neglected senses, at their limits they
function to return us from the extreme to a more normal state. Often a sense at its
limits demands a clear course of action: pain demands avoidance, fatigue demands
switch of attention, imbalance demands postural adjustment, etc. It is not clear,
however, what the experience of being swollen, and the distressing extent of feeling
like one will burst, demands. Perhaps this particular form of “putting on the brakes”
operates at a whole system-wide level, demanding interpretation. Unlike the other
physical senses, it functions to invoke conscious investigation and a high level of
interpretation.
To explore this phenomenon better, I talked to Marni Elder (Box 4.2).

Box 4.2. Marni, living with lupus: “it feels like every inch of your body weighs too much”
We know so little about the experience of feeling heavy, swollen, or stiff. Marni is 21.
She describes herself as “thoughtful” and “interested in how other people feel.” She is
someone who is “never knowingly boring.” Marni has had lupus since she was 16. I was
interested in particular in her experience of the pressure senses.

______________________________________

Chris: Tell me about when you first knew something was wrong.
Marni: I first presented symptoms when I was 16 but was not diagnosed until I was 17.
It started in Jan 2010. My hair started thinning. Slowly but surely the problems rotated
around my body. Each of my joints would become inflamed, hot, itchy, and really sore.
Initially it was in one joint at a time. My wrist would hurt, my elbow would hurt, and
next day my knee, my ankle. But then over time it became all of them at once. Then came
the fevers and complete lack of appetite, nausea, severe migraines, and tiredness. At the
time I was just concerned about my lovely locks falling out. But as the reality became
clearer and I realized it was more serious, I became less concerned with the hair loss.

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Box 4.2. Continued

Chris: Is being tired with lupus a different sensation than before the lupus?
Marni: Yes, I can’t remember what it is like to not be tired. So in a way I am really used to
it and I can manage it, but I am also hyperaware of it being there all of the time. It is the
same with joint pain. There is a strange way of being able to forget about it and carry on,
but also staying very aware of it, of any changes in it.
My fatigue now is so different than how it was before. When you’re a teenager you get
tired and don’t want to get out of bed. But now it is so hard a task that it becomes such
a physical challenge. I feel that when I am really tired in the morning it is almost like
there is literally a weight sitting on all of my limbs that can’t be moved. And lifting
yourself up is so tasking that sometimes you are not sure whether to just push through
it. Sometimes it is fine and I can carry on, but sometimes I think maybe I should listen
to it and just lie here. It literally feels like I am being weighted down. But from the
inside it’s like my muscles have become solid and dense, too dense for my body to take
the weight.
Chris: It does not sound like fatigue as we think of it: as an urge to stop.
Marni: No, that is right. It is different because it is not the mental lethargic fatigue with
a fuzzy head. It is not a full body tired that I need to go to bed and sleep. It is something
you have when you wake up. It feels like every inch of your body weighs too much.
Like it has been filled with something that should not be there, that shouldn’t be carried
around with you.
Chris: What other sensations are there?
Marni: The symptom I suffer the worse with is joint pain. That is the one I find disap-
pears the quickest as soon as I have immediate treatment. The lupus pain is about joints
swelling up and being hot to the touch. You can always feel my joints as hot. They go
red hot. Sometimes before they swell up. But that is a separate pain to being in a flare
because when I flare I have the swelling and the heat. Then comes the stiffness: they do
always get really stiff. But I am unsure whether they are stiff because of the huge amount
of swelling around the joints, or if they are stiff because it hurts so much to move them.
But I tend to keep any joint that is swollen as immobile as possible because it is the least
painful option.
Chris: Does the swelling and stiffness change how your move?

Marni: I have always been reasonably accident-prone. But I feel like it has made me a lot
less dexterous. It probably affects my hands the most. It obviously swells up and makes
them look strange. I do feel off-balance with it sometimes, clumsy. It is very normal for
me to walk into doorframes and lamp-posts when there are not really any obstacles in
the way.
Chris: how has the experience changed how you think about your body?

(Continued)

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 pr e ssu r e

Box 4.2. Continued

Marni: I don’t like it quite so much as I used to. Sounds like a weird thing to say but I
suppose in some ways I am more precious about it with everyday things I do. I tend to
think of my body as something more fragile now. I never used to think of it in that way.
I am definitely more aware of it being something that can break or be broken. But I’m
also less fazed by injuries. It does not shock me as much. But in day-to-day things like
bumping into things and knocking things, I am aware now that I am fragile. It is not a
nice feeling, really.
Chris: Do you feel you have control over the symptoms?

Marni: Sometimes. I am definitely better with it now. It has taken me a really long time to
understand my limits, as to where I can push myself and when I can take a back seat. I pre-
fer not to plan things. I obviously try as much as I can not to cancel, but if I am planning
a couple of weeks in advance I always feel like I am already potentially double-booking,
because I never really know how I am going to feel, so I tend to hold back on planning.
When I was first ill I missed two terms of school and everything I wanted to do socially,
which, when you are 16 and 17, felt like the end of the world. I felt I missed out on
so much. So after that I decided I would try and do everything that I could, within
­reason—which I maybe did too much of when I was recovering. So when I went to
university I thought, I need to pace myself more. But I don’t want any of the symptoms
to be something people notice about me. I don’t want people to think of me as weary,
boring, or tired.
Chris: Has there been anything positive about the experience?
Marni: Yes, there is self-improvement. I think I am definitely more sympathetic
toward other people. I understand other people who are feeling unwell. My friends
and family came through and continue to a lot. That is definitely positive. Also I
always think that if I had not been ill I would not have ended up studying English
literature. I had no indication what I wanted to do academically. I always found biol-
ogy and chemistry easy and I was going down a route of medicine. But if the lupus
had not happened I would not be studying English now. I would have just carried
on. And English is definitely the right choice for me. It is definitely, definitely, what
I should be doing.

______________________________________

It is not an expertise she ever wanted, but Marni is an expert on the pressure senses.
She cleaves apart the specific sense of having a body that feels too heavy from the
general senses of pain and fatigue. It has its own quality. So does the challenge of being
swollen. Like Emma earlier, Marni has had an education on the limits of her body,
of what is possible and when and how to adapt in response to pressure. But at stake
is also an ever-changing relationship with a body that is challenged and challenging.
Impressive is her strength of character in focusing on what is positive and what is
possible.

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Summary

We live in resistance. Every movement is against force. I have called the senses
that emerge the “pressure” senses because for me pressure captures the movement
against force. Constantly under negotiation in all four pairs of sensations is what is
the limit of the experience and what is its meaning. Although there is a rich psych-
ology of pain and of fatigue, as two examples, there is little to say about how best to
support people who are stiff, reduced, weighed down, or feeling like they are going
to explode. There is little advice for designers of our built environment about how
we judge our own strength, flexibility, or weight decisions. And there is yet to be
any study of how one’s relationship with core aspects of embodiment affects the
normal subjects of psychological study, such as motivation, affect, and cognition.
We have some work to do.

Notes

1. Reproduced from Ana-Maria Orbai, Katherine C. Smith, Susan J. Bartlett, Elaine Leon, and
Clifton O. Bingham, “Stiffness Has Different Meanings, I Think, to Everyone”: Examining
Stiffness From the Perspective of People Living With Rheumatoid Arthritis, Arthritis Care
and Research, 66 (11), p. 1669 (c) 2014, John Wiley and Sons.
2. Reprinted from Complementary Therapies in Medicine, 21 (1), Gina K. Alexander, Kim E. Innes,
Terry K. Selfe, and Cynthia J. Brown, “More than I expected”: Perceived benefits of yoga
practice among older adults at risk for cardiovascular disease, p. 17, Copyright (2013), with
permission from Elsevier.
3. Reproduced from You Can’t Get There From Here: Reaching the Outdoors in Senior Hous-
ing, Susan Rodiek, Chanam Lee, and Adeleh Nejati, Journal Of Housing For The Elderly, 28 (1),
p. 74, doi:10.1080/02763893.2013.858093 (c) 2014, Taylor and Francis. Reprinted by permis-
sion of the publisher (Taylor & Francis Ltd, http://www.tandfonline.com).

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 CHAPTER 5

BREATHING

B reathing, or, strictly speaking, ventilation, is the process of inhaling air from
the atmosphere (inspiration) and exhaling air from the lungs (expiration). It is
one part of a respiratory system that all aerobic organisms use to maintain a supply
of oxygen and manage the acid base in the body. For us, that means taking oxygen
from the air into the lungs and expelling carbon dioxide and water vapor. It happens
continuously, automatically, rhythmically, and largely out of awareness, even when
asleep. Breathing is also associated with narratives of emotion, especially surprise,
horror, fear, and romantic love. It is even enjoying a revival in the West as a focus for
the training of awareness and control over internal sensations, often in the pursuit of
anxiety management. It is so fundamental to life, however, that it goes unremarked
upon, except when we experience it in its extremes. Culturally, for example, there
are narratives of the first breath taken in the cry of the newborn baby, and of the last
breath taken at death. The millions of breaths in-between attract less attention.
Breathing has unique qualities that make it a suitable focus of attention as a neg-
lected sense. From biomechanical and physiological perspectives, ventilation is
similar to movement and balance. Innervated muscle and connective tissue provide
specific position, capacity, and force feedback, and receptors identify the pressure of
respiratory gases. It can be thought of as a special case of a pressure sense (see Chap-
ter 4) in its reliance on the partial pressure of oxygen. Breathing has similarities, also,
to the expulsion experiences discussed in Chapter 11, in that it operates largely out of
awareness and is an experience that happens to one as much as it happens with one.
But from a psychological perspective, breathing has a quality all of its own. Breathing
is recognizable as a specific sensation, understood and discussed as a phenomenon,
and we know what it feels like when it stops.
This chapter is devoted to the experience of ventilation as breathing. I review the
peripheral and central mechanisms of inspiration and expiration, and what is con-
sidered normal. But human breathing is flexible, shown by those who deliberately
attempt to control their breathing, either occupationally, in the management of a
lifestyle, or in exercise. Finally, I examine how awareness of respiration is central to a
psychology of immediate action, with a closer look at the case for relearning how to
breathe. Some people have no choice, so particular attention is given to the special
cases of panic and cardiopulmonary diseases for which air hunger (dyspnea) is the
primary complaint.

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Two people with very different experiences agreed to help me explore breathing
at its limits. First, there are people who train for many hours to increase their breath-
hold ability. I talked with Sam who is an experienced freediver and now a teacher of
freediving. She is an expert at breathing and at breathhold. Second, there are many
people who suffer from a range of cardiorespiratory disorders, the principal feature
of which is dyspnea, or what used be known as air hunger. I talked with Ian who has
an obstructive lung disease called bronchiectasis and has lived with dyspnea for the
last five years.

Catching your breath

Breathing often feels like one is actively forcing air into or out of the lungs. However,
counterintuitively, we do not expand our lungs by filling them with air. Instead our
lungs expand, creating a partial vacuum, into which air must rush. For inspiration,
both intercostal muscles (expanding the chest wall) and the diaphragm (contracting
and flattening) act to expand the lungs. For expiration, the diaphragm and intercostal
muscles return to their original position, reducing the volume of the lungs and hence
the pressure. This cycle is under central autonomic control, which is also governed by
a central brainstem concern for timing and rhythm (Feldman and Del Negro, 2006).
Core to the experience of breathing is the experience of agency, a feeling of whether
one is in or out of control of breathing, and the experience of rhythm, whether one’s
breathing follows a replicable and steady timing. These two characteristics of normal
breathing (agency and rhythm) become important when one seeks to override the
automaticity of breathing, and control or change one’s breathing pattern.
Before the air reaches the lungs it needs to pass through the upper respiratory tract.
The passage of air through the nasal cavity and into the trachea also has specific sen-
sory characteristics. The function of the nasal pathway is first to protect the subse-
quent respiratory path from air particulates, which are extracted into the mucous
blanket that through motion of its cilia can remove unwanted debris, swallowed
mostly into the stomach (Reznik, 1990). At the same time, air is moistened by the
action of the turbinates and warmed to body temperature.
These remarkable functions of the nose and nasal passage also create specific
experiences. Sniffing, for example (brief forced nasal inspiration), may function
for immediate olfaction, but it also breaks down particulates in the nasal vestibule
(Sahin-Yilmaz and Naclerio, 2011). The experiences of forced expulsion of debris or
mucus in sneeze or cough are investigated in Chapter 11. But the general experience
of the flow of air is part of the experience of breathing; for example, in the extent one
is spatially aware of the nasal cycle in which one switches the channel of air from
side to side, allowing turbinates to replenish. This is the experience one has of the
freer passage of air through one nostril rather than the other, switching rhythmically

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throughout the day, or of changes in its pattern during an upper respiratory tract
infection (common cold).
Proprioceptively, the experience of the movement and position of the chest also
form part of the experience of breathing. As we saw in Chapter 4, information about
force on the body and about its position give a specific sensation of being enlarged or
full at maximal inspiration, and, by extension, on expiration of being smaller and feel-
ing spent. In the abnormal case these feelings of inadequate inspiration or expiration
form a major part of the experience, described as feelings of tightness, restriction, or
ventilation inadequacy (Courtney and Greenwood, 2009).
Stretch receptors, known as baroreceptors, monitor changes in extension of the
blood vessels and associated changes in blood flow. Chemoreceptors in perhaps one
of the most unusual and mysterious of our peripheral sense organs, the carotid bod-
ies, sense change in blood oxygen in the arteries, in particular responding to a deficit
in oxygen (hypoxia) or a surfeit of carbon dioxide (hypercapnia) These chemorecep-
tors project to the brainstem, which is responsible for autonomic responses, most
critically here, respiration and blood pressure. It is not clear how far the peripheral
detection of oxygen and carbon dioxide is necessary for awareness of a change in
respiration, or whether awareness of respiration is merely a late product of a largely
autonomous system perfected for cardiorespiratory control.

Taking control of breathing

How long can you hold your breath? Thirty seconds, ten minutes? When was the last
time you tried? We don’t often investigate our own breathing—perhaps only when
panting from sudden exertion, inflating a balloon, running for a bus, or climbing
a flight of stairs. Indeed, why would we seek to attend to our breathing? The phe-
nomenology of respiration is kept out of conscious awareness because attention
to breathing or its consequences are at best unnecessary and at worst disastrous to
coherent and consistent behavior. However, there are times when attending to and
taking control over the rate, flow, rhythm, extent, and capacity of breathing are neces-
sary or desirable.
Control over breathing and its meaning are discussed in a number of different
contexts. Typically, we discuss taking control of breathing when there is an imme-
diate goal, as in holding your breath because of an unwelcome smell, or shouting
to try to make yourself heard in a crowd. Or we take control when a long-term goal
requires it, as in learning to sing, play a wind instrument, or excel at sport. Perhaps
the most extreme case is when the goal is an overarching one of survival: when one
attempts control over breathing because to do otherwise risks suffocation, such as
when breath control might allow one to stay longer in an environment where it is
hard (e.g., at altitude) or impossible (e.g., underwater) to ventilate.

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So far I have discussed respiration as an unconsciously controlled process. Expir-

ation, however, is particularly important for humans, serving multiple functions. In
resting respiration, we might exhale in a regular rhythmical flow, but the passage of
air over the vocal chords allows for speech and so is subject to tracheal, intercostal,
and diaphragmatic neuromuscular control. We control the pulses of expiration in
both speech and song, and in the playing of wind instruments. This interplay between
voice and respiration starts very early in our development, and there is evidence that
respiratory control and vocalization develop together. In one study, the breathing
and vocalization of 40 infants were observed: 1,864 vocalizations were grouped into
21 categories, with the most common being syllable utterances, followed by whim-
pers and grunts. In this exhaustive study, body mechanics were also assessed, includ-
ing body size, length, and lung volume. Tremendous variability in function was
found, with numerous mechanical degrees of freedom at play, as if the vocalization
and breathing control develop together, developmentally intertwined, and linked as
much to speech as to motor development (Boliek et al., 1996). This is a pattern that
continues to develop in early years. Taking control over breathing, typically in the
pursuit of speech development, happens from before the first vocalization, and devel-
ops alongside speech and voice.

Breathing to achieve

Three areas of human practice are of particular interest, all characterized by people’s
attempts to improve skills that involve breathing. The first is professional singing; the
second is sport, particularly sports that involve extreme cardiopulmonary challenge,
such as swimming and rowing; and the third is breathing to enable sustained con-
scious activity at altitude or underwater.
Collen Skull undertook an interesting qualitative study. She was intrigued by
how elite vocal performers manage a consistently high level of excellence. Five pro-
fessional opera singers shared their experience. As you would expect, practice and
preparation were key findings, but these singers were keen to stress the importance
of physical training of their vocal and breathing anatomy. She says:

In the area of fundamentals of vocal production from a physical perspective, the most
pervasive theme was the importance of breathing as the cornerstone from which all
advanced vocal production is based. Participants articulated the importance of prac-
ticing breathing and a sense of connectedness to the body as a necessity for sustaining
performance excellence. (Skull, 2011, p. 271)

This is a rare study of expert vocal performers and it is interesting that the man-
agement and training of breathing was high on their list of experiences to share. The

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importance of breathing for musicians extends beyond the direct use of the voice.
Lori Buma and colleagues explored the verbal reports of 44 elite musicians on what
they thought and what they did when under pressure during an exacting musical
performance. The most frequently endorsed statement, thought also to be the most
important strategy, was “I focus on my breathing” (Buma et al., 2015, p. 463). This is
discussed as a strategy for controlling anxiety and worry by focusing on the physical
aspects of performance. However, it is also possible that when faced with a complex
and demanding performance, a focus on breathing is part of an attempt to maintain
the timing of the music (Dogantan-Dack, 2006).
The training of breathing is an integral part of endurance sports such as
swimming, cycling, and rowing. Take distance swimming. Typically, distance
swimmers using a crawl stroke breathe after numerous (sometimes seven-plus)
strokes rather than every third stroke, which is more common in the amateur.
Low-frequency breathing means developing a tolerance for the urge to breathe.
One investigation of a program of mental training was undertaken with a group
of adolescent, club-level swimmers who had all competed at a national level. The
program included a focus on swimmers’ physical state, including a relaxation
component, but also including a specific component of “thought stopping” to
interfere with the automatic interruption of performance-denying thoughts—
thoughts such as “I can’t do this” or “I have to breathe more.” Overall the pro-
gram was successful (Sheard and Golby, 2006). For my purposes what is most
interesting in this study is the choice of psychological technique. Although the
frame of the study is multiple treatment components for general performance
and well-being outcomes, the specific components address the respiratory real-
ity of a sport that demands close management of breathing efficiency. Tackled
head-on is the experience of aversive sensation, and, as we will see with fatigue in
the distance athletes in Chapter 6, challenging the belief and automaticity of the
thought intrusion is important.
Roger Couture and his colleagues originally investigated these strategies with recre-
ational swimmers. They compared swimmers who were either instructed to distract
themselves from their bodily information by working on a mental task or focusing
on the end of the pool (which they call dissociative strategies), or were instructed to
focus on their breathing and the word air (which they call an associative strategy).
The associative strategy produced better swimming times than those achieved with
dissociative strategies (Couture et al., 1999).
The use of attentional focus is now common practice in sports training and per-
formance, but there is still little consensus as to the role of awareness in breathing.
Take running, for example. For students on a short-duration run, a dissociative strat-
egy of focusing on distance already travelled was found to be superior to a focus on
breathing when mean respiration rate was the outcome of interest (Neumann and

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Piercy, 2013). There is a lack of consensus of whether the direction of attention or its
content is what matters in altering performance. The exact strategy is likely to be
determined by a combination of factors, including the sport, skill level of the athlete,
and the parameter under investigation (e.g., pace, accuracy, etc.) (Brick et al., 2014).
I suspect that what works as a strategy of distraction from discomfort or exertion
in a short-duration activity is likely to be different to those in long-duration endur-
ance sports, and subject to individual differences. Further, I predict that regardless of
sport and individual training, a switch from dissociative to associative strategies will
take place as respiratory demand—and performance-destructive thoughts—start to
intrude and dominate.

Breathing at height and depth

Both expert musicians and elite endurance athletes are attempting to control respir-
ation and attention to the experience of breathing in normal environments, typically
at or near sea level, with normal atmospheric pressure. At high altitude, the oxygen
available for respiration remains constant but the partial pressure of oxygen falls with
the drop in atmospheric pressure; this makes gaseous exchange in the lungs ineffi-
cient, leading to hypoxia (oxygen deprivation). The carotid bodies will identify the
change in oxygen and carbon dioxide and inform respiration rate. Ventilation will
increase, with hypoxia occurring for most people who elevate to about 3,000 meters
above sea level (Peacock, 1998).
To put this altitude into perspective, the tallest building in the world is Burj Khalifa
in Dubai, at 829 meters, and the highest city in the United States is Leadville, Colo-
rado, at 3,000 meters. Mountaineers, however, need to learn to breathe at heights
beyond this. Mt. Everest base camp, for example, is at 5,500 meters, and its summit
at 8,848 meters. Figure 5.1 shows the relationship between the pressure of inspired
oxygen at different altitudes.
The deleterious effects of high altitude on cognition, night vision, decision making,
and mood are relatively well documented (Bahrke and Shukitt-Hale, 1993), but less
investigated is the experience of deliberate and purposeful climbing. Geoff Wilson
reviewed various narratives of climbing and being in mountain spaces about 8,000
meters, and found there was a preoccupation with the physical challenge of moving
in a hypoxic environment: “Narratives of pain, discomfort and suffering, for example,
permeate all accounts, especially with regard to the effects of high altitude and lack
of oxygen in the death zone” (Wilson, 2012, p. 31). Climbers suffered not only the dis-
comfort of labored and inefficient ventilation, but also cognitive decline. The reliance
on artificial breathing apparatuses changed the experience of flow and connection
with the environment that is highly valued by climbers.
The sense of distancing and disconnection from the environment with assisted
breathing apparatus is also one of the reasons given by freedivers for choosing to

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Inspired PO2 (kPa)

0 5 10 15 20

Altitude (m)

10 000

Mount Everest

Highest human
5000 habitation
Pike’s Peak

Ben
Nevis
Denver

0
0 25 50 75 100
Barometric pressure (kPa)

Fig. 5.1. The relationship between the pressure of inspired oxygen at different altitudes.
Reproduced from British Medical Journal, Andrew J Peacock, 317 pp. 1063–1066, Figure 2, doi:http://
dx.doi.org/10.1136/bmj.317.7165.1063 Copyright © 1998, BMJ Publishing Group Ltd. With per-
mission from BMJ Publishing Group Ltd.

dive without self-contained underwater breathing apparatuses (SCUBA). Emma

Farell describes freediving as “not a quest for depth or endurance, but rather an
experience of communion with our bodies, our breath, and our world” (Farell,
2006, p. 15). Freediving, also known as breathhold or apnea diving, is different
things to different people. For some, like Farell, it is close to a spiritual experi-
ence of engagement and flow. For others, it is a sport, technical and scientific, in
which one is constantly pushing physiological and psychological limits defined
by apnea. The current world record for static apnea is over 11 minutes, and for
diving to depth without assistance is over 200 meters. These are far outside of
the range of normal human experience. Although there is interest in the physio-
logical response to practiced apnea, and some psychology of the extreme, high-
performing athlete, there has been very little interest in the phenomenology of
deliberate apnea.
To learn more I talked to Samantha Kirby (Box 5.1).

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Box 5.1. Sam, the freediver: “it is massively a mental game”

Samantha was captain of the UK freediving team, and now helps others to learn to
freedive in her school SaltFree. She competes in two disciplines: static apnea and constant
weight. Static apnea is described as when “the freediver holds his breath for as long as
possible with his respiratory tracts immerged, his body either in the water or at the sur-
face” (http://www.aidainternational.org/). Constant weight is described as when “the
freediver descends and ascends using his fins/monofin and/or with the use of his arms
without pulling on the rope or changing his ballast; only a single hold of the rope to stop
the descent and start the ascent is allowed” (http://www.aidainternational.org/). Sam
describes herself as taking a scientific approach to the ­­sport—someone who is realistic
about the demands she is placing on her body and on her mind.

______________________________________

Chris: Tell me about the static apnea. Does it matter if you believe you can do it, if you
are confident?
Sam: Confidence is really important. It is massively a mental game. I think you obviously
have to have a level of physical fitness and ability. People can be overconfident and over-
stretch what they can do.
Chris: If it is a mental game, what are the thoughts that people have?
Sam: People might say, “I just had to breathe,” “It was in my head,” or they will say, “I had
contractions in my diaphragm” or “I couldn’t stop swallowing” or “I panicked.” The psy-
chological you can fend off and you can delay most of that feeling of “I need to breathe”
until you get the physiological signs, and then you can use the physiological signs to
pace how long you have got.
Chris: Do the thoughts come first, before the physiological signs?
Sam: Yes. I think, definitely. Even at a high level they do. Obviously they come later when
you have trained for it. I have had occasions when I think that I know my breathhold pattern
really well, I do a preparation, and then the clock will start. I will be fine and then nothing will
happen for a minute. Then at a minute and a half I’ll get contractions in my diaphragm and
I’ll fight them for another minute. I’ll have all that in my head about what my body has done.
Then on the day maybe I have prepared better and it does not happen like that, and I’ll think,
“It’s a minute and a half, why is my body not reacting?” and then that will start me panicking.
So, yes, it is hard to get rid of the psychological part. The thoughts are everywhere.
Chris: So, is it about managing breathhold or is it about managing panic?
Sam: A very good question, because they are interlinked. And actually you can have the
best breathe-up procedure in the world planned in your head and every time you dive
you do the same preparation. Everyone does something different, which for me says
there is no perfect breathe-up. Freediving. It is bizarre, the differences in preparation.
I am pretty convinced that all breathe-up preparation is mental, not physical. It is about
following your own ritual.

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Box 5.1. Continued

Chris: Tell me more about the thoughts that occur during a constant weight dive.
Sam: For me, I get very focused on the weight of the water above me. I can work out how
much this column of water above me weighs and it’s pushing on me and I can visualize
it and I think I have got to get all the way up through that. As you get deeper the pres-
sure is very obvious. Your mask pretty much collapses against your face and that makes
you panic. That is a suffocation response. Because you’ve generally got a space between
your nose and your mask and as you get deeper that space gets less and less. It is like
somebody putting their hand around your face and trying to squash you, and you have
to curl your body in to overcome that, which is again squashing your lungs, so it is a bit
like suffocation.
You know you can’t breathe until you get back up to the top. You know that if you have
a problem below about 15 meters you are on your own. Someone will meet you at 15–20
meters and swim up the last bit with you, but if you have a blackout or a wobble or a
panic before that, then you are totally on your own.
Chris: Do you have mental techniques to manage the thoughts?
Sam: Yes. I have what some people call mantras. I narrow my perception to the stages
of the dive and what I’m doing. And not letting those negative thoughts in because you
just can’t afford to. You are down at that depth. There is no point in panicking; it is only
going to make things worse. You’ve got to control that. I think that is what I like about
the sport, actually, in that you narrow so much, that you get so focused and in the flow of
what you are doing, that you can’t be down at 20 meters, let alone 40 meters, worrying
about how much money you’ve got in the bank, or what you’ve got to do tonight—
you’ve just go to think about the dive . . . the dive is all you can think about.
Chris: Perhaps we are being too negative. Are their positive experiences also?
Sam: Oh, yes. There are. Obviously, or we wouldn’t do it. There are immensely positive
feelings of achievement, and of beauty and peace and tranquillity underwater. All the
things about being on your own are also positive. It is me doing this; it is my body doing
this. It is not anybody else helping me. It’s about following your own ritual and achieving
for yourself.

______________________________________

The mental is never far from the experience of breathhold for the freediver. The dis-
sociative strategies are unlikely to work for long when a suffocation response is being
triggered, but Sam describes the control she exercises over associative strategies of
identifying her thoughts as thoughts, decoupled from knowledge of what her body can
achieve when hypoxic. The sense is almost of a private battle in which apnea is motiv-
ationally driving a single behavior—to breathe—but the sport demands mastery over
desire.

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Respiratory awareness

Athletes such as Sam achieve remarkable feats that help us define human limits. To
the nonathlete they can inspire awe and pique interest in our own physical limits. For
the athlete who deliberately invites huge levels of cardiopulmonary challenge, aware-
ness and control of respiration are a part of the sport, as important as muscle training.
But is there any benefit in respiratory awareness and control for the nonathlete? Why
should we attend to respiratory function, especially when it is so difficult? Or, put
differently, what happens if you are rarely aware of your breathing, if you never give
it a second thought?
For all of us, a lack of awareness of respiratory state can lead to adverse physical
experiences that are often misinterpreted as symptoms of a major physical health
problem. Hypoventilation leads to an increase in carbon dioxide concentration
known as hypercapnia, and hyperventilation leads to a reduction in carbon dioxide
concentration known as hypocapnia. Hypercapnia can be experienced as fatigue, pain,
and air hunger (dyspnea), which are easily misinterpreted as symptoms of other com-
plaints. Similarly, hyperventilation-induced hypocapnia is strongly associated with
arousal and anxiety, and with cardiac symptoms, which can also be interpreted as
frightening and serious. Panic is often misinterpreted as cardiac arrest.
Omer Van den Bergh and his research team at the University of Leuven in Belgium
have perhaps done more than any other group to explore the role of awareness of
respiratory function. He directs one of the only research laboratories able to experi-
mentally examine the effects of ventilation patterns on cognitive and behavioral
performance. For example, using a technique in which participants are asked to
“over-breathe,” Ilse Van Diest and colleagues compared performance on a numerical
Stroop task. Stroop tasks are tests of executive control over attention in which one
is presented with conflicting information from the same stimulus. To give the right
answer one has to overcome the urge to give the incorrect dominant response. They
found that induced hypocapnia slowed responding and increased errors on this test
of attention (Van Diest et al., 2000). Hyperventilation, they were able to show, does
lead to impaired cognitive performance.
Hyperventilation technically refers to an excess of air introduced to the lung alveoli
in relation to metabolic requirements. But it can be self-induced by two related behav-
iors: increasing the volume of inspired air from each breath (deep breathing), and
increasing the rate of respiration (rapid breathing). When we talk of hyperventilation,
it is often not the technical definition we refer to but the observable behavior of seek-
ing more air by breathing deeply or quickly. Voluntary hyperventilation is a com-
mon method for inducing hypocapnia and is relatively well understood as a method
of inducing biological stress (Zvolensky and Eifert, 2001). However, involuntary
­hyperventilation—or hyperventilation without awareness, when you start to breathe
more quickly and deeply but do not notice—is closely associated with fear, panic, and

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safety behaviors such as avoidance and escape. In fact, respiration is thought to map
closely onto emotional state, and is directly susceptible to changes in emotional state.
Elke Vlemincx and her colleagues from the Leuven laboratory were interested in
exploring the relationship between everyday emotion and respiration. They chose
the natural variability in how we breathe as their focus of study. Of course, the rate
at which we breathe and the tidal volume achieved with each breath varies within an
individual, between individuals, and is sensitive to context. Intraindividual respira-
tory variability, they argued, is particularly important for emotion. If breathing is so
closely tied to emotional state, it should perhaps change when emotion changes, but
the exact nature of the change was unclear. The emotional stressor Vlemincx and col-
leagues chose was worry. Worry is an index of general anxiety, referring to persevera-
tive verbal rumination about negative events that might occur in the future—events
that are threatening to self or relationships. They chose participants who were free
from anxiety disorder, and induced worry by asking them to think about their con-
cerns over social relationships, money, or health. In another condition, the same peo-
ple undertook a mindfulness procedure focused on breathing. Worry was associated
with a loss of variability in patterns of breathing, variability countered by practicing
mindfulness during worry. This rare study of normal worry and respiration gives us
a hint of why respiratory awareness may be important: simple worry, the kind that
occurs on a daily basis for many people, can be powerful enough to reduce respira-
tory variability, to make our responses rigid and slow to change.

Respiratory variability

Variability in respiratory function, like variability in heart rate, may be an accessible

marker of the healthy switching between physiological control systems. Heart rate
variability has been championed as an index of general health (Thayer et al., 2012),
whereas invariability or rigidity is thought to be a major risk factor for cardiovascular
disease and early aging (Thayer et al., 2010). The problem with heart rate variability is
that heart rate perception is poor. We are unaware of heart rate, and its variability is
impossible to monitor unassisted. Monitoring of an objective cardiovascular feature
through biofeedback is needed. On closer examination, most attempts at improving
heart rate variability involve relaxation or mindfulness protocols that teach breathing
awareness and control. Omer Van den Burgh and colleagues at Leuven have perhaps
identified a more specific, accessible, and readily translatable target for psychological
and psychophysiological interventions (Vlemincx et al., 2013).
A rigidity or lack of variability in both respiration and heart rate may serve a use-
ful primary function. In particular, hyperventilation behavior is initiated in response
to threat and is a feature of physiological arousal. In an interesting experiment, the
question of whether aspects of breathing could be conditioned by fear was inves-
tigated. Faces were selected as conditioned stimuli; these were then paired with an

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unconditioned stimulus, a loud human scream. Detailed respiration and heart rate
parameters were collected. In a unique finding, the rate of inspiration was observed to
increase as a learned response to fear (Van Diest et al., 2009). Perhaps increased speed
of breathing is part of a learned mechanism to promote escape and avoidance from
danger. In the laboratory, at least—and I suspect the same is true of everyday ­­life—
it is possible to induce hyperventilation by linking it to fear. In particular, one can
increase the rate of inspiration. Outside of the laboratory, increases and decreases in
respiration vary unconsciously by how one feels, and can become paired with specific
anxious behaviors. In this study, the aversive stimulus of a human scream was both
unrelated and introduced. Consider, for example, how cues can easily be established
in those surviving suffocation or asphyxiation.

A focus on rumination

The role of worry has been more comprehensively investigated in cardiovascular

activity. Jos Brosschot has argued repeatedly that the primary culprit of the pro-
longed and inflexible physiological activity we call stress is emotion (Brosschot, 2010).
This cardiorespiratory inflexibility response is thought to be adaptive in acute threat,
as it prepares one to flee, but it is potentially damaging in the context of chronic
threat. The behavioral expression of this stress, Brosschot argues, is worry, or more
specifically the ruminative aspect of worry, which he calls “perseverative cognition.”
These are the thoughts about bad things that might happen that just won’t go away.
This cognitive ability of ours to reflect on the causes and consequences of events, and
to plot possible avoidance of danger, leaves us exposed to the risk of persistent, aver-
sive worry, a learned respiratory response, and the chronic state of reduced flexibility
in both respiration and heart function. A focus on both conscious and unconscious
worry as a mediator of the stress and its effects on respiratory involvement in disease
may be fruitful. Indeed, Brosschot suggests that a modern consideration of stress can
now abandon its unhelpful restrictive duality between physiology and psychology.
What cardiopulmonary reactivity shows us is that emotional and interoceptive
experience are inextricably linked.
Hypoventilation is less investigated. Awareness of reduced breathing rate is rarely
discussed and could be a useful target for future investigation. There are studies in
which special populations, such as pilots, are trained to identify hypoxia (Malle et al.,
2013). But in everyday life, causes of nonspecific hypoxia are typically through acci-
dental or deliberate self-poisoning by tobacco smoke inhalation, opioid use, and from
airway obstruction due to obesity or physical restriction. The emotional association
of hypoventilation is discussed in depression as a consequence of hypoactivity and
loss of motivation, because of a sedentary behavioral pattern (Lin et al., 2011). It would
be helpful to know if, just as worry increases inspiration rate, induced emotions can
also lead to decreases in inspiration or expiration rate.

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Relearning to breathe

The idea of spending time learning to breathe again might seem at best inefficient,
and at worst noncredible as a health-promoting or recreational activity. Surely we
know how to breathe! After all, we have been doing it, on average, 15 times a minute
our entire lives. But relearning how to breathe is exactly what is advised in a range of
popular health-promotion or stress-reduction programs. Perhaps the most popular
is known as mindfulness-based stress reduction, or just mindfulness training. Mind-
fulness is a form of meditation that attempts to raise awareness of presence. It pro-
motes a form of “open” attention that allows one to be receptive, nonjudgmental, and
accepting of current experience, free from the distal preoccupations characteristic
of worry, of what might have caused an event, what its consequences might be, and
what could or should be done. A nonreactive focus on the present may have benefits
to general health in nonpatient populations, although it is fair to say that the evidence
is to date underwhelming (Chiesa and Serretti, 2009; Khoury et al., 2013).
Most mindfulness techniques, like relaxation protocols before them, make use of
breathing exercises, and often involve interoceptive, proprioceptive, or haptic aware-
ness. They focus, for example, on the experience of breathing, moving in space, or
being in contact with the ground. Mindfulness is most developed in mental health
domains; in particular, in disorders characterized by experiential avoidance, when
thinking about something is painful, and so trying not to think about or acting to
change the experience is the norm, as in depression and anxiety disorders. But its
value has not been established in physical disorders in which somatic awareness is a
given and the interpretation of physical experiences is important. For example, in a ran-
domized controlled trial of a mindfulness and breathing therapy, Richard Mularski
and colleagues found no effect of the therapy in improving breathing characteristics
of patients with a chronic obstructive pulmonary disorder (Mularski et al., 2009).
Perhaps the attentional redirection and meditative aspects of mindfulness are not
crucial for people with conditions in which somatic awareness or preoccupation is
already established. What might be fruitful is the development of protocols aimed
directly at key features of the respiratory response to stress discussed here, with
content explicitly focused on improving respiratory variability, or on the extinction
through exposure of learned increases in the rate of inspiration, and to interoceptive
awareness of arousal more generally.
Finally, it is clear that it is entirely possible to manipulate aspects of the breathing
cycle in the short term. It can be altered: whether one is singing a difficult aria, div-
ing underwater, or, as a subject in an experiment, listening to a loud human scream.
What we don’t know, however, is whether one can meaningfully alter a pattern of
breathing over the long term without an immediate goal (such as exercise or medita-
tion) to provide purpose and motivation. Daily practice of breathing exercises as part
of a program aimed at improving emotional regulation can improve cardiovascular

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health and the self-report of well-being, but there is no evidence that one can improve
respiratory variability in the long term without continual conscious interference.
One normally needs to have a strong reason to engage in what would need to be a
daily activity of learning to breathe again.
There are two populations of people who have just such a reason to relearn to
breathe. The first are those who experience panic disorder in which hyperventilation
is a principal feature. The second are those with a primary cardiovascular or respira-
tory disease in which difficulty breathing (dyspnea) is a primary complaint.

Panic

The relatively sudden, unbidden, unpleasant, and rapid escalation of anxiety is called
panic. A panic attack is accompanied by a range of experiences, including autonomic
arousal such as a pounding heart and temperature changes; feelings of ego separation
such as derealization; fear of death; and dyspnea extending to a belief of being suffo-
cated by smothering or choking (Craske et al., 2010). An attack must have a rise-and-
fall pattern, peaking within ten minutes, to separate it from the experience of a more
constant terror. Panic attacks occur with other anxiety disorders and phobias. Think
about how some of us react on seeing a spider or when entering a large, windowless,
crowded store with low ceilings. Many people have had a panic attack; one does not
need to have an anxiety disorder to have a single or small number of episodes, if the
context is right. The lifetime prevalence of a single panic attack is almost 25 p
­­ ercent—
even higher when the triggers are known (Kessler et al., 2006).
Because of the social and emotional consequences of panic, feelings of shame,
embarrassment, and low confidence can severely disable people. Panic is often treated
together with agoraphobia, the fear of leaving a secure and familiar environment and
going into the open. If it happens repeatedly, one might attract a diagnosis of panic
disorder, which is defined pragmatically as the frequent experience of panic attacks in
a range of contexts, together with disability, social isolation, and subsequent fear of
future attacks. Although not common, panic disorder is socially and economically
disastrous for individuals and their families (Skapinakis et al., 2011).
Despite respiratory function being one of the criteria for diagnosis—and a com-
mon feature occurring in 86 percent of cases in one illustrative sample (Cox et al.,
1994), and 95 percent in another (Starcevic et al., 1993)—it attracts less interest than
other features of autonomic arousal such as cardiac symptoms. Christiane Pané-Farré
and her colleagues investigated patient reports of their first panic attack, and found
cardiorespiratory symptoms to be the most distressing feature. Unfortunately they
did not separate out these features and report respiratory features alone. They specu-
late that cardiorespiratory symptoms could trigger avoidance behavior, especially if
linked to fear, and especially if this link occurs the first time one has a panic attack.
(Pané-Farré et al., 2014).

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 pa nic

Missing from the study of panic is a focus on the paradoxical presentation of an

increased inspiration rate, accompanied by dyspnea; that is, people breathing in
quickly but still feeling like it is just not enough. It is not clear if this respiratory pat-
tern initiates, accompanies, or follows the cognitive and emotional peak of feeling
morbidly threatened, urged to escape, and powerless. Meuret et al. (2010) attempted
to look in some detail at the precipitating factors to a panic attack. Forty-three adults
with a panic disorder were recruited from the community and asked to wear ambu-
latory physiological and respiratory monitors for a 24-hour period (see Figure 5.2).
An event-sampling procedure was used in which the participant identified the onset

Fig. 5.2. Equipment for 24-hour monitoring of breathing and ambulation.

Reprinted from International Journal of Psychophysiology, 78 (1), Alicia E. Meuret and Thomas Ritz,
Hyperventilation in panic disorder and asthma: Empirical evidence and clinical strategies,
pp. 68–79, Copyright (2010), with permission from Elsevier.

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of the panic attack manually, producing a time signature around which physiological
recordings could be mapped, and triggering self-report of the experience. In all, 13
panic attacks were recorded. This remarkable study showed for the first time that the
time before a panic attack is characterized by undetected respiratory changes. The
researchers found

that the hour preceding the onset of naturally occurring panic attacks was marked by
significant cardiorespiratory instability. These changes were largely absent in the con-
trol periods. The physiological instabilities occurred in repeated bouts often initiated
by HR [heart rate] accelerations. The period surrounding panic onset was domin-
ated by respiratory changes. Before panic onset, VT [tidal volume or the depth of each
breath] decreased and PCO2 [carbon dioxide on expiration] increased, plateaued, and
then decreased. At panic onset, HR and VT rose and then PCO2 dropped.1

The common view of panic is that it is brought on, or exacerbated by, hyperventi-
lation. This view is perhaps driven by our observation of the immediate surface fea-
tures of a person in flight mode: breathing rapidly and scanning the environment for
escape. The opposite may be true. Meuret and colleagues’ findings suggest that hypo-
ventilation may occur an hour before a panic attack, providing sufficient means for
a panic response to develop. They tentatively support Donald Klein’s ideas of panic
as response to a suffocation false alarm in which hyperventilation is triggered intero-
ceptively as either a hypersensitivity to carbon dioxide or, as here, in a precipitated
suffocation reaction to hypoventilation (Preter and Klein, 2008).
Peter Lang and colleagues developed this further. They examined alarm caused
by a suffocation challenge (an experimenter-controlled restricted airflow), show-
ing heightened defensive responding to cues of suffocation. Taken together, there is
a developing view of panic as a consequence, not the cause, of respiratory reaction
(Lang et al., 2011). Breathing appears to be more than simply a passive reaction to
threat. How we breathe may be critically important to the prevention of panic attacks
and the development, for some, of a panic disorder (Pappens et al., 2012). As methods
and technology develop, allowing more ethnographically sophisticated research, we
will achieve a better understanding of exactly which aspects of breathing matter.
Although it is exciting to discover that breathing does matter in predicting suffo-
cation reactions, including panic, Alicia Meuret and colleagues are not yet able to say
whether people have any awareness of respiratory function prior to panic. They say:

‘It is unclear whether patients sensed these events as an aura of the impending panic,
giving them a premonition that a full-blown attack would follow.’2

It is not clear whether one’s awareness of respiratory function is desirable, or even

possible, as part of a strategy for managing suffocation anxiety or fear of panic attack.

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 dyspne a

Further, extending the ideas of Jos Brosschot, it would be interesting to discover

whether the period of growing hypoventilation prior to panic is associated with per-
severative cognition.
Currently, research in the field of panic is at an interesting respiratory crossroads.
The study of breathing patterns, made more possible by technology miniaturized to
allow constant physiological monitoring, provides the possibility for new applica-
tions of methods of restoring partial carbon dioxide, or in relearning to breathe. If
there is a strong enough reason to relearn to breathe—as in reducing the incidence
and severity of panic attacks—then how and when should one breathe differently,
and what should one do? Alicia Meuret and her team reviewed all of the studies on
breathing retraining and on exposure to feelings of restricted breathing, but were
disappointingly unable to conclude whether retraining had any value (Meuret et al.,
2005). The critical question remains unanswered: is primary prevention of panic
attack a realistic possibility? Or can we only focus on secondary prevention, on rec-
ognizing and managing the symptoms when they occur, in part through changing
one’s breathing? Long-term changes in respiratory behavior by the deliberate con-
scious attempt to alter breathing, with or without meditative content, may simply
be ineffective. More fruitful, applying the findings of aversive conditioning from the
Leuven laboratory, might be to relearn the signals of altered breathing. The interpret-
ation of respiratory signals, perhaps signals starting far outside of awareness, may be
a more valuable target. One might usefully attempt to identify suffocation anxiety
as a signal to alter one’s breathing pattern, reset resting respiratory variability, and
challenge the thoughts about what one’s labored breathing might mean: perhaps
not impending suffocation, but a signal to return control over respiratory variability
(Sánchez-Meca et al., 2010).

Dyspnea

There are different experiences of being breathless. The exact experience is in

part related to the physical cause. For example, an asthmatic attack can feel differ-
ent to hypercapnia caused by respiratory depression from opioid consumption.
One man, in an interesting psycho-biographical study reminiscent of twentieth-­
century neurology, shared his unusual experience. Michael Faulkner had the mis-
fortune to experience three discrete forms of severe respiratory dysfunction in
one lifetime: first from hypoxia caused at altitude, second from myasthenia gravis
(a neuromuscular disease), and third from a pulmonary embolism (arterial block-
age). Because he had undergone training in a decompression chamber during his
time as an aeronautical research scientist, he was able to identify hypoxia. It was
that training that helped him to survive. He teamed up with Clare Galtrey and
Damian Wren from St. George’s hospital in London to talk about the different
experiences.

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At altitude Michael Faulkner experienced hypoxia first as cognitive decay and then
as increased respiratory rate. With myasthenia gravis, the breathlessness was specific
to activity; in particular, exertion. He says:

Swimming also provides an illustration, if I tried to use power the breathlessness cut in
before my muscles had time to limit me. Provided I limited my swimming to low en-
ergy levels I would reach a state that I could sustain being mildly breathless and swim as
long as I wanted. One length at my maximum strength would leave me gasping for air.3

The embolism, at this time undiagnosed, was a different sensation: “Over the fol-
lowing month my breathing deteriorated, at times it was so difficult it felt like near
complete blockages, despite home oxygen I was still not coping. I realized that I was
hypoxic which came in frightening waves.”4
There are many people who live every day with exactly the feeling of activity
restriction and feelings of suffocating. These people are not climbing at altitude or
diving to the bottom of the sea; they are among the millions of people living with
an obstructive lung disorder, with cardiovascular disease, with asthma, or dying of a
late-stage malignant disease such as cancer. Chronic obstructive pulmonary disorder
(COPD), for example, is a leading cause of death in many countries, ranking on aver-
age as the fifth most common, an incidence that is growing (Buist et al., 2007). COPD
has a number of symptoms, including cough, increased sputum, pain, and fatigue—
but its principal feature is dyspnea.
Although dyspnea is a common complaint in COPD and end of life, it is a highly
intense and personal challenge (Akgün et al., 2012). It can be more than simply a
hunger for air: “Dyspnea is not one experience, but encompasses a whole range of
sensations (e.g. air hunger, feeling of increased effort, rapid breathing) that are highly
subjective” (Hayen et al., 2013, p. 46). It encompasses feelings of urge to breathe, of
obstruction, and of effort in breathing (De Peuter et al., 2004). In a qualitative study
of people receiving palliative care at home, eight people who were receiving oxygen
therapy were asked what dyspnea felt like. Some described it as a catastrophe: “Oh,
it feels like it’s the end of the world to me” said one, and “I might feel like dying” said
another. Other people focussed on the sensations of restriction, dizziness, fatigue or
air-hunger (Jaturapatporn et al., 2010, p. 766). Such dramatic and detailed descrip-
tions are common. The sense of being on the edge of panic and living in fear of feeling
suffocated appears to be the primary challenge.
In another study, 94 older people with COPD and 55 age-matched people without
any history of respiratory disorder were asked to share the words they use about dys-
pnea (Williams et al., 2008, p. 490). If people reported never having been breathless,
they were asked to think about when they were out of breath after a challenge such as
walking upstairs. Table 5.1 shows the descriptors that people used and gives a flavor
of their intensity. The most common descriptors were emotional. People with COPD

96
Table 5.1: Language used to describe breathlessness by those with and without a Chronic Obstructive Pulmonary Disorder

Volunteered Language Category No. of Subjects Volunteering % of Total No. of Descriptors

Descriptors Volunteered

COPD (n = 94) Non-COPD (n = 55) COPD (n = 94) Non-COPD (n = 55)

Frightening: “terrified, fear, panic, scared, bloody frightening” 42 (15) 1 (0) 12 (16) 1 (0)
Annoying: “bloody annoying, frustrating, nuisance, fed 29 (11) 2 (1) 9 (12) 2 (2)
up with it all”
Awful: “horrible, terrible, bloody awful, think you’re going 27 (8) 0 (0) 8 (9) 0 (0)
to die”
Unique somatic: “sweat, painful, feel faint, headache 22 (4) 10 (4) 6 (4) 8 (8)
and hot”
Difficulty breathing in: “can’t take next breath, hard to breathe 21 (8) 1(1) 6 (9) 1 (2)
in, starved for air”
Uncomfortable: “discomfort, not good” 19 (5) 7 (5) 6 (5) 6 (10)
Tight: “tightness, constricted, chain around chest” 16 (3) 6 (3) 5 (3) 5 (6)
Strategies: “need to concentrate, find somewhere to lean, sit 15 (3) 14 (5) 4 (3) 12 (10)
down and rest”
Helpless: “nothing you can do to stop it, nothing seems 15 (4) 3 (2) 4 (4) 3 (4)
to help”
Suffocating: “suffocating, choke, like drowning, gasping” 15 (3) 2 (1) 4 (3) 2 (2)

(continued)
Table 5.1: (continued)

Volunteered Language Category No. of Subjects Volunteering % of Total No. of Descriptors

Descriptors Volunteered

COPD (n = 94) Non-COPD (n = 55) COPD (n = 94) Non-COPD (n = 55)

Hard to describe: “difficult to put into words, there is no 15 (1) 9 (2) 4 (1) 8 (4)
word to explain it”

Can’t breathe: “can’t breathe, hard to breathe, can’t get air 15 (2) 3 (0) 4 (2) 3 (0)
in or out”
Worried: “anxious, apprehensive, nervous, stressful” 15 (2) 3 (0) 4 (2) 3 (0)
Short of breath: “short of breath, out of breath, can’t catch 15 (7) 22 (11) 4 (8) 18 (22)
breath”
Labor: “labored, heavy, hard, physical effort to get air” 14 (6) 6 (4) 4 (6) 5 (8)
Unique affective: “like a cow in a paddock, awareness of 12(1) 1(0) 4(1) 1 (0)
breathing”
Regret: “not what I used to be like, can’t do tasks I used to 10 (2) 1(0) 3 (2) 1 (0)
be able to”
Depressed: “inept, you’re not worth anything, wish you 8 (4) 0 (0) 2 (4) 0 (0)
were dead”
Tired: “tired and weak, tiring, general exhaustion” 6 (3) 5 (2) 2 (3) 4 (4)
Deep: “can’t take a deep breath, want to expand but 5(1) 1(1) 1(1) 1(2)
lungs won’t”
Difficulty breathing out: “can get air in but can’t get it out, 2 (0) 0 (0) 1 (0) 0 (0)
can’t get breath out”
Does not bother me: “doesn’t hurt, what I expect to be, 1 (0) 16 (7) 0.3 (0) 13 (14)
never alarming”
Unfit: “unfit, unconditioned, not as fit as I used to be” 0 3 (1) 0 3 (2)
Doesn’t last long: “doesn’t last long, recover quickly” 0 4 (0) 0 3 (0)

Reprinted from CHEST, 134 (3), Williams, Marie; Cafarella, Paul; Olds, Timothy et. al., The Language of Breathlessness Differentiates Between Patients
With COPD and Age-Matched Adults, pp. 489–496, Table 2, doi:10.1378/chest.07-2916, (c) 2008 American College of Chest Physicians. Reproduced with
permission from the American College of Chest Physicians.
*Numbers in parentheses are best volunteered descriptors.
 br e at hing

report being terrified, frustrated, annoyed, scared, and frightened, and thought they
were going to die.
Unusually for a study investigating people’s experience, a sample without the experi-
ence followed the same protocol. What this revealed was intriguing: if you ask people
to think about an experience they do not have, they will focus on the mechanics of
the behavior, whereas what is really prominent in the experience is its emotional chal-
lenge. The authors of the study summarize:

In general, only COPD subjects volunteered the descriptors “frightening,” “worried,”

“helpless,” “depressed,” and “awful.” However, only non-COPD subjects volunteered the
descriptors “can’t breathe out,” “doesn’t last long,” “doesn’t bother me,” and “unfit.” . . .
When up to three statements of breathlessness were selected by subjects, 69% of subjects
could be accurately classified within their original group. In general, only COPD subjects
selected the descriptor statements “smothering,” “constricted,” “suffocating,” and “can-
not get enough air,” while non-COPD subjects selected “breathing more” and “rapid.”5

Terror management

Because breathing is such an omnipresent and emotionally immediate experience,

it can be both common and unique: common to the population but unique to the
individual. Marit Kvangarsnes and her colleagues interviewed ten people in depth
about their experience. Unusual in this study was the report of extreme experiences
leading up to acute exacerbations. Some people wanted to talk about changes in how
unreal the world can seem when severely breathless, when nightmares are so vivid
they are hard to ignore, or when, during an exacerbation, colors, furniture, and peo-
ple seemed distorted (Kvangarsnes et al., 2013). This is the first hint that the extremes
of derealization may play some part in the experience of dyspnea.
The psychological treatment of breathlessness is relatively underdeveloped, at least
in comparison to pain and fatigue. The focus has been on primary prevention (e.g.,
smoking cessation), on secondary prevention of exacerbation, on comorbidities (e.g.,
anxiety, depression), and on the provision of simple techniques of relaxation or educa-
tion (Baraniek and Sheffield, 2011; von Leupoldt et al., 2012). There is not yet an exam-
ination of how emotion can influence respiratory variability (and vice versa), and how
the interpretation of breathing influences behavioral intentions, planning, and action.
A focus on action in the context of the threat of suffocation might be an interesting
avenue for investigation, as would the transfer of learning from normal respiration
with its focus on variability and speed of recovery. Also important would be a focus
on any perseverative cognition that might accompany the threat of suffocation.
For a functionalist account of breathing, what matters is the meaning of breath-
ing and breathlessness, and their motivational significance. The phenomenology of
breathlessness is intricately related to its meaning. For some it is a minor restriction,

100
 t e r ror m a nage m e n t

for others it is a constant reminder that taking away breath means taking away life,
hope, and future. The emotional challenge of not being able to breathe can never be far
away. I suspect that what is at the heart of the experience of dyspnea is a chronic form
of terror management. Perhaps, as Michael Faulkner describes, there are “frightening
waves” of breathlessness that sometimes threaten activity, and sometimes threaten
suffocation, leading at the extreme of experience to dissociation. (Feinberg, 2011).
To explore these ideas further I talked with Ian Taylor (Box 5.2).

Box 5.2. Ian, living with dyspnea: “it is about feeling vulnerable”
Ian is a playwright, and has been a coal miner, builder, and an assistant to an accountant,
among many other jobs in his life. Ian is a remarkable man with a rich personal history and
many stories to tell. I met him with his wife in their home. He has severe bronchiectasis,
a condition of expansion of lung tissue, and has repeated infections caused by chronic
pseudomonas and stenotrophomonas. He suffers from chronic dyspnea, overproduction
of sputum, fatigue, pain, and anxiety. Ian was happy to talk to me about the experience of
finding it hard to breathe. Of course, what does not come across here is that our conversa-
tion was punctuated by frequent pauses for Ian to use breathing techniques, clear sputum,
or to use the continuous positive airway pressure machine to help him breathe.

______________________________________

Chris: When did you first notice that breathing was becoming difficult?
Ian: The first time was about 15 years ago. The breathing started to bother me. I found
that on occasion breathing normally had become a problem. I didn’t make anything of
it. It went on like that. And then about five years ago I could hardly do anything without
being extremely beyond the point of breathing comfortably. I just could not breathe. I
would then notice what is called a panic attack whereby you get to a point where you
can’t breathe and you’re simply gasping, gasping for breath, and you can’t find that
breath. That is the most horrifying thing you can ever imagine because you feel as if you
are, well, you feel as if you are dying.
Chris: Tell me about the first time you had one of these panic attacks.
Ian: When it first happens it is quite shocking. The first time it really happened I was on
a trip to the cinema. I just stopped. I just could not breathe. I was in absolute agony and I
mean real agony, not feeling a breath in my body, trying to find one. I waited and waited
and then it passed. I sat there on my chair for about a quarter of an hour, and I was then
fine. But it shocked me: that this had happened. And then it began to happen more. I
remember going into a shop and all of a sudden—“woosh”—it happened. I had to hang
on to the post. A young man came up and said, “You’d better come and sit down,” and I
was just sitting there gasping, gasping, gasping for every breath I could get. He wanted
me to go to hospital and I said, No, no, no, no, this will pass. And after about half an hour

(Continued)

101
 Box 5.2. Continued
it passed and I settled down. But this is what happens. Every now and again I get stuck. I
am told it is a panic attack.
Chris: Does this idea of panic make sense to you?
Ian: I could never understand it. The first time someone told me it was a panic attack,
it sounded a feeble thing. Considering what you are suffering. I mean, I know you will
never stop breathing as such. The breath will always be there as long as you are not actu-
ally dying. But if you have one of the conditions I have, you will not die, your breathing
will just be bad. But the shock it gives you. You don’t know when it is going to happen.
And I find the worst thing of all is the anxiety. It depletes me no end.
Chris: Are there ways you have found to cope with the attacks?
Ian: I have picked up ideas from here and there. Dorothy House [Hospice] have given
me some tips. But they are only tips in the sense that you still have to go through with
it. I have a way of coping with the attacks now. But it is surprising how sometimes you
get caught out. For instance, I watched a violent film and it left such a mark on me. I was
panting, ill, and everything. I am not sure why it bothered me so much. I worked out that
it is about feeling vulnerable.
Chris: Do you every have a sense of things not being real?
Ian: Yes. I have had that. That happens.
Chris: Have you ever experienced overcoming the sense of panic?
Ian: Yes—when I had a cataract removal. I was lying down and all of a sudden I was
thinking: “I am not going to be able to manage this”; “I am not going to be able to do it”;
“All of this stuff is going to come up I am going to block myself off.” And then all of a
sudden something in my mind said: “You can do this”; “You can do it.” And I did it.
Chris: Has there been anything remotely positive about the experience?
Ian: Yes; it makes me think more deeply. You think more about your own life. It teaches
me tolerance. I was brought up in a tough town in the 40s and 50s. And I was not used to
accepting. To think that I have to be careful now is hard for me.
Chris: Does confidence make a difference?
Ian: I think it must do. I mean, I know that if there was something wrong with my wife
and she needed help I would throw everything off and do what I had to do. Nothing
would stop me.

______________________________________

Ian describes the overwhelming sense of shock and terror that is a core part of the experi-
ence of dyspnea. For Ian the label of a panic attack was unhelpful. In part this is because
of the phenomenology. The experience was always narrated as difficulty breathing that
leads to high anxiety, not the reverse. Living with a severe and chronic breathing dis-
order is like living with the weight of water pressing down on one. Managing the terror
and finding a way to resist the derealization is part of what it might mean to cope.
 su m m a ry

Summary

Breathing is the most functionally pure of the physical senses. Apnea urges breathing.
When one is denied the ability to oxygenate—by illness, disease, or environment—­
the experience can bring one close to terror and provide an extreme drive to breathe.
However, when difficulty breathing is chronic and explained, in chronic disease or
in sport, people develop mental and physical techniques of managing the physio-
logical and psychological consequences of apnea. Breathing is like funambulism
(tightrope walking) in the sense that we are very close to death, seconds away. Unlike
funambulism, we are born expert and do not need to think about it. When we do
think about it we come closer to the terror. The psychology of breathing is surpris-
ingly well developed. It has some of the best experimental science, the most creative
of methods, and has real promise for developing new interventions. Understand-
ing respiratory variability and its relationship with perseverative cognition offers
real hope not only for depathologizing panic but also for helping people cope with
chronic dyspnea.

Notes

1. Reprinted from Biological Psychiatry, 70 (10), Alicia E. Meuret, David Rosenfield, Frank H.
Wilhelm, Enlu Zhou, Ansgar Conrad, Thomas Ritz, and Walton T. Roth, Do Unexpected
Panic Attacks Occur Spontaneously?, p. 990, Copyright (2011), with permission from
Elsevier.
2. Reprinted from Biological Psychiatry, 70 (10), Alicia E. Meuret, David Rosenfield, Frank H. Wil-
helm, Enlu Zhou, Ansgar Conrad, Thomas Ritz, and Walton T. Roth, Do Unexpected Panic
Attacks Occur Spontaneously?, p. 990, Copyright (2011), with permission from Elsevier.
3. Reproduced from Practical Neurology, Clare M. Galtrey, Michael Faulkner, and Damian R.
Wren, 12 (1), p. 51, doi:10.1136/practneurol-2011-000116 © 2012, BMJ Publishing Group Ltd.
With permission from BMJ Publishing Group Ltd.
4. Reproduced from Practical Neurology, Clare M. Galtrey, Michael Faulkner, and Damian R.
Wren, 12 (1), p. 52, doi:10.1136/practneurol-2011-000116 © 2012, BMJ Publishing Group Ltd.
With permission from BMJ Publishing Group Ltd.
5. Reproduced from Marie Williams, Paul Cafarella, Timothy Olds, John Petkov, and Peter
Frith, The Language of Breathlessness Differentiates Between Patients With COPD and Age-
Matched Adults, CHEST Journal, 134 (3), p. 494 doi:10.1378/chest.07-2916 © 2008, American
College of Chest Physicians.

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 CHAPTER 6

FATIGUE

F eeling spent, exhausted, tired, weary, lethargic, listless, or suffering from fatigue,
are common complaints of everyday life. In fact, in a UK survey of 2,474 adults, a
staggering 41.3 percent said they were feeling tired or run-down (McAteer et al., 2011).
These were adults living in the community, going about their business—not clinical
subjects seeking medical help for a fatigue problem. There is no reason to think of
fatigue as a peculiarly British phenomenon, as similar data have been collected in the
United States and Scandinavia (Loge et al., 1998; Ricci et al., 2007). The experience of
being tired is extremely common, but for some people more than just an inconven-
ience: it is a major, limit-defining feature of life.
Fatigue has attracted a great deal of psychological debate. In this chapter I explore
the different experiences we refer to when we describe ourselves as tired. There is a
recurring metaphor of a limited “energy supply” that is never far from fatigue talk,
and it is worth spending some time unpacking what the evidence is for fatigue as a
depletion of resource.
There are other ways to think about fatigue, however. I contrast resource accounts
with motivational accounts of fatigue as a general mechanism for switching away
from unrewarding tasks that have minimal reward and high cost. Perhaps fatigue is
less about energy depletion and more about energy optimization. Fatigue, viewed
in this way, highlights two main problems, both of which we see clearly in extreme
experiences. First, there are many people who experience severe, chronic, debilitating
fatigue as unstoppable exhaustion. Second, there are people who operate with little
rest, who rarely complain of feeling spent, and who instead boast vitality and energy.
I explore both extremes with the help of two people whose lives are defined by these
traits: Kerry, who is an endurance ultra runner (the thought of which is enough to
tire most of us), and Sarah, who has had chronic fatigue syndrome for 16 years and
who lives a life carefully balancing what she wants to do with what she judges to be
possible.

Being tired

There are two traditions of fatigue research, which approach the problem from very
different angles. First is the occupational study of fatigue in people engaged in work,

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sport, or leisure; second is the medical study of fatigue as a symptom of disease or

disorder—as the primary presenting problem in clinical settings.
From almost the beginning of scientific psychology, the study of mental fatigue
was a central concern, in part because it is a constant methodological problem in
many experimental procedures. Measuring performance requires repetition over
time, but repetition of simple tasks tends to induce fatigue, boredom, and the desire
to alter behavior. Fatigue in the particular context of the experiment is a proced-
ural nuisance to be controlled and managed, but it is much more than an artifact.
In the early part of the twentieth century, fatigue was a major concern in the still
industrializing West. Psychology was intimately involved in the social engineer-
ing of how to battle fatigue and thereby improve social, educational, and industrial
performance.
From the very beginning of fatigue research, mental fatigue was recognized as an
emotional and motivational construct. The problem was originally given as: why
does continuous performance on a task lead to reduction in output, aversive feelings,
and thoughts of wanting to stop? For a striking early example and definition of the
problem, Tsuru Arai reported her now-famous experiments on repeatedly solving
arithmetic sums, and the observation that in an experiment with herself as subject,

the time taken to do a certain number of examples is almost doubled during twelve
hours of mental multiplication. . . . In the case of the group of individuals (inexperi-
enced subjects), the increase in the time taken to do a certain amount of work is 24 per
cent during two hours of mental multiplication. (Arai, 1912, p. 114)

We might marvel at the dedication involved in this tradition of experimental intro-

spection and at the twelve-hour marathon of arithmetic, but it does bring to life the
problem of fatigue as a shorthand way of referring to the decrement in performance
on repetition.
The classical and popular explanation for the problem of fatigue is that it is a sign
of resource depletion, as a spluttering engine signals spent fuel. The modern view is
that fatigue signals the need to change behavior. Although I have cast these as classical
and modern, it would be wrong to think that one has replaced the other. Early studies
of fatigue used a more phenomenological psychology and so very quickly became
aware of the primacy of desire. It was recognized early that being tired is not an inabil-
ity to concentrate, or an idle openness to random ideas, or even an unwillingness to
engage in task demands, but rather the overwhelming desire to disengage from a task
that is becoming aversive. As early as 1899 Thorndike observed that subjects in his
cognitive experiments did less work when tired, “not because this stock of mental
energy was running low, but because ideas of stopping, of ‘taking it easy,’ of working
intermittently came in and were not inhibited” (Thorndike, 1899, p. 712).

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Despite the early recognition that fatigue is not best characterized as a marker of
spent energy, the more functional and phenomenologically rich view of fatigue was
lost in the search for improved industrial performance.

The fallacy of resource depletion

Metaphors direct psychological thought and science. We become used to describing

cognitive processes as limited by structural constraints such as “filters” and “spot-
lights” (Fernandez-Duqu and Johnson, 1999), or the dominant overarching meta-
phor of mind as computer. Cognitive functions as restricted to the limits of a finite
resource is one of the more enduring and stubborn metaphors in psychology. David
Navon (1984) laid bare the fallacy of resource depletion as a model of performance,
largely due its lack of parsimony. Ideas in psychology that resort to resources can
be described without reference to resources. Resources provide a shorthand way of
referring to a range of observable phenomena for task performance, but divert scien-
tific attention from alternate explanations for those phenomena.
Resource talk is difficult to eradicate, and has been recently rekindled in the mod-
ern return to the psychology of willpower, impulse regulation, and self-control. Roy
Baumeister and colleagues promote a model of self- and motivated choice known
first as the strength model of self-control (Baumeister et al., 1998), later as the ego
depletion model. The principal observation across numerous studies is similar to the
classical problem of fatigue: that the exercise of self-control in deliberately resisting
automatic or desired choices is reported as effortful and detrimentally affects per-
formance on the next task or choices. Muraven and Baumeister (2000) drop the ref-
erence to resource as a theoretical inference and reify it as a structural constraint,
similar to energy expenditure in a muscle. This strong version promotes the idea of
energy “conservation” in cognitive and motivational tasks, and the importance of
“replenishment.”
The idea of weakness through use and the need to replenish the spent resource
of willpower provides a peculiar problem. How does one account for the return of
performance? If the resource is unknown (and hypothetical), how does one replen-
ish it? Ego repletion is suggested by a range of commonsense hypotheses, including
doing something else, resting, sleeping, thinking positively, ­­and—controversially—
increasing blood glucose, thought to be in part a mechanism of depletion (Gailliot
and Baumeister, 2007). This physiological turn is a sign of a metaphor in trouble, an
idea being made to work too hard. The glucose hypothesis has been roundly criti-
cized as overly simplistic and lacking in evidence. Indeed, the resource hypothesis
as a whole has been described as “unlikely to be correct (in particular, the glucose
version of a resource account)” (Kurzban et al., 2013, p. 715) and as a “sweet delusion”
(Lange and Eggert, 2014).

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The idea of fatigue as a sign of a depleted resource is a fallacy. Of course behav-

ior is metabolically limited, but fatigue emerges before metabolic limits are met.
The process by which this is governed is the subject of much research, especially in
sports performance. Physical fatigue is subject to the subtle interplay of expectations
of exertion, experience, and central nervous system control. The exact operation of
any central control over exertion is not known, but there is wide acceptance that the
experience of fatigue occurs long before biological homeostasis is threatened. This is
true for both physical and mental performance.

Fatigue as motivation to change

The question persists, then, of why fatigue emerges if it is not a signal of a limit
reached or a resource spent. Fatigue is an aversive emotional response to the demand
of continuing a task, and a desire to stop or switch away from that task. Whether
the primary task is a simple vigilance game or one of deliberate self-control, fatigue
functions to motivate change. This motivational view of fatigue marks a return to
Thorndike’s original ideas, and now appears in different forms. There are at least four
versions of a motivational view of fatigue that position it as (a) an intrinsic cost of
mental control, (b) a method to promote awareness of the opportunity cost inherent
in persisting with a task, (c) an aversion to the decoupling of attention, or (d) more
simply, the “stop” emotion.
The first idea is that all tasks carry an intrinsic cost. This approach views the prob-
lem of fatigue from the perspective of studies on an economic long-term trade-off
between competing demands. Task persistence is simply a way of achieving dimin-
ishing marginal returns. The longer you do something the less gain is possible: “In the
context of prolonged, obligatory mental effort, the marginal cost of further effort is
elevated, leading in some cases to a subsequent withdrawal from cognitively challen-
ging activity” (Kool and Botvinick, 2014, p. 139). From this rational economic perspec-
tive, mechanism is irrelevant to the explanation of behavior. What is needed is simply
an understanding of the utilities and their costs.
A similarly economic view is that subjective effort relies on selection, and where
there is selection there is opportunity cost. One can attend only to a small number of
tasks at the same time. Every selection means that other targets are not selected. The
opportunities that could have come from selecting differently should also be thought
of as costs. Hence the longer we continue with something, not only do the marginal
returns diminish but the opportunity costs also increase. Robert Kurzban and col-
leagues argue that there is a calculation of exactly this cost-benefit trade-off, which is
dynamically computed over the time of that task performance: “The crux of our argu-
ment is that the sensation of ‘mental effort’ is the output of mechanisms designed to
measure the opportunity cost of engaging in the current mental task” (Kurzban et al.,

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2013, p. 665). Fatigue grows as the opportunity costs of persisting with the same task
grow. In this way fatigue functions to motivate people to switch to more profitable
behaviors by reducing cognitive engagement.
A focus on disengagement is at the heart of fatigue for David Navon. He argues
that the perception of effort arises from the disengagement, what he calls a decoup-
ling from task: “Effort is not any scarce commodity. It is the aversive valence of the
operation of decoupling. The more sustained decoupling is, the more aversive it is”
(Navon, 1989, p. 203). This is an interesting idea subtly different in its suggestion that
the negative feelings of fatigue are a by-product of the switch in attention, not the
cause of the switch. A dynamic view of attending has signals preconciously vying for
prioritization. Some signals may be strengthened over repeated failure and finally
break through and capture attention in a forced decoupling that is felt aversively.
Fatigue in this way is a symptom of an attentional system operating in a context of
many competing demands. Again, there is no need here to postulate resources or any
central unitary control (Navon, 2013).
Finally, fatigue has been called a stop emotion. Drawing on the distinction between
liking and wanting currently of interest in the neurobiological study of reward and
pleasure, fatigue does not affect a judgment of the valence of the reward, but affects
the extent to which one is willing or able to extend effort to achieve a reward (Van der
Linden, 2011). Fatigue shares properties of basic human emotions in its universality
and specificity, but perhaps recasting it as an emotion is unnecessary. Nevertheless,
this focus on the motivational properties of fatigue as an urge to disengage is valuable.
These different ways of thinking about fatigue share crucial properties. First, they
are functional accounts: they are interested in how fatigue functions to change behav-
ior in a context of multiple possible demands and rewards. Second, a consensus is
emerging that tasks that are demanding of executive control (updating working
memory, inhibiting automatic responses, decision making) are more susceptible to
fatigue. Third, competing demands are at some level always linked, and perhaps in
constant trade-off. And fourth, the felt experience of fatigue, whether it leads to a
switch in behavior or follows a switch in behavior, is aversive even when the task one
is persisting with is valued.
Bob Hockey captures the return to considering the function of fatigue in his excel-
lent book The Psychology of Fatigue. In summary, he argues that “fatigue may be con-
sidered, like anxiety, to have an adaptive function, serving to protect the organism
from over-commitment to specific goals, in the service of a balanced motivational
strategy” (Hockey, 2013, p. 22). This motivational view of fatigue is essentially posi-
tive. Although the felt experience is unpleasant, its purpose is adaptive. This has
practical considerations for the organization of work; for the design of tasks, espe-
cially simple and monotonous ones, for which the emergence of the desire to stop or
avoid altogether is likely; and for the training of elite, highly skilled performance that
requires one to control fatigue—to overcome the desire to stop.

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The urge to sleep

Before considering the absence of fatigue, and our two extreme experiences of feeling
energetic or tired all the time, it is worth mentioning briefly a specific case of fatigue,
the urge to sleep. Horne (2010) notes the different ways we talk about sleepiness that
include many of the features of fatigue, such as drowsiness, reduced environmen-
tal responsiveness, and the lack of motivation to engage in effort. Sleepiness is not
always a need for sleep. Of interest for the motivational model of fatigue is the inter-
ruption of attention by the strong urge to sleep. In the case of sleep, fatigue is perhaps
less a switch away from a task that offers only diminishing returns, but more a switch
to a higher order goal of total cognitive disengagement. Sleep onset is associated with
a range of physiological and behavioral changes, including loss of awareness and loss
of control over thoughts, most of which are experienced as gradual (Yang et al., 2010).
Resisting the urge to sleep is experienced as a battle, sometimes a battle that is lost
very quickly and without warning (Herrmann et al., 2010). Fatigue urges disengage-
ment from task, but not into sleep. We often confuse sleepiness and fatigue; the word
tired in English refers to both. It is important in research, in clinical practice, and per-
haps in life to distinguish the two.

Vitality, energy, and perseverance

I started this chapter with a UK finding that over 40 percent of people felt tired or
run-down (McAteer et al., 2011). But that means nearly 60 percent were not tired.
Maybe some of this majority felt not just the absence of fatigue but felt energetic or
vital. Persuading people that they could feel more energized, or helping people to
overcome fatigue is big business. Which of us would say no to the promise of feeling
more energetic?
There are three main traditions of research into the question of how to improve a
subjective sense of feeling energized and able to outperform the norm. First, there is
a strong humanist tradition in psychology interested in vitality as a marker of per-
sonal growth and self-awareness. In contrast, there is a thoroughly nonhumanistic
approach to performance enhancement, often by psychopharmacological means.
Lastly, the experience of unusual individuals who achieve elite status in a chosen field
can be instructive. People who have extreme abilities to persevere under duress may
teach the rest of us about what is possible.
Vitality is captured by the report of feeling alive, alert, and bursting with energy
(Bostic et al., 2000). Subjective vitality has been defined as “one’s conscious experi-
ence of possessing energy and aliveness” (Ryan and Frederick, 1997, p. 530). This
definition is circular and exchanges synonyms: energy, vitality and aliveness. It works
well enough as a marker of a unique experience that is beyond the average. Modern

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psychology has not fully engaged with the study of positive experiences such as feel-
ing energized. Research ranges from the study of energy and vitality as the absence
of fatigue, to the more recent positive psychology that promotes a focus on happiness
and personal growth. Vitality is linked with creativity, flow, positive distraction, and
mindfulness (Hefferon, 2013). There is a mature clinical and counseling literature on
personal growth, a literature on aging and late life development, and an educational
and occupational psychology of engagement with work.
Casting vitality as the result of the active engagement of self in pursuit of meaning
is in line with a functionalist account of fatigue. If fatigue is the motivational conse-
quence of the diminishing returns of unrewarding behavioral selection, then one can
understand why switching to a focus on the complexity of outdoor environments
(Ryan et al., 2010) or the personal sharing of theories of self when investing in close
relationships (Lambert et al., 2011) would counter fatigue or be potentially vitalizing.
This is a motivational approach to vitality. We are motivated more than by the simple
desire to increase pleasure and reduce or avoid discomfort.
Huta and Waterman (2014) summarize this approach to vitality as the study of
eudaimonia—a concern with personal growth, with striving for value, authenticity,
and meaning—in contrast to the study of hedonia: the pursuit of pleasure or avoid-
ance of distress. The activities here thought to improve vitality are not passive; they
are likely to involve complex cognitive activity. It is interesting that the study of
­vitality—with its roots in Gestalt and humanistic psychologies—seems to escape
metaphors of resource, capacity, or limits. The theories and ideas are motivational
and developmental, about human striving and growth (Maslow, 1971).

Brain training

In contrast, the study of how to improve performance by improving perseverance

is more susceptible to the fallacy of resource depletion. There are many studies of
how to improve performance on a task, whether by means of prescribed pharma-
cological stimulants, such as amphetamine and methylphenidate; commonly
available substances, such as caffeine or nicotine; nonpharmacological interven-
tions, such as exercise or physical training; or what is popularly known as “brain
training.”
The use of prescribed stimulants as a method of cognitive enhancement is com-
mon in some populations. In one review of studies with school or university students,
between 2.5 and 35.5 percent reported using prescribed stimulants to enhance cogni-
tion (Smith and Farah, 2011). Despite the findings that the effects on decision making
and working memory are relatively weak, there is a strong belief among the young
that prescribed stimulants improve cognitive performance. Similarly, the nonpre-
scription market for cognitive enhancement is now dominated by energy drinks (i.e.,

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the sugar and caffeine industries), which are increasingly discussed as a public health
hazard (Reissig et al., 2009). Both caffeine and nicotine have been found to improve
aspects of cognitive performance in the laboratory, but as most are consumed with
other substances—sugar and alcohol lead the list—research is now focusing on the
interactive effects of multiple substance use. Most studies of cognitive performance
do not measure subjective judgments of vitality or fatigue, so it is often not possible
to tease apart short-term cognitive performance changes from the phenomenology
of fatigue. Despite this shortcoming, there are some enthusiastic supporters of the
caffeine stimulant market (Glade, 2010), but also some high-profile detractors. Kent
Sepkowitz (2013), for one, discussed the harmful effects of high levels of caffeine, and
pointed out that people who consume energy drinks may be unaware of just how
much caffeine they are getting.
So if you can’t reliably buy more energy in a drink, how else can you energize?
Going to the gym may be a better way. Although exercise, being metabolically
costly, is thought to reduce resources, in fact acute exercise is found to confer small
improvements in cognitive performance (Chang et al., 2012). There is much debate
about exactly what type of exercise matters, in whom, and for how long the bene-
fits last, but at least there is consensus that exercise is mentally advantageous in the
short term. Practices that combine physical movement with attention-control strat-
egies such as Tai Chi can also improve cognitive performance (Wayne et al., 2014), as
can strategies of attention management alone, such as mindfulness training (Chiesa
et al., 2011).
Thus taking control of attending, however briefly, may well have benefits on cogni-
tive performance, at least when measured in the shorter term and on the specific task.
There is no compelling evidence, however, that these effects sustain or transfer. The
lack of effects has not stopped the growth in the business of selling “brain-training”
devices and instruction. At best we have rediscovered the findings from the early
psychology of fatigue: repeated performance leads to practice effects. In what should
be considered a landmark study of over 11,000 people undertaking online computer-
ized brain training, Adrian Owen and colleagues could not find any evidence for the
idea that using “brain-training” devices benefited cognition. Although people believe
it is effective, there was no effect. (Owen et al., 2010).
Unfortunately, missing from most of these studies of nonpharmacological inter-
ventions is any concern with felt experience, with the onset or persistence of fatigue
and with aversive thoughts of stopping. Meditation, mindfulness, and other strat-
egies of cognitive control are typically studied only for the effect they may have
on improving cognitive or motor performance, or for reducing the aversive effects
of long-term illness. There are no studies of their effects on fatigue in a normal,
everyday population. The earlier discussion of the history of fatigue research per-
haps tells us why. Like any other cognitive activity, meditation is effortful. Taking
control and directing one’s attention is an active process. To choose to do it would

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need an overriding primary reason, such as the belief that it is leading to some long-
term effect when framed in a narrative of training, or the belief that it will reduce
a stronger aversive sensation associated with illness. Without a strong primary
motivation, a nonpharmacological strategy for performance enhancement is just
another form of task: it might improve performance momentarily, but will lead to
fatigue and disengagement eventually.

Indefatigable

One last source of evidence for the study of vitality is to learn from those who consider
themselves indefatigable. Successful people are often described, or describe them-
selves, as tireless, and such language normally operates to draw attention to socially
valorized character traits such as being hard working, perseverant, or determined.
However, the serious study of persistence without fatigue, or even despite fatigue,
is sparse. There is a renewed interest in the study of both success and of successful
people, whether in business, the military, academe, sport, the arts, or personal life.
A number of overlapping terms for positive characteristics are in use, and are being
explored for their relationship with fatigue and performance. Terms such as hardiness
(Bartone et al., 2013), courage (Rate et al., 2007), and resilience (Kitamura et al., 2013) are
widely used. A favorite is the rhetorically colorful idea of grit (Duckworth and Gross,
2014). Angela Duckworth and colleagues define grit as the ability to persevere and
work toward a long-term goal:

Grit entails working strenuously toward challenges, maintaining effort and interest
over years despite failure, adversity, and plateaus in progress. The gritty individual ap-
proaches achievement as a marathon; his or her advantage is stamina. Whereas dis-
appointment or boredom signals to others that it is time to change trajectory and cut
losses, the gritty individual stays the course.1

There are no accounts of how people who repeatedly demonstrate an ability to

persist in challenging tasks experience fatigue, long past the time that the average per-
son has responded to the stop signal. It is not even clear whether they do experience
fatigue or are simply “bursting” with energy and vitality. In the absence of data, there
are competing hypotheses. Perhaps the vital, high-performing, persevering person is
pursuing a goal that is so important that they are able to be “single minded.” Perhaps
their skill is in diminishing the value of any possible competing tasks, in bolstering
the value of their goal so it remains overwhelmingly important. Alternatively, the
opposite may be true: high-achieving people may actually be in a permanent state
of fatigue, living with the repeated aversive interruption by thoughts of quitting,
but they have techniques to bat away the interruption with repeated switching back

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to their goal. Are endurance athletes less susceptible to fatigue when motivated to
achieve, or more skilled at managing inevitable fatigue?
To explore these ideas further I talked with Kerry Sutton, an ultra-marathon run-
ner (Box 6.1).

Box 6.1. Kerry, the ultra runner: “when my body says stop I won’t accept it”
Kerry describes herself as “challenge driven.” When I interviewed her, she was train-
ing for the 100-mile, 24-hour run from London to Oxford. We met in a university
sports training facility where she took time out to “refuel” and talk about her experi-
ence of fatigue. She is an experienced athlete, having run the Marathon de Sables, a
250-­kilometer cross-desert race, and the Jungle Ultra in Peru, a self-supported, five-day
race with a marathon stage, a hill stage, an endurance 100-kilometer run, and a sprint
stage. I asked her about her motivation, about how she experiences fatigue, and about
how it has changed her.

______________________________________

Chris: I am interested in your motivation. Why extreme running?

Kerry: I don’t know. I have theories. I think if I set a goal I will not give up because of my
sense of failure. I don’t want to fail. I am driven in some senses to compete: with myself.
It is always pushing myself harder. I am trying to get me better. It is to do with my self-
worth. I needed a massive challenge. I needed to pitch myself against myself. When I
started, I didn’t care about the result. I just wanted to push myself to my utter limits and
see if I was as tough as I thought I was.
Chris: What is the feeling of fatigue like? How would you describe it?
Kerry: You mind is tired of thinking about it. I am tired of having to think about having to
push myself on. But I interpret that as fatigue. I am physically tired and my body wants to
stop, but I believe that it’s not—that my body can keep going. My muscles will keep going.
It is my mind that is my weakness, not my body. I don’t believe there is anything my body
can’t do. It will all be in my head. I trust my body will hold up. I trust in my body.
Chris: What are the thoughts you have?
Kerry: “I don’t want to do it.” I am angry. I get the extremes of my emotions. “I am not
good enough,” “I haven’t trained hard enough,” “other people are better than me,” “I feel
heavy and cumbersome.” In the ultra-running community it is known as “hitting the
dark side.” We all get it. We all know it is there. All my demons come out. It is my mental
state that will stop me well before my body is ready to stop. Absolutely, I want to stop.
I get bored of pushing myself. That is the wrong word maybe. Constantly running to a
time over hours and hours and hours, I think my mind becomes fatigued. It is repetition
and the constant push. “I don’t want to push myself.” Then I start to question why I am
doing it. It is mental fatigue in terms of the repetition of the action.

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Box 6.1. Continued

Chris: Is it like height vertigo, being drawn to danger, or the unshakable belief that to
climb higher or go to the edge is irrational?

Kerry: It is not as strong as a fear of falling off an edge; it is a different thing. It’s sort of
more of an anger. “I don’t want to do it anymore.” “I don’t want to do it.” “I do not.”
Chris: What does failure look like?

Kerry: There was a race I stopped. That was my mind thinking I was fatigued, and I wasn’t,
because I’d run too fast. I had gone out too fast. I was trying to keep up with the front-
runners and after two hours I was just, I was exhausted. I thought: “I can’t do this.” Had I
even just dropped a bit I would have won the battle with my mind. But I couldn’t ration-
ally figure that out at the time. And my mind won and I gave up.
Chris: Does fatigue affect your judgment?

Kerry: I am scared of that bit: the irrationality, when my judgment goes slightly awry.
In the jungle when I was on my own, and I was fatigued, and I was feeling threatened, I
was very aware of my surroundings. I was running but unaware of my running because
I was on high alert and became super-aware. My judgment was OK. Spot on. But there
are times when I’m really fatigued and I am struggling with this mental block and I am
completely unaware of the running. There is no world around me. I am totally oblivious
to what is happening. I can’t have music; I can’t have any distraction. I am just me. I am
not even aware of my physical presence, just of that little bit of road in front of me.
Chris: Are you an expert on your body, or have you learned to ignore your body?

Kerry: When my body says stop I won’t accept it. I listen to my body, but I can’t trust it. I
have to become an expert in it. It is trying to be wise in managing both mind and body.
I will try to listen to my body, and understand it—the same with my mind. I will try to
pick apart the thought patterns. It is a dogged determination. I might feel fatigue but I
have no option. So I override it. I will override my senses.
Chris: Has the experience of being at the limits of fatigue been useful in the rest of life?

Kerry: It has given me the capacity to deal with things in life. It does give me confidence.
I am sure that I employ things I have learned in my race in everyday life, in dealing with
situations. I have a much more relaxed approach to things. If people are getting upset
about something, I tend to listen and assimilate, which I would not have done. It is not a
personality trait of mine. I have changed that now.

______________________________________

In this extract Kerry captures well the challenge of fatigue. I suggested two possibilities:
that interruption from thoughts of stopping is reduced in being single minded, or that

(Continued)

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Box 6.1. Continued

interruption happens all the time but is managed with repeated switching back to the
goal. For Kerry it is the second. She is competing in severe and extreme fatigue. What
is remarkable about her endurance is not only the physical but the mental ability to
continue against the rage of interruption demanding switch. Unexpected, because not
discussed in research, was the emotional aspect of that switching back: the angry deter-
mination and the objectifying of fatigue as an aggressor to battle against.

Being tired all the time

It is not only elite athletes who are learning how to endure. There are many people
who suffer unbidden and unplanned fatigue, people who are quick to tire, who find
everyday demands overwhelming, who experience fatigue all day and every day.
Persistent fatigue is often experienced with disease or its treatment. It is a com-
mon and disabling symptom associated with many problems, including depression
(Arnold, 2008), stroke (Lerdal and Gay, 2013), and cancers (Wagner and Cella, 2004).
Fatigue is frequently given as a primary symptom causing distress and disability, and
can be confusing and challenging for people as they struggle to make sense of what is
normally temporary. It is often hard to know whether the feelings of fatigue are rele-
vant to the disease and its management, or an unfortunate side effect (Kirkevold et al.,
2012). For example, when asked to share thoughts, 73 fatigued cancer patients used
the opportunity to write about their struggle with the idea of being cancer survivors,
and in particular how to think about fatigue after cancer. The dominant discourse of
successful cancer treatment involves the idea of return to previous health. The com-
mon ways of thinking and talking about life after cancer rarely recognize that people
feel fundamentally different. Many continue to experience disabling fatigue, which
they struggle to make sense of (Pertl et al., 2014).
Perhaps the most challenging clinical presentation of fatigue is those with a pri-
mary complaint of persistent and unremitting fatigue that limits or stops mental,
physical, and social engagement, captured popularly by the label chronic fatigue syn-
drome (CFS). Although recognized as a clinical problem in its own right for many
years, it was only in the 1980s that research was reignited. Calls for better definitions,
for clarity about comorbidities, and for consistent language and approach were
everywhere in the 1980s. It was perhaps not until Keiji Fukuda and colleagues from
the International Chronic Fatigue Study Group published a statement on preferred
terminology and criteria for assessment that the field started to coalesce.
The use of the term syndrome in chronic fatigue syndrome draws attention to
the multifaceted nature of many complaints. The definition includes ideas about

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causation; in particular, it excludes any cause due to overexertion. The definition also
references the condition’s resistance to treatment (it is not helped by rest) and by the
presence of cognitive problems, especially with memory and concentration (Fukuda
et al., 1994). Other case definitions exist, and most now define “chronic” as the per-
sistence of symptoms for six months or longer. Although case definitions are import-
ant for science and medicine, the search for what is specific—for a “caseness”—can
obscure what is general. Glyn Lewis and Simon Wessely, UK psychiatrists interested
in common symptoms such as fatigue, pain, and anxiety, argued early on that most
people with chronic fatigue could helpfully be thought of as at the extreme on a con-
tinuum of fatigue (Lewis and Wessely, 1992).
The idea that clinical fatigue is an extreme of general fatigue was not meant to
diminish the clinical need of patients who present with serious and debilitating prob-
lems. On the contrary, these and other authors repeatedly stress that the way to con-
quer chronic fatigue is to understand how people behave when fatigued, and how
fatigue functions to halt adaptive behavior (Holgate et al, 2011).
The causes of CFS are unknown, but are likely to be varied, unlikely to be psy-
chological in origin, and very likely to involve both central nervous and immune
system dysfunction. Dantzer et al. (2014), attempting to combine neurological,
immunological, and psychological studies of fatigue, as well as research with nonhu-
man species, remind us of the impact of illness on motivation. Sickness in general,
they argue, causes lack of interest, failure to explore, and habit failure, all of which
are immune-system mediated—evolved responses that function to promote with-
drawal. Although preliminary, this view is motivational in the recognition that the
defining feature of human fatigue is the interruption of behavior by signals to halt
and withdraw, which in humans is verbalized as the growing dominance of thoughts
to stop and switch.

Cognitive behavioral model

Cognition, then—in particular, the thoughts about needing to stop a particular

behavior and the inability to engage in other behavior, even when desired—is at
the heart of a science of chronic fatigue. Cognition is also the target of treatments
aimed at management, rehabilitation, and recovery. Broadly, this focus on thought
and action is referred to as a cognitive behavioral model. Its focus is pragmatic. It
is not concerned with what precipitates or causes chronic fatigue but with what
maintains it and what hinders recovery. Hans Knoop and his team narratively
reviewed the role of beliefs, attitudes, and illness attributions (beliefs about the
causes of fatigue and recovery) in the maintenance of CFS. They focused first on
the specific beliefs that people hold and their effect on behavior, and second on
the treatment literature, which often reports beliefs as mediators of treatment
outcome (Knoop et al., 2010). This is a useful division, but it is worth adding a

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third source of evidence: patients’ report of their experience—the phenomenology

of chronic fatigue.
The role of cognition in the maintenance of fatigue and disability has been known
for some time. The early ideas focused on patient judgments and the presumed over-
estimation of the debilitating effects of physical effort and fear of disability caused
by that effort (Fry and Martin, 1996). This focus on a mismatch between patient
belief and presumed ability with use of terms such as overestimation and exaggeration
reinforced an unfortunate mind-body dualism that continues to pervade the litera-
ture. For academics this is a minor philosophical problem and an intellectual irritant,
but for patients it can be devastating.
The dualistic habit of describing symptoms as explainable by objectively observ-
able disease causes major problems for patients suffering with so-called medically
unexplained symptoms. The implication that chronic fatigue syndrome is in some
way a failure in individual judgment propels many patients into a battle to legitimize
their suffering, exposing themselves to stigmatizing disbelief from professionals and
the public. In short, fatigue has no objective measure. It is by definition subjective.
The search for a method of removing the patient report of their experience in explain-
ing the patient’s experience is misguided. The idea of comparing patient report of
fatigue with an observer judgment of what is normatively possible may be even more
fraught with problems. We have seen from a number of studies the overwhelming
evidence that the aversive cognitive demand to stop occurs long before any physio-
logical limit has been reached.
In a thoughtful comment on medicine’s formal attempts to make it possible to talk
about cognition as important in the treatment of chronic fatigue, Wojtek Wojcik and
colleagues discussed the beliefs of different medical professionals, principally neu-
rologists, about how to classify CFS as a disease—a practice known as nosology. They
conclude that chronic fatigue does not fit neatly into current ways of thinking about
ill health and call it an “orphan illness”. They call for better communication between
medical professionals from different specialties about patient need, and less concern
with nosology (Wojcik et al, 2011).
A functionalist account of chronic fatigue focuses on how fatigue functions to alter
behavior through the establishment and maintenance of beliefs that stop recovery. It
is useful to ask the question: what would be the consequence of the continual inter-
ruption of an unpleasant urge to stop? Framing the question in this way highlights the
attention-demanding nature of the interruption.

Attention to threat

For a number of years, Rona Moss-Morris and her group have been investigat-
ing whether people with CFS show an attentional bias toward information that is

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threatening. The idea is a simple one. Being continually interrupted by a threatening

stimulus can lead one to be vigilant for future interruption, paradoxically increas-
ing the likelihood of interruption. In an early study, the researchers did not find
bias toward threatening information in the form of words, such as collapse, sick, and
fatigue (Moss-Morris and Petrie, 2003). This is now a fairly consistent general find-
ing, although some researchers have demonstrated bias in some circumstances
(Hou et al., 2014). There are questions about the methods of standard attentional bias
research, in particular the relevance of words as a trigger of threat, and as to whether
bias toward threatening words is relevant given that these words are common in the
environment of the chronic fatigue patient. But, in summary, there is no good evi-
dence for a clinically relevant and stable bias of chronic fatigue patients attending
toward illness-related cues.
Also unclear is the extent to which there is a bias toward interpreting ambiguous
but potentially threatening information as threatening. These studies typically pres-
ent people with information that could be safe or threatening. The idea is that those
with chronic fatigue will adopt an “if-in-doubt” strategy of assuming the worst: if it
could be threatening, then safer to assume that it is. Although there were early dem-
onstrations of this bias, they have not been easy to replicate (Martin and Alexeeva,
2010), and their clinical relevance remains questionable.
The evidence is missing that chronic fatigue patients habitually attend to the
threat of illness and fatigue. It is unlikely to be true that people become vigilant
to fatigue. What appears more compelling is the evidence on how people cogni-
tively respond to fatigue. Chronic fatigue patients appear to demonstrate a high
level of self-­criticism and negative perfectionism (Luyten et al., 2011). People are
highly critical and demanding in a self-defeating pattern that fuels ruminating
thoughts of failure, and so depression. This pattern can be self-perpetuating as
people fail to reach unrealistically high targets, which reinforces a belief of per-
sonal inadequacy. Specific beliefs are that the fatigue is uncontrollable, likely to
lead to catastrophic outcomes, and that further activity will lead to physical dam-
age. All appear to play a part in maintaining a lack of engagement with activity
(Lukkahatai and Saligan, 2013).
Other strong beliefs, perhaps fuelled by the social context of CFS as a contested ill-
ness, are beliefs about the causes of the disease and what needs to be done. Simply put:
if one believes strongly that exercising is not only going to be fatiguing but that it will
cause damage, then one is unlikely to exercise. Further, one is likely to consider any-
one who is suggesting exercise to be at least unwise and perhaps unkind. Ironically,
the person with CFS can appear to observers to be passive and resting. The opposite is
normally true. People with fatigue tend to be actively ruminating about possible solu-
tions, and often desperate for change, but may be engaging in self-defeating attempts
to achieve unachievable solutions.

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Cognitive behavioral therapy

Some treatments attempt to work with these beliefs and help people make gradual
and sustainable changes rather than sudden radical ones. Attempts at altering beliefs
about fatigue, its causes, meaning, and consequences are part of cognitive behav-
ioral therapy (CBT), which is increasingly offered as the most evidence-supported
treatment approach. Typically these therapies are delivered as part of a program of
rehabilitation that includes re-engagement with physical and social activity. A recent
large trial published in The Lancet contrasted three different approaches to treatment
based on different ways of thinking about fatigue. One treatment is based on the
energy-resource model of fatigue I discussed earlier as a fallacy. Essentially, there is
a dominant cultural view that fatigue is a signal of a depleted scarce resource, sig-
naling that one should conserve energy and avoid exertion; instead one should use
one’s body as a guide. The alternative treatments do the opposite; they work on the
assumption that for those with chronic fatigue one’s body is an untrustworthy guide
and should not be followed. The stop signals should be thought of as false alarms.
CBT essentially seeks to shift people from fatigue-determined behavior to planful
behavior in which one works toward meaningful valued goals according to how one
has planned in advance, regardless of how one feels in the moment. This trial, the
largest of its kind, showed that the treatments that are aimed at gradually increasing
activity had better results overall than standard care, and were better than the treat-
ment that proposed changing activity depending on how one felt (White et al., 2011).
Part of the CBT approach is learning that the beliefs one has about fatigue, however
sensible and internally coherent, may not be true, and, more importantly, may be
unhelpful.
The beliefs one holds about fatigue do seem to be important in deciding how
to behave and what is possible. Unfortunately, however, there is little guidance in
research on what the experience of trying to ignore the strong and interruptive urge
to stop is like for the person with chronic fatigue syndrome. There are many qualita-
tive studies of what it is like to live with CFS but these tend to focus on the broader
challenges. In a review of 34 qualitative studies of CFS, for example, the common
themes that we would expect were found: of living a disrupted life, and of struggling
with stigma and changes in identity (Anderson et al., 2012). Missing is any phenom-
enological study of what it feels like to live with this urge to stop. Is it the same or dif-
ferent as that experienced by the person continuing a repeated task with diminishing
marginal returns? Is it the same as someone like Kerry, deliberately undertaking an
extreme sport, working far beyond their limits, ignoring the desire to stop by focus-
ing on a superordinate goal, and learning to reinterpret her body? Or is it nothing like
those, but instead a constant base level of motivational drag, where the very thought
of initiating action is quickly defeated?
To explore these ideas further I talked with Sarah Prior (Box 6.2).

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Box 6.2. Sarah, living with fatigue: “everything is planned”

Sarah works part-time as a senior fundraiser for a charity. She was diagnosed with post-
viral fatigue at 17, which was later diagnosed as chronic fatigue syndrome. When I inter-
viewed her she described herself as “being in remission,” having just recovered from a
significant relapse. She has attended a rehabilitation program that teaches both energy
management strategies and cognitive behavioral strategies, which she found very use-
ful. I asked her about what the fatigue actually feels like, her relationship with her body
and the information it gives her, and how she now lives her life.

______________________________________

Chris: What does the start of the day feel like?

Sarah: I wake up at seven. For the first hour after I have woken up I feel like I have the
worst hangover. I feel like I haven’t slept even though I know I have. I feel sick, have a
pounding headache, and my brain feels like it is cotton wool. But I know it will die down
so I listen to the radio. It takes about an hour to pass.
Chris: Are you tempted to sleep again?
Sarah: It is not that I am tired and need to sleep; it is a different type of tired. It feels like
I haven’t slept, but sleep will make no difference. I don’t need to sleep. It is exhaustion;
not a lack of sleep. I say that it feels like I have not slept because that is the closest I can
get to the sensation. I use hangover because it is like that. It is like I have been poisoned.
But it passes.
Chris: Tell me about the most recent time you overdid it?
Sarah: One Saturday I was reasonably careful in the morning. I did some housework. I
had an event on in the afternoon. I felt it was important to go. There were a lot of people
there I knew but hadn’t seen for a long time so there was energy in talking to them. Then
it got to four o’clock and I started to feel pain in my lower back, then a headache, then
I started to feel slightly fluey. But I ended up leaving at five o’clock and I had a chore to
do on the way home. And yes: I completely misjudged it and it was too much, unfortu-
nately, and I then felt really poorly. So I got home and had to just lie down.
Chris: What are the thoughts when that happens?
Sarah: “Oh, my God, I am so stupid. Why have I done this? Oh, I can’t believe it.” I start
planning. Yes planning, planning, which is not very restful. That is often how it goes
when I have overdone it and I have been rather foolish about it. I should have been more
careful.
The feeling is like a profound exhaustion. Like my battery has just died. It is flashing on
1 percent. That is how it feels. I think that “I need to lie down this second.” I can’t think
straight. I can just about hold a conversation. But it probably does not make much sense.
I feel shaky.
(Continued)

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 fat igu e

Box 6.2. Continued

Chris: What happens to your judgment?
Sarah: Oh, that is quite impaired. I say to myself: “This is not the time to make decisions
about what you are going to do. Just leave that.” But I have had to learn to do that, because
the decisions are either too emotional, or just not reasoned. It’s like making a decision
when you are drunk. You can’t rely on it. It is not reasoned, it’s not thought through. It’s
not going to be a sensible decision when you are that tired.
Chris: Are you an expert on your body now?
Sarah: Yes, I am. So there is a judgment call about how much can you tolerate before
you have to step in and take control. But, on the whole, my body is normally right. And
I should listen to it. That has certainly helped me to improve. It is hard to listen to your
body at first. It is partly cultural. You push on through. You go to work. You try harder.
So at first I couldn’t understand why it wasn’t working. I was trying but was getting
worse. I was pushing. So I just ignored it. I ignored all these symptoms and carried on
anyway. But gradually I understood that I had to listen to my body.
Chris: Do you trust the information your body gives you?
Sarah: Yes, that was a hard lesson to learn. I did not want to accept it. I absolutely did
not. This is not who I am. To do so little is wrong, I believe. I am only young. I should be
working full-time, I should be doing all the sport I want to do, that I used to do. And I
should be going out with my friends. So I have had to learn. I have tried to push through.
I have absolutely tried that. But it doesn’t work. I had to learn to listen to my body. If it
is telling me that it is not just tired, that it is ill, then I had to stop. So now I am good at
reading it.
Chris: It sounds like a life without spontaneity.
Sarah: There is almost no spontaneity. There can’t be. Everything is planned. Which is
sad. It is probably not how I would choose to be. But it works. You kind of weigh it up.
And now I don’t really worry about it too much. You know: it’s a trade-off.

______________________________________

Sarah lives a planful life closely managing the boundaries of what is possible when there
is the ever-present threat of severe fatigue. For her the idea of working through fatigue
is something she tried that did not work. She has a close relationship with her body as
a source of information that tells her what is achievable. Unlike Kerry, however, Sarah
trusts the information her body gives her and tries to follow it. Like Kerry, Sarah is an
expert on fatigue and motivation. The fatigue she describes is similar to Kerry’s: a strong
urge to stop. The thoughts are hard, if not impossible, to ignore. She knows not to make
hasty decisions and that being active and achieving is an important part of who she
is, but it must be done now in the context of the threat of relapse from forgetting hard
lessons learned.

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Summary

Feeling tired is a common physical complaint. We often talk about feeling tired. Sur-
prisingly, however, as a perception it is still poorly understood. The idea that feeling
tired is a reliable sign of depletion in energy resource can be rejected as a fallacy. Instead,
fatigue seems to function as a signal of the growing costs of persisting in behavior
for too long, as a motivation to change behavior. It functions to interrupt current
engagement with a fairly well-formed and hard-to-ignore belief that one should stop.
In this sense fatigue operates to limit performance or achievement, especially when
that elite performance is dependent on persistence and repetitive practice. Attempts
to remove or alter that limit by artificial or natural means have not proven successful,
with the possible exception of physical exercise and attempts at self-actualization,
both of which, paradoxically, are effortful. We can learn a lot, however, from those
who live their lives in chronic and severe fatigue, whether deliberately by engaging in
endurance sport, or non-deliberately in struggling with chronic fatigue syndrome. In
the extreme cases, what is at stake is how far one can go in ignoring the urge, or, more
accurately, the demand to stop and switch.

Note

1. Reproduced from Angela L. Duckworth, Christopher Peterson, Michael D. Matthews, and

Dennis R. Kelly, Grit: Perseverance and passion for long-term goals, Journal of Personality and
Social Psychology, 96 (6), pp. 1087–1088, doi:10.1037/0022-3514.92.6.1087 © 2007, American
Psychological Association.

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Yang, C.-M., Han, H.-Y., Yang, M.-H., Su, W.-C. and Lane, T. (2010). What subjective experiences
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nition, 19, 1084–1092.

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 CHAPTER 7

PAIN

W e are born in pain, we will most likely die in pain, and many of the signifi-
cant events that punctuate the story of our lives (such as childbirth, illness, or
injury) occur in the presence of pain. The good news, however, is that as a species we
have become quite skilled at the science and practice of pain relief, from the prepa-
ration of pharmacological analgesics to the management of incurable pain. Pain is
perhaps one of the most challenging of the physical senses in that, like fatigue, it func-
tions to halt, limit, or change behavior, but in doing so can challenge our very sense of
who we are and what is possible in life.
Although common, pain is most often temporary. For example, in an early
observational study in Ontario daycare center, 56 children ages three to seven were
observed throughout a school day. On average a child complained of pain every
20 minutes. The pain “booboos,” as this Canadian team called them, created distress
lasting approximately ten seconds (Fearon et al., 1996). These fleeting pain experi-
ences are part of how we are shaped, how we grow, and how we learn about our
environment. There is no suggestion that they should be removed or treated as aber-
rant. But not all pain experiences are short-lived, and not all have any obvious value.
To give some idea of the numbers: in a recent study of adults from eight European
countries, 70 percent reported a major pain experience in the last month, and 77 per-
cent of them thought it serious enough to seek analgesia (Vowles et al., 2014). The
experience is not a uniquely adult one, either. Sara King and colleagues reviewed
epidemiological studies on pain in childhood, and found high prevalence rates, with
headache being the most common, closely followed by abdominal and musculoskel-
etal pain (King et al., 2011). Although many of these individual experiences of pain are
clinically uncomplicated, and perhaps psychologically insignificant, some people go
on to have disabling chronic pain. In one large survey of over 46,000 adults in Europe,
as many as 19 percent of the sample reported their pain to have lasted longer than six
months, half of whom said it was constant (Breivik et al., 2006).
What do we mean when we say we are in pain? In this chapter I explore the way
we have come to think of pain as a problem to be fixed. I also take the opportunity to
discuss what little there is on the rather strange idea that pain might in some cases be
experienced as positive, or at least as a bearable cost in the pursuit of a greater gain.
Last I introduce the idea of a normal psychology of pain that extends a nonpathological
account of pain behavior. Adopting a normal psychological approach allows us to

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make sense of how people behave when the pain becomes countercultural (cannot be
fixed); how one adapts to a life lived against the backdrop of the constant interruption
by the threat of pain.
Three people offered to share their experiences of pain in extremes. First, Ilana
and Crispin are both amateur runners. They decided to run the New York City Mara-
thon together and they agreed to think about their pain while doing it and share their
experience with me. I also talked with Rupert who has had low back pain for over 20
years. He rarely talks about it, but agreed to help me make sense of how it has changed
his life.

The problem of pain

The International Association for the Study of Pain defines pain as “an unpleasant
sensory and emotional experience associated with actual or potential tissue damage,
or described in terms of such damage” (Merskey and Bogduk, 1994; see http://www.
iasp-pain.org/taxonomy). This definition recognizes three psychological realities of
pain: first, that it is an immediately aversive emotional experience; second, that it is
a subjective sensation that acts in reference to presumed physical trauma; and third,
that it is social—pain communicates in a language of damage. In recent updates of
the definition, the communication aspect has been developed to include nonverbal
expressions of pain, primarily because of a concern that an emphasis on language
allows for a denial of pain in those who are unable to verbalize.
This definition of pain, although successful in capturing pain as immediately aver-
sive, physically referenced, and fundamentally social, is unsuccessful because it is
silent about the function of pain. Pain functions primarily to alarm about a threat
to physical integrity. It alarms to promote escape, avoidance, succor, or repair; by
definition, it is threatening (Eccleston and Crombez, 1999). This threatening aspect
of pain—or, for short, its threat value—is how it achieves interruption of current
thought and action. When pain strikes, it starts a psychological chain reaction of first
displacing whatever is in consciousness, such as thinking about your next meal or
carrying on a conversation, and directs attention to the location of the pain, simul-
taneously promoting behavior that will remove the pain from your attention. It is this
functional perspective that provides a springboard for a consideration of “the normal
psychology of pain” explored here.

Pain mechanisms

There are different ways of classifying pain. One common system is by location (e.g.,
musculoskeletal vs. visceral vs. head pain). Another is by presumed mechanism.
Fernando Cervero (2008) describes three types of pain based on the presumed

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mechanisms of inflammation (inflammatory), nerve damage (neuropathic), or the

action of the peripheral nociceptors (nociceptive).
Pain can start in the periphery or can be centrally generated. Nociceptors—nerve
cells specialized for the identification of damage or the threat of damage—have been
mapped in most, although not all, tissue, are abundant in skin, in muscle and con-
nective tissue, and are also present in specific structures such as the eye and the tooth.
There are large gaps in nociceptor distribution and not all damage is identified; in par-
ticular, the changes in viscera. Nociceptors are often defined as “high-threshold” in
that they respond at the higher levels of energy intensity (e.g., bright light, high pres-
sure, high or low heat), and some are “polymodal” in that their free nerve endings will
react to noxious input from a range of modalities (pressure, heat, chemical). They also
operate at different transduction speeds through both slow unmyelinated C fibers
and fast myelinated Aδ fibers, bearing some responsibility for the different qualia of
throbbing dull pain and sharp stabbing pain, respectively. The idea, however, that
pain can be explained fully by the function of peripheral sensory mechanisms has
been long rejected. We have learned that pain experiences are dynamic, subject to
change by both peripheral and central sensitization.
Spinal, brainstem, thalamic, and cortical systems are all involved in the further
modulation of nociception. The brain has no “pain center.” Pain is distributed across
multiple structures, many of which are involved in non-pain activity such as orient-
ing, attending, expecting, motor preparation, memory, interpretation, anxiety, and
even higher-order emotional functions such as empathy, planning, and decision
making. The involvement of multiple structures has led some to propose a “pain
matrix” or interconnected pattern of structures involved in pain. This idea, has, how-
ever, been more recently cast aside, described by some as only a comforting myth
(Canavero and Bonicalzi, 2014). Valery Legrain and colleagues argue that what we see
in neuroimaging studies of pain may be better explained as the operation of a salience
detection mechanism. They consider pain within the context of a larger defensive
system (Legrain et al, 2011). Emerging is a dynamic view of pain operating within a
broad salience detection system: not one mechanism, but multiple systems that select
(and deselect) action in complex environments. Aaron Kucyi and Karen Davis from
Toronto propose that we should think of pain as a “dynamic connectome”: a mass of
interrelated, constantly changing saliencies in response to environmental demands
and individual differences (Kucyi and Davis, 2015).

Motivated interruption

Reframing pain as part of a salience detection system, functioning for the defense of
the whole organism, is more radical than it first appears. A focus on the alarming qual-
ities of pain suggests new targets for treatment development, both pharmacological

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and psychological, with a focus on altering attention rather than sensation. It also
leads to novel explanations for why pain can become chronic, as we try to understand
what maintains pain as a priority for selection over competing environmental priori-
ties (Borsook et al., 2013).
Of course pain is more complex than a simple alarm system. But a focus on atten-
tion to threat allows us to view pain from the perspective of what it stops us from
doing (Vlaeyen and Linton, 2000; Crombez, et al., 2012). To understand what makes
pain salient, one needs to understand the motivational context in which pain emerges
and is maintained, a context that is often changing, has multiple, competing, and
sometimes contradictory goals, and a context that can change at the will of the per-
son. Whether you accept, deny, distract, endure, catastrophize, or seek to change the
meaning of pain, all make a difference. The context of interruption matters. Whether
the pain is from an injury that can be fatal if not treated, or from complaining muscles
as you are about to achieve a personal best in your sport, will fundamentally change
the experience.
Pain that is not experienced as threatening is hard to achieve, but perhaps not
impossible. There are communities of activity within which pain is constructed
as either positive, necessary, or both. Three examples are instructive. The first is a
religious view that constructs pain as a necessary part of suffering, which is itself an
unavoidable consequence of humanity. The second is pain as a source of pleasure
in activities described as transcendent or transgressive. And the third is a pragmatic
view of pain as a useful source of information in the pursuit of a higher goal of excel-
lence or survival.

Religion

C.S. Lewis, known to most as the writer of children’s classics such as The Chronicles of
Narnia, was also, in his later life, a committed Christian who chose to position pain as
ultimately positive in dragging people back from worldly distraction. In The Problem
of Pain—which might better have been called A Defense of Suffering—he argues that
“pain insists on being attended to. God whispers to us in our pleasures, speaks in
our conscience, but shouts in our pain: it is his megaphone to rouse a deaf world.”1
This Christian apologia, written during the Second World War, is an unusual defense
of pain, and to the modern ear difficult to understand. However, although this par-
ticular form of the defense of suffering as a consequence of human shame (in the fall
from grace) is far from most people’s understanding of pain, it is interesting that it is
possible to understand these ideas even in our modern cultures: it retains the power
to resonate.
Elaine Scarry extends an analysis of the central place of pain and suffering in
Jewish and Christian belief. In The Body in Pain, she explores the central aspect of

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embodiment. The Old Testament God is without form, and the corporeality of
humanity is exactly a means to live in weakness and to suffer punishment. Indeed,
in modern English pain takes the Latin form of poena; literally, punishment or pen-
alty: the price that must be paid. Scarry describes this tension over physical form
in the Old Testament:

God’s invisible presence is asserted, made visible, in the perceivable alterations He

brings about in the human body: in the necessity of human labour and the pains of
childbirth, in a flood that drowns, in a plague that descends on a house, in the brim-
stone and fire falling down on a city, in the transformation of a woman into a pillar of
salt, in the leprous sores and rows of boils that alter the surface of the skin, in an inva-
sion of insects and reptiles into the home of a population, in a massacre of babies, in
a ghastly hunger that causes a people to so glut themselves on quail that meat comes
out of their nostrils, in a mauling by bears, in an agonizing disease of the bowels, and
so on, on and on.2

The fleshiness of mankind is, from an Old Testament view, both the cause and
source of suffering. The Christian narrative extends this focus on pain with the emer-
gence of God’s son as embodied and so the focus of pain and suffering. Although
there is a radical transformation from the God of anger and punishment of the Old
Testament to a God of love and forgiveness in the New Testament, the place of pain
as a bodily source of punishment for the weak, heinous, and unbelieving remains
stubbornly in place.
The remnants of these ideas are still with us. Pain as a price to pay in necessary
suffering can be found in measures of beliefs about pain. For example, Noreen
Glover-Graf and her colleagues in Texas surveyed patients with pain, some of whom
endorsed beliefs such as “I am grateful to God or a Spiritual Power that I have my pain-
ful condition” and “I believe that my painful condition is a punishment for wrong-
doings that I have committed” (Glover-Graf et al., 2007, p. 29). In studies on general
coping, one also finds religious beliefs and practices implicated in the attempts people
make to cope with pain. Praying and relying on faith in God, for example, are com-
monly found in measures of adaptation to pain and disability (Robinson et al., 1997).
José Closs and her colleagues in the United Kingdom, experts in meta-synthesis
of qualitative data, undertook a systematic review of studies investigating religious
identity and chronic pain. They deliberately extended the search for studies beyond
Christian beliefs to Muslim, Hindu, Jewish, and Sikh beliefs, but were frustrated in
their search, finding virtually no studies in non-Christian populations. Within the
studies of Christian communities, they could also find no consensus on the domin-
ance of particular beliefs, although it is clear that in modern life people can and do
construct pain as a redemptive price to pay, and are able at times to cast it as positive
(Closs et al, 2013).

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Rites of passage

Secular narratives also exist that structure pain as potentially positive. It is possible
to talk about pain as educative, teaching one about one’s strengths and weaknesses,
or as transformative, altering one’s perspective on life. Consider the rite of passage, the
change in individual status within a collective. Often transitions in status are marked
by public social practices, many of which involve an ordeal and a display of emotion,
often in a trial of endurance to unpleasant events such as shame, embarrassment,
and, surprisingly often, of pain. In her analysis of female initiation rites in 75 socie-
ties, Judith Brown finds that painful initiation rites, typically genital operations, are
performed largely as form of coercion into gender-specific roles for both men and
women (Brown, 1963). Alan Morinis explores pain as part of initiation rites for ado-
lescents. It is perhaps better in his own words:

Reports tell of initiands being beaten, bitten, starved, incised, scarified, pierced, tattoed,
terrified, mutilated, circumcized, infibulated, cicatrized, bound, and subject to the re-
moval of parts of their bodies (especially teeth and fingers). It will be unnecessary for
present purposes to provide a full compendium of the tortures and mutilations hu-
mans have invented to try their young, as the practices are well documented. . . . The rec-
ord clearly shows that the delivery of a consistent, deliberate, direct experience of pain
to participants in the ritual is a remarkably recurrent aspect of adolescent initiations.3

The role of pain in such initiation, Morinis argues, is not punishment but a sacrifice of
autonomy in transitioning to a larger group identity. The public submission to, and
endurance of, pain operates as a sign of acceptance and readiness to conform—or
perhaps just surrender. Further, it functions to promote self-awareness by removing
innocence, safety, and security, forcing young people to experience what they fear.
Morinis argues that the presence of pain in practices that mark transition have spe-
cific functions that are positively framed—if not for the individual, then for the group
or society. He does not argue that the experience of pain as unpleasant is changed. On
the contrary, in this context the pain should be hard to endure, endured in public, and
even celebrated.

Self-injury

Not celebrated, and a more private experience of mutilation, is the pain that occurs
with self-injurious, nonsuicidal behavior such as self-cutting, strangulation, or
bruising. The study of the phenomenology of self-injury relies on self-report after
the event, but it is often associated, as pain in ritual can be, with the absence of pain
report, and a sense of depersonalization (Nock, 2010). The advent of event-sampling

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techniques, in which people report on what they are feeling remotely at the time of
the event, is allowing us access to experiences previously hidden.
Edward Selby and colleagues reported such a study with a focus on motivations for
harming. The two main reasons given for repeated self-injury are to distract from hurtful
thoughts and feelings, and to attempt to feel something—anything—in those who report
being emotionally numb. In their clinical study of 30 adolescents, Selby and colleagues
found that many of the adolescents wanted to feel pain because it was a relief from an
absence or emptiness of feeling, and a commonly reported source of “satisfaction” (Selby
et al., 2014). In this very particular context of extreme emotional dysregulation, injury that
is avoidable and deliberately self-inflicted is associated with complex positive experiences.
Brock Bastian and his colleagues have argued that the feelings of satisfaction and
control associated with abnormal practices such as deliberate self-harm may have
their origins in features of a pain experience normal to us all. They argue that relief
from pain is a critical pleasure, indeed a necessary part of pleasure: pain has the
ability not only to provide pleasure in its offset but also to enhance that pleasure.
Table 7.1 summarizes the variety of ways they consider pain to be linked to pleas-
ure. Further, they intriguingly extend the argument offered by Alan Morinis, that
pain serves to mature an awareness of meaning, relevance, and social order. In its
modern version, Bastian and colleagues suggest that one is immediately more self-
rewarding (self-comforting) if one has pain that is judged to be unfairly inflicted.
On a much broader level, they argue that pain educates—or, more accurately,
­perhaps—that it has the capacity to edify (Bastian et al., 2014). This challenge to our
view of pain as uncomplicatedly negative is an interesting check on our cultural
analgesic tendencies. We tend to think of pain as always aversive and unwelcome.
Pain can function in different ways, some of which are in the promotion of pleasure.

Goal pursuit

Pain at your own hands, or hurting so much that you can feel pleasure when it stops,
are philosophically interesting, but rare experiences. What is common is the experi-
ence of pain that we believe to be an unavoidable part of a process of attempting to
attain a higher-order goal. There are many goals that supersede the avoidance of
pain. They include the natural (e.g., childbirth), the protective (e.g., inoculation), the
aesthetic (e.g., depilation, surgery, tattooing, piercing), and the emergency. In many
cases, pain is endurable because it is considered safe and brief, as in wax depilation.
However, for other activities, deciding whether the pain is endurable, or worth endur-
ing, is an ongoing, personal, cost-benefit analysis.
Endurance sport provides an environment for exploring the trade-off between pain
and achievement. In one study of 114 amateur marathon contestants, the runners reported
their beliefs at different stages of the race. They remembered weighing up the costs of pain
against the benefits of completing the race, and this analysis peaked at 30 kilometers into

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Table 7.1: The benefits of pain and associated processes

Benefit Process

1. Pain facilitates pleasure

i. Pain enhances subsequent pleasure Pain provides a contrast for pleasure, and
this increases the relative pleasantness of
subsequent experiences.
ii. Pain heightens sensory sensitivity Pain heightens arousal and constrains
attention on sensory experience, thereby
increasing sensory receptivity.
iii. Pain facilitates pleasure seeking Pain provides a justification for indulgence
of pleasures that might otherwise arouse a
sense of guilt.
2. Pain enables self-regulation and
enhancement
i. Pain increases cognitive-affective control Pain captures attention and brings cognitive
resources online for effective problem
solving in response to the threat of pain.
ii. Pain enables identity management Pain promotes a physical experience of the
self, thereby reducing high-level self-
awareness and enabling identity change.
iii. Pain demonstrates virtue Pain may be interpreted as providing a
symbolic test of a range of personal virtues.

3. Pain promotes affiliation

i. Pain arouses empathy in others The expression of pain increases empathy and
arouses care concern in others.
People seek social support in response to pain.
ii. Pain increases relational focus Pain therefore provides a novel source of
social connection with others.
Pain may be used to increase the value of
iii. Pain increases solidarity relational ties with others, and shared pain
may increase interpersonal bonding.

Reproduced from Brock Bastian, Jolanda Jetten, Matthew J. Hornsey, and Siri Leknes, The Positive
Consequences of Pain: A Biopsychosocial Approach, Personality and Social Psychology Review, 18
(3), pp. 256–279, Table 1, doi:10.1177/1088868314527831 Copyright © 2014 by SAGE Publica-
tions. Reprinted by Permission of SAGE Publications.

the 42.2 kilometer race (Brandstätter and Schüler, 2013). Interestingly, this peak point,
what Brandstätter and Schüler call an action crisis, does not occur at the end of the race. The
last phase of an amateur marathon appears to be marked, at least for those who finish, by
an extreme motivational drive. In a study of why distance runners collapse at the finish
line, and collapse in the same anatomical pattern, the question of why people persist in the
last quarter and persist right to the line is not asked (St. Clair Gibson et al., 2013).

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What is the place of the felt experience of pain in the dynamic trade-off of competing
goals: finishing vs. stopping the pain? How does enduring pain retain its value of “a price
worth paying”? To explore these ideas of the dynamic trade-off of pain as sometimes
positive and worth enduring, I recruited the help of two amateur marathon runners who
had just run the New York City Marathon together, Ilana and Crispin Wigfield (Box 7.1).

Box 7.1. The Wigfields, running a marathon together: “what I often do is think
‘one more mile’”
Ilana entered as the experienced runner, having already finished eight marathons. For
Crispin, this was his first. They had taken mental notes and tried to record their feelings
on a digital recorder as they went along. We talked after the race, about how they had
felt at each mile marker point. I was interested in what the pain felt like, what thoughts
they were having, and how it affected their motivation. The race didn’t go to plan. Which
races ever do? Ilana was struggling with an injury and Crispin was in self-confessed
“unknown territory.”

______________________________________

Chris: Was it as you expected it to be?

Ilana: Well, it hurt. But you are expecting it to hurt. It is rather like childbirth. It is some-
thing you are anticipating and there is a positive outcome at the end of it. But it is not
something you can’t deal with. You just do. And you know it will end. It has a finite time.
It depends on how much you are willing to put up with.
Crispin: It was my first marathon and I went in with the mindset that it might be the only
marathon I do. I spent a lot of time researching and trying to anticipate what it would
be like.
Chris: And what surprised you?
Crispin: Every now and again there was a rise in anxiety and a feeling of despair. The long
avenues are a challenge. Nobody had talked about the long avenues in Brooklyn.
Chris: Tell me about the pain.
Crispin: My pain was very low at the beginning, 5 out of 100. For the first 10 miles or so the
pain was never more than a slight ache. There was no ache anywhere else, no chest pain.
It hardly registered as pain. I started to struggle at mile 21 going uphill again to another
bridge. Just knowing it is a long way. And I think at that point that my feet were begin-
ning to hurt a bit. It is farther than I have ever run before. That thought does come. Also,
at that point you are starting to see a lot of people walking and stopping with cramp,
which is anxiety provoking. I thought, “Is it going to be me next, is it going to happen?”
So it was not just pain but it was a buzz of anxiety.

(Continued)

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Box 7.1. Continued

Ilana: It was sore. At 12 miles it was 5 out of 10 and I felt desperate. At mile 20 I was think-
ing, “Gracious, this hurts.” I felt I had to keep going. What I often do is think “one more
mile.” I can keep it going and see how it is after the mile. It got to a point and never got
any worse, so I then thought, This is it, just one more mile. I did not hit a wall in terms
of difficulties of cognition. It was just pain. It was probably at 17 miles and it carried on.
At 22, 23 it was just pain.
Chris: Did you think of stopping?
Ilana: No. But I thought to myself frequently: “I don’t need to do this anymore, I don’t
need to do more marathons, I don’t enjoy this anymore. There is no point in doing
more.” And the disappointment was in not doing as well as I have done in previous
marathons. “What is the point of carrying on?” There was a lot of that negativity going
on at the time. And running on an injury, I thought, “Oh dear, what a stupid thing to do.
This is really going to set me back. Whose idea was this? I am not going to be able to run
for months.” There was a lot of worry. It got less as I went on and the pain did not get
worse. But yes, there was quite a lot of worry.
Crispin: At mile 22, on Fifth Avenue, any communication between us had just shut down.
I contemplated getting the dictaphone out to make notes but it was just too hard. I con-
centrated on just running, not falling over, not doing something that would just hold me
up. Not walking, because if I started walking I would not start running again. About then
someone in front of me stopped abruptly to take a telephone call and I nearly ran into
them! It was then I knew I was off the pace so I tried to put some extra effort in and noth-
ing happened, which was slightly alarming, and at mile 23 it was unpleasant and I could
see that my time was getting slower and slower and slower. At 23 it was disappointment
not pain. There were a lot of people walking at that point and a lot of people looking at
me. The thought I had was “I want to finish and I want to finish well.” I was very aware
that any little thing could just ruin it.
Chris: What motivated you to finish?
Crispin: The crowds are just fantastic. There is a motivation boost, an extra rush. It is
exciting to see so many people raising money for good causes and to be a part of that.
Motivation was hard and I started to think about the people who had sponsored me. At
mile 24 you enter the park and I was drained. I had nothing left. The crowd was great
at pushing you along. Round about mile 25 it was getting cold in the shade; I had had
enough; I was ready for it to finish.
Ilana: The main motivation for keeping going is that I don’t like giving up on anything. If
I was going to give up I should not have done it in the first place. I should have given up
early, not at 20 miles.
Chris: It sounds like a marathon is as much a motivational challenge as a physical one.
Ilana: Yes, you do think about other things like hoping the children are having a nice day,
and the beautiful scenery, but as it goes on maybe 50 to 70 percent of my attention was
spent thinking about my body and the pain.

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Box 7.1. Continued

Crispin: Yes, by the end I was just aware of how I was feeling, and the finish line. It was
hard work then. But we crossed the line together.

______________________________________

Pain in the context of a marathon is one part of multiple challenges. But sampling two
people’s very different experience across a long exposure to pain shows that the pain
was always being judged against the possibility of success, of avoiding failure in with-
drawal, and of drawing support from other motivations like the crowd and the scenery.
As it goes on, however, pain takes up more space and comes to dominate. Unexplored is
the social display of endurance in pain, which, although not a rite of passage, is a public
ordeal. Pain as a private mental event is displayed in public, with one’s response to it
open to private and public judgment.

Paying attention to pain

Finding value in pain—either in overcoming it to achieve positive goals such as finish-

ing a marathon, or in its public endurance in a rite of passage—are rare experiences.
These positive frames take effort to create and sustain; they involve much personal
and cultural work. By far the most dominant experience of pain is of the intrusion of
an unwelcome, aversive, threatening, hard-to-ignore bodily event, one that increases
anxiety and challenges our motivation to achieve other goals. In short: pain inter-
rupts, worries, and disrupts.
The positive experiences of pain, although very different, share one feature: the
meaning of the pain is known. However, the meaning of most pain is at first not
known, and the extent to which it persists in interrupting, worrying, and disrupting
is related to the search for meaning and for how long the search continues. David
Morris captures this well when he says that humans have always approached pain
as something to be explained, as a conundrum (Morris, 1991). Delia Cioffi extended a
similar argument. All physical sensations start with attention, but then very quickly
they demand interpretation. This interpretation begins with a simple verbal labeling
and then leads quickly to an attribution, a belief about the cause. This labeling and
interpretation are open to influence from prior experience, from anxiety, and from
other people’s beliefs (Cioffi, 1991). More simply put: we want to know what the pain
means and what threat it poses. For example, imagine that as you are sitting reading
when you have a sudden pain in your chest. Is it meaningless? Is it a cramp from not
moving enough? Or are you having a heart attack? The interpretation you choose will
lead to very different defensive behaviors (Eccleston and Crombez, 2007).

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Psychologists have been busy developing ways to measure different forms of anx-
ious responses when in pain. In one study, we asked 508 adults to complete the most
popular nine measures of anxiety used in pain research, including the Pain Catastro-
phizing Scale (Sullivan et al., 1995). Collapsing across all measures, we showed a latent
three-part structure that underpins the experience of threat when pain is attended to:
we labeled the parts cognitive intrusion, general distress, and fear of pain from injury/illness
(Mounce et al., 2010). These three interrelated constructs might account for how the
context of pain determines the overall experience. For some, the intrusion upon our
thinking is itself highly aversive and hard to disengage from. For others, pain pro-
motes a general, global sense of distress. For others still, the interruption of pain is
taken as evidence for exactly what was feared all along: a catastrophic illness or injury
is causing the pain (Vlaeyen and Linton, 2000).

Living in an analgesic culture

The simplest example of pain, perhaps the pain experienced by children in the play-
ground every 20 minutes, is when it is normative. By normative I mean that it is cul-
turally typical and follows the tacit rules we have for pain. We live in an analgesic
culture, defined by the dominant belief that pain should be short-lived, diagnostically
meaningful, and denote a fixable problem (Morris, 1991).
Some people find casting pain aside harder than others. For example, we devel-
oped a measure of the experience of cognitive intrusion in those without a clinical
pain problem called the Cognitive Intrusion Scale. As the name suggests, we were
interested in the extent to which people experience pain interruption (“Pain easily
captures my thinking”), persistence (“I keep thinking about pain”), and dominance
(“It is hard to think about anything else but pain”) (Attridge et al., in press). Those
who have this pattern are indeed more disrupted in their daily lives. The repeated
work of labeling sensations, interpreting them as nonthreatening, and returning to
previously interrupted goals and tasks takes time and effort.
What keeps people focused on pain is the subject of much research. Fear of pain as
a source of distress is thought to be the cause of both a risk of pain-related disability
and of avoidance of activity. The fear can be of the pain itself (e.g., “having a muscle
cramp”) (McNeil et al., 1998, p. 407) or that pain will lead to damage (e.g., “physical
activity might be harmful”) (Buer and Linton, 2002, p. 487). These fears are common
in the population and not specific to patients. Friends, family, carers, and health care
professionals often believe that pain is a reason to withdraw and rest, when for many
people with chronic musculoskeletal pain the opposite would be more helpful. (Sim-
monds et al., 2012). For example, in a study we undertook with mothers of adoles-
cents with chronic pain, we saw exactly the dilemma that those who care for others
can have. We created an experiment in which mothers could watch their children
taking part in painful rehabilitation. Mothers seeing their children in pain during

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activity understandably wanted the therapy to stop, even when they knew that the
pain was part a higher goal of rehabilitation, and their child had chosen to do it (Caes
et al., 2011, Study 2). When we act protectively, for others and ourselves, we are acting
normatively. Our analgesic culture prioritizes escape from pain first and always.

Pain that won’t go away

What is surprising about this analgesic culture we inhabit, and the normative expect-
ations of pain it promotes, is that it persists despite the overwhelming evidence that
the rules of pain we hold are frequently inadequate, false, or damaging. Scientific and
experiential data show repeatedly that often pain is not diagnostically helpful, often
pain emerges without explanation, often pain cannot be fixed, and all too often pain
does not go away.
The large study of the population prevalence of pain in Europe found that one in
five adults reported chronic pain (Breivik et al., 2006). However, these are average
rates; they are more than twice as high in the older population (Johannes et al., 2010).
In fact, chronic pain has developed into a major public health problem in many socie-
ties. Winfried Häuser led an investigation of chronic pain prevalence in Germany and
helpfully focused on the broader impact on disability and distress. Comorbid disease,
depression, and social inequality, indexed by employment, housing and family status,
all had a contributory role to play in exacerbating the consequences of pain (Häuser
et al., 2014). There is no suggestion that these factors are causal for pain and disabil-
ity; rather, they significantly accelerate the impact of chronic pain. Given that most
postindustrialized populations are aging, we should expect the population burden of
chronic pain to increase. In an interesting summary, Stephen Gibson and David Lus-
sier commented that we are unprepared and unplanned. It looks like we will struggle
to meet the needs of the expanding pain population (Gibson and Lussier, 2012).

Trying to cope alone

However unprepared we may be for pain, we still try to find a solution, try to cope. I
prefer a broad definition of coping as any attempt made in response to the stress of pain
(Tunks and Bellissimo, 1988). In this sense coping is always active. Even when people
are avoiding, praying, accepting, or distracting, these are often effortful and mindful
attempts to escape from pain or its consequences. Not all attempts to cope with pain
fail, but we know little about how people with chronic pain who do not present to
health care settings manage their pain. For many people with chronic pain, attempts
at escaping its negative consequences can actually increase suffering. When faced
with inexplicable pain, many people persevere with attempts to find meaning. Indeed,
patients often find it difficult to accept pain that cannot be explained (Martin et al.,
2014), and often experience the idea of acceptance as surrender (Risdon et al., 2003).

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For many chronic pain patients, three distinct patterns of behavior emerge, all of
which are extreme versions of normal defensive behavior. Paradoxically, these pat-
terns often achieve the opposite of what they were intended to achieve, propelling
people into further suffering. First, being vigilant for pain and signals of impending
pain can become a problem all by itself. Second, worry over the possible causes and
consequences of pain can cease to be useful and can become a further independent
source of distress. And third, when attempts to solve the problem are not effective,
knowing when to persevere with the same tactic or when to try something new can
be very confusing: often those with chronic pain wait too long to disengage from
strategies that are not working.

Vigilance

If pain demands your attention because it might signal damage, when is it OK to not
pay attention to it? For many people who experience a lot of pain, it makes sense to
become vigilant. It is like being in a dangerous environment. For example, if you are
on a battlefield, vigilance to the shout of a confederate may be life-saving. You learn
to be more aware, not to ignore the signals of danger. Many chronic pain patients
show the same learned pattern of heightened vigilance, in which the threshold for
being interrupted by signals of possible danger is lowered (Crombez et al., 2004).
This vigilance effect has been examined as a form of stable attentional bias in experi-
mental studies. A meta-analysis of 50 of these studies found evidence for altered
attention as a mechanism of chronic pain. Interestingly, there were no effects in
those with naturally occurring acute pain, or in pain-free participants subjected to
pain—just those with chronic pain (Crombez et al., 2013). For people who live with
the threat of pain, attending toward signals that the pain might increase becomes
habitual. Whether this habit of chronic attending is helpful has not yet been prop-
erly explored. It may emerge that it is ultimately a helpful strategy, or might be a
cognitive fault line that lies behind the unpleasant experience of intrusion and
repair in attending.
Distraction, a common strategy for coping with acute pain, is the opposite
of vigilance. When the pain is short-lived—for example, during an injection for
­inoculation—deliberately attending away from pain can be helpful. But when the
pain is chronic, attempting to attend away from it all the time can be fatiguing, fuel
helplessness, because it so often fails, and can obstruct the learning of other tech-
niques. This is not an unconscious process: people are very often aware of this pat-
tern of attending. For example, we followed 62 chronic pain patients over a two-week
period and periodically asked them about their pain. Many patients report attempts
at distracting themselves from the pain, with varying degrees of success. Distraction
is often a failed strategy in the management of chronic illness, but it is one that people
hold in high regard. Even though it does not work, we often believe it does. This is

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 wor ry

perhaps more to do with a belief about how one should be rather than how one is—a
pain-coping stereotype, perhaps. All over the world there are people attempting not
to think about pain and growing increasingly distressed when it cannot be banished
but persists as a threat.

Worry

Where there is threat there is a plan to avoid it. For some chronic pain patients, how-
ever, the ever-present threat and planning to avoid it are experienced as worry, which
can become an added problem. Talking about worry is always fraught with linguistic
danger. Worry is a meager word that has connotations of an avoidable neuroticism,
or moral judgment; it is rarely thought about positively. There is, however, a positive
story to tell about worry as a fundamentally helpful aspect of human psychology.
Worry should be thought of, in the context of pain, as a normal response to threat.
Consider what problems would ensue if we did not worry about pain in ourselves or
others. Worry is often purposeful, active, and adaptive. It helps us prioritize; it makes
us take pain seriously (Aldrich et al., 2000).
We were interested in exactly what it was that pain patients spent time worry-
ing about, and what the experience of that worry was like in comparison to other
sources of worry. Again using a diary method, we asked 34 chronic pain patients,
over a seven-day period, to record each time they realized they were worrying.
They also recorded the content of that worry and qualitative aspects such as how
intrusive, dismissible, or distressing it was. The patients reported 473 discrete
episodes of worry in the week, of which 271 were about pain. The worries lasted
approximately 20 minutes each. The most common cause of worry was medical
uncertainty linked with uncertainty about the future and fear of disability. One
person reported:

My most common worry is: will the pain ever go or will it continue on and off for the
rest of my life, possibly getting worse? It already stops me from doing major exercise
and reduces the amount of effort I can put into playing with my children and gardening.4

Not only does the pain interrupt and persist, but so too does the worry about its
cause and consequence. For many patients this pattern of rumination around pain
exacerbates distress and makes one vulnerable to a more far-reaching depression
(Linton et al., 2011). Letting go of this worry, however, is very hard to achieve with-
out therapy. For many patients, stopping the planning for a cure feels like defeat.
Clumsy suggestions of not worrying about pain or accepting it are typically experi-
enced as punishing. We found that patients endorsed a strong belief that they had to
battle for the legitimacy of their concerns and this strengthened the framing of their

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problem as curable (Eccleston et al., 1997); a findings that is repeatedly reported

(Froud et al., 2014).

Courageous engagement

The fear avoidance model introduced by Johan Vlaeyen and Steven Linton in 2000
was enormously helpful in shifting research away from presumed patient psycho-
pathology and onto the normal function of pain as threatening. It helped us put
into context why people behave as they do when in pain. What seemed like unusual
behaviors of people persevering with strategies that have brought only misery make
sense when one realizes that pain urges action. Better to keep doing something that
does not work than do nothing. A consequence, however, of the dominance of the
fear-avoidance model has been the focus on persistence as nearly always negative.
Even in our own model of worry and problem solving, perseverance is presented
negatively (Eccleston and Crombez, 2007).
Stefaan Van Damme and Hanne Kindermans have attempted to redress the balance
and ask us to think about persistence in its motivational context. They use a language
of self-regulation, referring to how we constantly update multiple goals. For them,
persistence or avoidance can only be made sense of within the context of meaningful
goals (Van Damme and Kindermans, 2015)
What is needed perhaps is less a theory of fear avoidance, and more a theory of
courageous engagement. What matters in chronic pain, as we saw with endurance
athletes, is what the costs of approaching or avoiding pain might be. One also wit-
nesses patients engaging bravely with pain in the pursuit of a valued goal, or in the
belief that that pursuit will lead to lasting analgesia. Unfortunately, many attempts
are misdirected or lead to further distress and disability. But not all. And the action
of engagement can itself be rewarding (Hasenbring et al., 2009). Nicole Andrews
and her colleagues recently reviewed studies of engaging and avoiding patterns of
reacting to chronic pain. They attempted to tease apart the findings hiding within
different studies on pacing, activity, and coping. They did find the expected result
that avoidance of activity is related to greater pain and disability. However, they
also found hints that endurance may not always bring negative outcomes (Andrews
et al., 2012).
The person in chronic pain is like an endurance athlete. They make repeated trade-
off decisions about how much pain is tolerable in the context of achieving other goals.
Some people endure, persist, worry, and plan their lives to achieve what is meaning-
ful for them despite the constant presence of pain. However, many do not. Trying to
find the best method of solving the problem of chronic pain, of coping, either alone
or within a family, is a challenging and equally chronic task.
To explore these ideas further, I talked to Rupert Fingest (Box 7.2).

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 cou r ageous e ngage m e n t

Box 7.2. Rupert, living with chronic pain: “I will always push through if what I am
doing is worth it”
Rupert is a journalist in his late 40s. When he was twenty he was in a road traffic acci-
dent in which the car he was travelling in was hit by a firetruck attending an incident.
He has chronic low-back and hip pain. Despite multiple interventions, the pain never
left. He stopped searching for a cure in his 20s. He is now 46. He describes himself as
tenacious and uncompromising.

______________________________________

Chris: How would you describe the pain?

Rupert: It is mostly a dull ache that is always there. On bad days the volume goes up and
starts to block everything else out, but normally it is like background noise. More irri-
tating than anything else.
Chris: People often talk about pain as distracting. Is that true?
Rupert: Yes, that is true. But pain is a funny distractor. Sometimes it is hard to think
about anything else, but most of the time it just lurks in the background and occasion-
ally jumps out! So it is distracting when it pushes itself on me, but otherwise it is only
distracting if I go looking for it.
Chris: Why did you stop looking for a cure?
Rupert: After a while you have to realize that you are searching in vain. I would go and see
doctors and they would fidget and look away and in the end I realized that they were sort
of telling me to get on with it. It was hard at first, but when you realize that it is not going
to kill you, you have to decide where to put your energies. Keep searching for a holy grail
or start to learn how to live with it.
Chris: Have you accepted that you will always have pain now?
Rupert: No. I don’t like that word because to me that just means that I have given up just
like everyone else. Pain is not something to accept. It is something to fight. But fighting
does not have to be negative. Maybe fight is the wrong word. I think of pain as an annoy-
ing travelling companion. Wherever I go, it goes. Most of the time it adds nothing to the
journey, often it distracts me from beautiful things going on outside, but sometimes it is
helpful, like when it is time to change course. I would rather be travelling alone but you
don’t always get to choose.
Chris: How do you know when to listen to the pain and when to push through?
Rupert: Hindsight is great teacher. I am much wiser about what I should have done than
what I should do next. I am not a great planner. I find that if I plan for pain then that gives
it too much respect—planning gives pain a space to expand into. Best not to pay it any
credence. In fact, I think I have talked more about pain in this interview than I have in
years! I will always push through if what I am doing is worth it. And it is normally worth
(Continued)

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Box 7.2. Continued

it. Pain would stop everything if it could, so I try to make sure what I am doing is mean-
ingful. If I don’t care what I am doing, then it is easier to get distracted and pain will come
in. That does mean that I am not very good at trivia anymore. Small talk is an impossible
chore for me. It is just inviting my body to distract me.
Chris: Some people have tried to say that pain can be positive. Does that make any sense
to you?
Rupert: Not easily. You can make it make sense if you want to. I think I am more deter-
mined to achieve than I would have been without it. But it is hard to say. The worst thing
about pain is that it forces me to live within quite tight boundaries, physically and men-
tally. I don’t make plans, but I rarely go out of my comfort zone. I am never spontaneous.
But on the positive side, my life is full of meaning. To keep pain in its box I make sure that
I spend as much of my time with people I love, and put all of my energies into things that
are valuable and will make a contribution.
If I had not been in pain I think I might have allowed myself to have more fun. Who knows?

______________________________________

Rupert offers a nuanced approach to the idea of courageous engagement. We are used to
the patient account in which pain intrudes, is hard to control, and comes to dominate.
We also have accounts of enduring short-lived pain in high motivational environments
such as sport. Rupert, who by his own admission rarely speaks of pain, offers a differ-
ent, unexplored view of the person coping in silence. Here is the idea of goal-directed
activity bringing reward and being analgesic. High value and meaningful activities are
prioritized repeatedly, and pain is positioned as a threat to those, or as a nuisance. Unex-
plored in the research on pain and motivation is this more subtle idea of how one can
live within the tighter boundaries created and policed by pain.

Helping people to cope

Some people do manage to live unaided with chronic pain, finding a balance in man-
aging interruption. Rupert’s account is one example. We know very little about how
people who do not present for help cope. We really need to find out more. Many peo-
ple, however, do not find ways to live with pain, often swinging from avoidance to
overactivity, from denial to misery, from hope to despair. Unfortunately, living with
pain that does not follow the rules of our analgesic culture can leave one cast adrift in
a nightmarish battle for legitimacy as a patient whose status as needing help is always
being challenged (Delvecchio Good et al., 1992). For those who reach a psychological
treatment facility or who can access rehabilitation for chronic pain, the focus will
inevitably return to function, not sensation.

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 he l ping peopl e to cope

There is a rich tradition of psychotherapeutic and rehabilitative approaches to helping

people manage chronic pain. Mark Jensen described what he refers to as a “family” of cog-
nitive behavioral approaches, meant to capture the relatedness and the distinctiveness of
different approaches (Jensen, 2011). Some focus on the management of symptoms. Such
approaches include biofeedback, habit reversal, hypnosis, attention focusing, and rein-
terpretation. Others focus on the specific motivational aspects discussed here: problem
framing, skills training, altering beliefs about cause and consequence, and addressing
avoidance and endurance. The most common approach is to develop a program that
combines different treatments, often with physical and occupational therapy alongside.
Unlike other areas of health psychology, there has been, and continues to be, devel-
opment and innovation in psychological treatments for chronic pain. Overall, the
evidence for the effectiveness of interventions is at best promising. For the Cochrane
systematic review of psychological interventions for adult chronic pain, last updated
in 2012, we included 42 randomized controlled trials. Compared with doing noth-
ing (by leaving patients on a waiting list) or treating them with usual care, the treat-
ments were relatively effective in altering disability and mood (Williams et al., 2012).
In short, there is a strong case for the development of psychological treatments for
chronic pain. Nevertheless, the very complexity of the problem—reflected in the
huge variety of treatment approaches, types, and characteristics for a wide variety of
patients—make the coherence of an overall review challenging.
Psychological interventions for chronic pain are best considered as emerging from
their troubled adolescence. They have definitely grown out of infancy. There are well-
established treatments. We know that people who otherwise would be left in misery
can be helped safely in treatment. However, we don’t know what works best for whom,
in what circumstance, and for how long. Both treatment development, and, by exten-
sion, evidence synthesis, are at an interesting crossroads in the psychology of chronic
pain. There is now recognition that there is no such thing as an “average” chronic pain
patient, that we need to move beyond a general (catchall) treatment approach, and that
outcomes expressed as a population average are close to meaningless. These lessons
have been learned in nonpsychological treatments for pain already (Moore et al., 2013).
The next generation of studies will focus on specific psychological treatments with
specific outcomes for individuals. For example, we have reported the evidence for
treatments of chronic pain in children (Eccleston et al., 2012a) and for their families
(Eccleston et al., 2012b), finding value in working directly with adolescents and their
parents. When one is able to be more specific, the relevance of the analyses and guid-
ance for future treatments both improve.
There are also new treatments being developed that offer a bright hope for the
future. Some adopt hybrid techniques but focus on specific settings like the work-
place (Linton and Fruzzetti, 2014). Other treatments are designed for very specific
purposes with selected populations; for example, those needing to reduce or stop
their prescribed opioid medicine (Windmill et al., 2013). Trials are also underway with

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specific populations, such as those with neuropathic pain conditions (Eccleston et al.,
in press). Finally, there is an increasing focus on modern methods of delivery, such as
the Internet (Eccleston et al., 2014).

Summary

Our analgesic culture teaches us that pain is bad, should be short-lived, is diagnostically
relevant, and should be removed. Closer examination shows that there are many expe-
riences of pain: most escape research attention; some are educative or edifying. Endur-
ance of pain and suffering is a marker of personality, group membership, achievement,
and maturity. Our marathon runners pounding through the streets of New York,
increasingly consumed by pain, being cheered by a crowd of strangers, are an example
of the public role pain and its endurance can play. Chronic pain that flouts the received
wisdom of pain as temporary offers a specific challenge to psychology. Psychology has
attempted to explain chronic pain behavior with ill-fitting psychopathological models.
By thinking about the normal response to an abnormal event, one begins to under-
stand how persistent pain behavior is maintained, and how many people who present
for help find themselves stuck in self-defeating patterns of vigilance, fear, worry, and
perseverative problem solving. There are, however, well-established and promising
treatments for people struggling to cope alone. A remaining challenge is to understand
more about how the majority of people who cope in silence live with pain.

Notes

1. THE PROBLEM OF PAIN by CS Lewis © copyright CS Lewis Pte Ltd 1940.

2. This material was originally published in The Body in Pain by Elaine Scarry and has been
reproduced by permission of Oxford University Press http://ukcatalogue.oup.com/­
product/9780195049961.do. For permission to reuse this material, please visit http://www.
oup.co.uk/academic/rights/permissions.
3. Reproduced from Alan Morinis, The ritual experience: pain and the transformation of con-
sciousness in ordeals of initiation, Ethos, 13 (2), p. 151, doi: 10.1525/eth.1985.13.2.02a00040
© 1985, American Anthropological Association.
4. Reproduced from European Journal of Pain, 5 (3), Chris Eccleston, Geert Crombez, Sarah Aldrich,
and Cathy Stannard, Worry and chronic pain patients: A description and analysis of individ-
ual differences, p. 312, doi:10.1053/eujp.2001.0252 Copyright (2001), with permission from
Elsevier.

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 CHAPTER 8

ITCH

I tch functions to urge scratch. Of all of our ten neglected senses, itch, or pruritus, as it is
known clinically, appears to be the most functionally straightforward. The psychol-
ogy of itch emerges as both complex and intriguing. Traditionally, itch was thought of
as a variant of pain. Although itch and pain feel different they were considered to be
physiologically and behaviorally similar. This perception has been strong enough for
the interest in itch to be subsumed for years under the broader canopy of the study of
pain. Itch, however, deserves attention as a sensory experience in its own right.
As with all of our ten neglected senses, there is a unique sensory quality to itch; we
know what it means to itch, and we know how the relief of itch feels when we scratch,
rub, touch, or change temperatures. Culturally, itch is a marker of an urge that can-
not be ignored; it is a primary and growing need that must be met, as in the idea of a
“seven-year itch” in marriage, or the “itch” to purchase consumer goods, or as a gen-
eral motivation when colloquially describing oneself “itching” to go. Its motivational
character—an urgent quality—lies at the heart of its definition.
Similarly, scratch—the deliberate counterstimulation at the site of itch, including
rubbing, pinching, or pushing skin—is inextricably linked to itch. Scratching with-
out itch may be rare, normally accidental; when deliberate, it has a wholly different
function of marking or sensation seeking. Why and how we scratch, and its conse-
quences, are part of the enigma of itch and need to be examined together.
First, however, it is useful to review the mechanisms of itch, both peripheral and
central, and especially how they promote self-stimulation and counterstimulation,
such as scratching. Itching and scratching are considered within a context of per-
sonal and social hygiene. Finally, when itch becomes chronic it ceases to have any
useful social or personal function. The experience of people with chronic pruritus
is explored, with a focus on their attempts to live being constantly urged to scratch.
Itch is a part of almost everyone’s life. But two people were particularly helpful
in offering unusual insight into this neglected sense. First, I talked with James who
works every day surrounded by plants and insects that most people avoid because
they can cause itch; he inhabits a pruritogenic environment. James is the keeper of
reptiles, arachnids, and insects in a wildlife park. I also talked with Neil who lives
with chronic itch: his face itches constantly and has done so for as long as he can
remember. He is an expert at making sure that he is never in a situation where it is not
possible for him to scratch.

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 f u nc t ion of i tch

From itch to scratch

Itch is commonly defined as an unpleasant urge or desire:

the unpleasant sensation that leads to the desire to scratch the skin. The terms “itch” and
“pruritus” can be used interchangeably. Itch can be so severe that it causes insomnia,
and scratching can be so intense that the skin is left raw and bleeding. (Hanfield-Jones,
2009, p. 273)

This pragmatic definition can be criticized for its lack of precision (Savin, 1998), in
part because of its insistence on the unpleasant quality of itch and on scratch as inevi-
table. However, it does capture the experience well. Here itch is defined broadly as
unpleasant and a motivating desire for counterstimulation and relief.
There have been other attempts to define itch by the presumed cause and by the
presumed mechanism of action. Itch can be the product of peripheral mechanisms
in the skin or generated neuropathically due to presumed nerve damage or disease
(Twycross et al., 2003). Much of the debate in recent years has been about the per-
ipheral mechanisms. Earl Carstens describes how itch was once considered low
frequency pain, but with the identification of specialized receptors, or pruriceptors,
attention has shifted to a more selective mechanism. Further evidence for the select-
ivity of receptor pathways comes from numerous studies showing that pain can sup-
press or inhibit itch. According to Carstens,

The bulk of the current evidence favors the concept of an itch-selective pathway, ori-
ginating from mechanically insensitive, pruritogen-selective C-fiber afferents which
project to lamina I spinothalamic tract neurons that, in turn, convey itch signals to the
lateral thalamus and cortex. (Carstens, 2008, p. 118).

The evidence for central involvement in itch comes also from the novel recogni-
tion of sensitization to itch but not pain, and from the realization that cause of itch is
often systemic, originating far from the skin—in particular, with the kidney or liver.
Histamine as a mediator for itch perception is well documented and plays a clear role
in many but not all itch experiences. Centrally, itch enters the cortex via the thalamus
and then projects widely, as with other interoception, to affective, motivational, and
motor control areas (Hsieh et al., 1994; Davidson and Giesler, 2010).

Function of itch

Why do we itch? The common answer is that itch operates like pain to warn of
potential danger; in particular, of chemical attack from plant or animal. It is worth

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remembering that we share the planet with approximately 8.7 million other spe-
cies (Mora et al., 2011), many of which bite, puncture, secrete, invade, or infect. Jef-
frey Demain explores the causes of itchy skin weals and rashes (papular urticaria) in
humans caused by a hypersensitive immune response to bites and stings. They come
from exposure to Arachnida such as mites, ticks, and spiders; from insects such as
mosquitoes, flies, midges, lice, caterpillars, and beetles; and from Reduviidae such
as bedbugs. We are extremely close to many creatures who provoke severe itch. For
example, “It is estimated that more than 1 million people are bitten by mosquitoes
daily” (Demain, 2003, p. 297). Itch may be an important part of our overall defensive
system that warns of harm inflicted.
Whereas pain promotes defensive withdrawal behavior to avoid danger, itch pro-
motes a rubbing, wiping, or scratching to remove whatever is attacking through con-
tact or puncturing of the skin. Although an intriguing idea, there is very little evidence
that itching functions to promote scratch solely in defense of attack. There are a num-
ber of related reasons. First, the event rate of scratching is so high and occurs so often
without external attack that such an explanation leaves the majority of scratch behavior
unexplained by proximal causes. Second, scratching is often judged to be pleasurable
and continues beyond the simple first phase of adjustment or removal of an irritant.
Third, human-made barriers to external irritants such as clothing and furniture are tol-
erable despite constant abrasion and stimulation. Fourth, both scratching and itching
are highly socially contagious in a way that almost none of our other senses are. Finally,
itch can be induced by exposure to itch-relevant cues, such as images of insects.
An alternative way to think of itch is as a signal to promote broader social hygiene
behavior. Itch urges scratch, but it also serves the primary purpose of promoting skin
awareness in both ourselves and in observers, and it initiates a range of self-touching
behaviors that function to check the integrity of the skin and elicit grooming.

Grooming

Many primates self-touch, in particular on the face. Face touching is surprisingly

common. How often have you touched your face today? In one study, British students
at rest with no task to perform touched their face on average 8.5 times in a ten-minute
period, 51 times an hour (Hatta and Dimond, 1984). We don’t know how many of these
face touches are itch-relevant, or how aware people are that they are doing it, but it
is clear that touching mouth, nose, and chin are common. Faces are often unclothed
and accessible, and have highly innervated, cortically dominant areas such as the
mouth, so may simply be the most likely target. However, faces also house structures
that perhaps require defense against parasites. Self-touching of the face may be a form
of abrasion to wipe away possible ectoparasitic organisms.
Whether one needs to itch in order to scratch becomes a relevant question. Scratch-
ing, rubbing, and wiping are self-grooming behaviors used by animals to reduce the

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 soci a l con tagion of i tch a nd scr atch

parasite load. Pavol Prokop and colleagues explored human grooming. They argued
that there is as yet insufficient evidence as to whether our grooming behavior needs
external cuing, or whether we are more like animals whose grooming is under regu-
lar rhythmic (endogenous) control. The two may be related. It is entirely possible
that we have a base rate of endogenously cued grooming, but the rate of grooming,
including scratching, increases when cued externally. In an interesting study, Prokop
and colleagues exposed students to cues of parasites and to cues of a biological con-
trol; in this case, images of hormones. The cues of parasites increased awareness of
scratching and of formication; formication was captured with the question, “How
many times during the last 45 minutes did you have a feeling that something is crawl-
ing on your body?” (Prokop et al., 2014, p. 43).
This cuing of grooming by parasites has also been reported separately. In a similar
experiment, Donna Lloyd worked with a smaller group but went beyond self-report
of awareness of scratch to actually observing scratching. They also captured the par-
ticipants’ perception of itch. In this study they had better control stimuli and used
images of nonthreatening insects such as butterflies. The participants reported being
more than three times as itchy when viewing the itch- compared with the non-itch
pictures, and a tenfold increase in scratching behavior was observed. In a further ana-
lysis, the investigators found that the cues for itching and scratching may be highly
specific. The itch pictures were of three types: itch-related stimuli in contact with the
skin, such as an ant on skin; humans scratching; and objects that relate to itch but in
a different context, such as an ant on the ground. Lloyd and colleagues found that
images of people scratching were related to increased scratching, but images of agents
of itch, such as biting insects, resulted in greater itching. (Lloyd et al., 2013). Getting
closer to the exact triggers may be particularly important for people who suffer with
recurrent or chronic, environmentally maintained pruritus.

Social contagion of itch and scratch

Scratching yet? These studies point to an intriguing aspect of itch; perhaps more than
any of the other nine neglected senses, itch and scratch are socially contagious. Why
should cues of itch and scratch increase the felt experience and lead to scratching
behavior?
Although the social contagion of behavior is a very popular idea, there are still few
studies, and even fewer explanations. In one modern study by Alexandru Papoiu and
colleagues, 14 adult volunteers without skin complaint and 11 with mild-to-moderate
atopic dermatitis (eczema) watched short films either of people scratching or a neu-
tral comparison: same people, same place, same amount of time—but no scratching.
Next, itch was induced with histamine; a placebo induction was also given. Scratch-
ing during the films was observed and self-reported itch noted. Compared to those
without a skin problem, people with atopic dermatitis reported increased itching,

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they scratched for twice as long, and they scratched more body areas when exposed
to the placebo. Similarly, when exposed to the histamine irritant, they also reported
longer and more extensive itching, and scratched more than controls; these results
were amplified by watching people scratch.
Two intriguing findings were hidden in this study. First, as in earlier studies, those
without a skin condition scratched for more than twice as long when watching videos
of people scratching, but itching was not greatly increased. But in the presence of an
irritant, the itching and scratching were both amplified by social contagion. Second,
the researchers found that the pattern of scratching was different after contagion in
those with and without atopic dermatitis. Figure 8.1 shows the pattern of distribution.

5
3 Sites scratched
11
by healthy subjects
3 2

4 10
1

7 7

Sites scrached
by AD patients 2
8
1
6
4 9

Fig. 8.1. The distribution of scratching episodes in widespread (scattered) areas, in patients
with atopic dermatitis (AD) and healthy subjects. (Plate 1)
“The distribution of scratching episodes in widespread (scattered) areas, in patients with atopic
dermatitis (AD) and healthy subjects, reveals that patients with AD experienced an itch that ex-
tended beyond the local itch induction site, becoming generalized, while they watched the itch vid-
eo. Scratching beyond the local site in healthy participants was limited to the face [2], neck [1] and
contralateral forearm [4]. The areas scratched are shown in ranking order (by mean duration) for
an exposure to the itch video, when the local itch stimulus (histamine) was delivered to the right
forearm (i.e., scratching on the contralateral forearm is represented). Subjects with AD scratched
mostly their contralateral forearm (1), mid-back region (2), face (3), neck (4) and scalp (5).”
Reproduced from Contagious itch in humans: a study of visual ‘transmission’ of itch in atopic
dermatitis and healthy subjects, A.D.P. Papoiu, H. Wang, R.C. Coghill, Y-H. Chan, and G. Yosipo-
vitch, British Journal of Dermatology, 164 (6), pp. 1299–1303, Figure 4, doi:10.1111/j.
1365-2133.2011.10318.x Copyright (c) 2011, John Wiley and Sons.

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 a h ygie ne pa r a dox

For those with a skin disorder, the scratching was quite widespread. For those without
a skin disorder, scratching was limited to face, neck, and scalp (Papoiu et al., 2011).
It is not clear whether itching, scratching, or both are contagious. There are clearly
differences in the extent and pattern of scratching in response to cues between those
with a propensity to itch due to a skin disorder and those without a pre-existing con-
dition. The pattern differences shown in Figure 8.1 are particularly interesting from
a functional perspective. In those without a reason to itch, observing scratching
may induce self-touching of the face, perhaps as grooming—an increased hygiene
response. However, in those already itching and scratching, observing others scratch-
ing may lower the threshold for attention to itch extensively across multiple sites. The
same observable behavior may be functioning differently in different contexts.
The mechanism by which observing another’s scratching increases our own
scratching behavior, whether as increased grooming or as response to itch, is not
known. Ashley Feneran and colleagues from the same Wake Forest laboratories as
Alexandru Papoiu explored the idea that scratching may be due to mirror neuron
involvement. However, in an observation study of pairs of monkeys, they found that
the monkey behavior in response to a cage mate’s behavior was not specific but gen-
eral: scratching increased but was not limited to exactly the same location as observed
(Feneran et al., 2013)

A hygiene paradox

Human grooming is more egocentric than that of other primates: we do not rely
explicitly on others to reduce our parasite load—we do it ourselves. The extent to
which we self-groom or other-groom functions in part by how fearful we are of dis-
ease: the more vulnerable we feel, the more we groom ourselves; the less vulnerable
we feel, the more we touch others (Thompson, 2010). The reliance on self-grooming
would, hypothetically, heighten the need for visual cuing of self-scratch. Less “You
scratch my back and I’ll scratch yours” and more “I see that you are scratching your
back, so I should scratch mine.”
The idea that itch may function as part of a larger set of behaviors that are best
thought of as serving a hygiene function has some problems. Bug removal is import-
ant, and scratching may well be useful as a method of removing ectoparasites, but it
also does two things that, paradoxically, increase the likelihood of infection: it trans-
mits infection from surfaces to sites of entry of the body, and it can create new wound
sites of entry.
An interesting report on home hygiene and infection behavior from the Interna-
tional Scientific Forum on Home Hygiene reminds us that when it comes to infection,

hands are probably the single most important transmission route because, in all cases
[gastrointestinal, respiratory, and skin infections] they come into direct contact with

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the known portals of entry for pathogens (the mouth, nose and conjunctiva of the eyes),
and are thus the key last line of defence. (Bloomfield et al., 2012, p. 8)

Putting our hands to our faces is the main method of transmission of multiple infec-
tious diseases. Itch, and so, by extension, contagious itch, may increase the likelihood
of infectious transmission. One might also expect that in an environment in which
itch is common (e.g., a dermatologist’s reception area), scratch would be common,
and so by extension will be hand-to-mouth transmission of infectious disease. I could
find no investigation of attempts to reduce scratch cues in, for example, hospital envi-
ronments, and their effect of infection rates, but this could be a novel area for study.
Scratching can often, if extended, cause skin lesions and so introduce new sites
of infection. It can also produce secondary complications of new injury, albeit self-
inflicted. Sometimes, however, scratching goes beyond the cessation of itch and can
be mediated either neurologically, behaviorally, or both, as in the interesting case of
skin picking in adolescents. In these cases the immediate reward of self-attention,
or distraction from other unpleasant sensations or emotions, reinforces a skin-­
destructive behavior (Bohne et al., 2002).

On the pleasure of itch

Much of the discussion so far has stressed the unpleasant aspects of itch, principally
around the quality of urgency, that provoke scratching. However, itch may also be
a pathway to pleasure. In a study of different sites of itch, itch was induced and an
experimenter scratched those itches producing different but closely related judg-
ments of pleasure in the person being scratched (bin Saif et al., 2012). Papoiu and his
colleagues extended this idea, but recognized that self-scratching is motivationally
different from being scratched. They investigated pleasure and itch using neuroimag-
ing while people underwent their own itch-scratch routine. However, they did take
the opportunity to compare scratching oneself with being scratched. Intriguingly,
when one is in control of both the relief of itch and the pleasure of scratch, there
is quite extensive involvement of reward processes in the midbrain affect systems,
brain areas that are not involved when being scratched by another (Papoiu et al., 2013).
Scratching yourself is much more pleasurable than being scratched.
Pleasure should perhaps be considered an inherent part of itch, rather than sim-
ply a potential consequence. The hedonic qualities of itch may arise from various
sources. First, scratching an itch has a pure reward involvement and so a centrally
generated hedonic quality. Second, the cessation of itch provides a quality of relief
that may be experienced as pleasure in its own right. Third, just as there is evidence
that pain offset enhances the pleasure of the experiences that follow, it would be inter-
esting to examine the sensations that follow the offset of itch, to see whether they are

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also hedonically exaggerated; that is, are they more pleasurable because they follow
itch? Finally, it is possible that itch generates not only immediate scratch, but is also a
gateway into a larger class of self-stimulation, self-soothing, or patterned grooming
behaviors that are experienced positively. Indeed, it is not clear when scratching turns
to stroking the skin next to the site of itch, or when a rough stroke turns to a smooth
and so more pleasurable stroke (Essick et al., 2010). Affective touch is a common emo-
tional regulation behavior, but it is not well studied in psychology, with some notable
exceptions (McGlone et al, 2014).
To explore the possible nonaversive, even hedonic, qualities of itch and scratch,
it is helpful to explore itch in a context where it is experienced as welcome, neces-
sary, or unavoidable. With some of the physical senses one can easily find people
who engage or endure despite the aversive experience (consider pain, fatigue, imbal-
ance, hypoxia). However, there are very few people who deliberately engage with
pruritogenic environments. But there are some. Those who venture into wilderness
environments—jungle, desert, mountain, or cave—encounter insect-rich places and
massively increase the risk of parasite load and infection (Miller et al., 1996). Likewise,
there are people who choose to work with the very itch-inducing creatures that most
of us try to avoid.
To explore what it is like to be in an environment of itch, I talked to James Reynolds
(Box 8.1).

Box 8.1. James, working with itch: “it is the horrible looking creatures that I see
a beauty in”
James is a herpetologist. He is the keeper of the reptiles and arachnids at the Cotswold
Wildlife Park, which has one of the largest collections in the UK. When I met him he was
examining the delivery of amphibian food, which was a box of live jumping crickets.

______________________________________

Chris: What is it about working with arachnids, insects, and reptiles that attracts you?
James: It started when I was young, with an interest in bird-watching. Now, it is all the
weird and wonderful stuff that I find interesting. Not the fluffy stuff. That bores me,
really. It is the horrible looking creatures that I see a beauty in.
Chris: So, does being around insects and spiders all day make you itch?
James: I think you have levels. When you start your levels are low. You look at a tarantula
and you might be scared. With experience and knowledge about the animals it gets better.

(Continued)

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Box 8.1. Continued

For example, with the tarantula they have hairs they flick and they can get into your nose.
They rub the back legs on the abdomen which then releases the hairs into the atmosphere
and then as soon as you touch something with them on, they are there lying dormant.
They go into your skin and it gets really itchy. The feeling is not like a chemical feeling; it is
just really irritating. It feels like hundreds of tiny hairs digging into your skin and irritating.
Chris: Do you still get itchy when you see some insects?
James: Yes, I still get that. Not with the ones I am familiar with, but the ones that are dif-
ferent, like orb-weavers, which are big spiders—they are long and spindly and kind of
disgusting. We are getting some in, so I hope in a couple of weeks I will get used to them
and hopefully that itchiness will start to subside. Well, it should do. You get used to it. At
the moment we have these lovely little tailless whip scorpions. They look disgusting. At
first it is horrible. But now I can have them on my hand. No problem at all.
Chris: Why do you think people itch more with some creatures?
James: I think it is the idea of an insect getting caught on their skin that would make them
itchy. When people come into contact with insects, they want to get them off their skin
as quickly as possible. It is a sense of getting away from skin. Especially in the arms.
For example, we use a lot of crickets as food, and at first crickets worry people. But now
the sensation is no longer itchy, you are just used to it. The only time you might itch,
and you will think this funny, is if you lose one on your skin and you feel them crawling
through your clothes later on.
Chris: It sounds like you no longer worry too much . . .
James: Well, don’t get me wrong. I hate to be bitten. I was bitten in Costa Rica a few years
ago. I was in bed and I felt like there were insects all around me. I could not sleep. So there
are times when it gets too much for me.
Chris: So you are not completely immune to itch . . .
James: Yes, that is right. There are still some insects that make me itchy and there are still
contexts that make me itch. I hate to be bitten and I don’t like to itch. In some places I
will be worried about being bitten and I will check my body. So, yes, it doesn’t go away.
Chris: Do you try to educate others about which animals can itch?
James: If people ask me questions, I will help them out. But I won’t go out of my way to
correct people and say that what they think is itchy isn’t, like spiders; because in their
context it might be. So, it is hard to tell them it is not itchy because it could be.
Chris: You have said a few times that the spiders and insects are horrible, but you seem
to respect them a lot.
James: I just say “horrible” because that is how they are portrayed and how people first
think of them. I think that maybe if people looked at creatures as a form of beauty rather

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Box 8.1. Continued

than something disgusting it would help. If you look at the structure of, for example, a
stick insect, it is amazing looking. It is completely different from any other animal in the
world.
Chris: Is there pleasure in being surrounded by things that itch?
James: It is about understanding their behavior. It is understanding that they are creepy
and horrible looking and they make you itch and they might bite you, but that they are
very basic animals. Understanding the animal and learning about its behavior. Although
they are basic, they can sometimes surprise you.
Educating other people is the really positive thing. And generally being around the ani-
mals. It is a real pleasure. Sometimes you get an animal that you think, “That is smash-
ing. I am so happy I am working with it.” Or you might get a rare animal and you think,
“Am I ever going to work with this again?” Yes, your knowledge and understanding is
important. If you learn about them the curtain starts to lift a bit more and you see more
of the beauty of an animal. Once you get past that first judgment and you look at it, I
mean you really look at it, then you can get past the horror, and really see the beauty of
the animal.

______________________________________

James lives surrounded by creatures that might itch. But the extinction of itch and
scratch behavior is specific to the creature he is exposed to. It does not generalize to all.
He discusses what looks like a self-delivered, graded exposure process where the more
time he spends with a new creature, the less disgusted, less itchy, and more fascinated he
becomes. The general, perhaps hardwired, dislike of itch is not affected. Also interesting
is the role of general avoidance. A consequence of behavioral avoidance of creatures
considered pruritogenic is ignorance of what actually poses a threat, and in what form.
James discusses eloquently the role he plays in educating people about the beauty of
insects one can marvel at if one can move beyond avoidance.

Chronic itch

For most people it is hard to find anything positive about itch; it would just be nice
to be far away from things that threaten itch. Itch is a very common experience and a
common symptom of many diseases. Given its function in promoting skin awareness
and hygiene, we should expect itch to be highly prevalent. However, for some people
itch can be frequent and chronic. The definition of chronic itch is a pragmatic one: it
is itch lasting six weeks or longer, severe enough to promote complaint and request
for help (Weisshaar et al., 2012). The prevalence of chronic itch has been reported as
high as 10 percent in various community studies (Weisshaar and Dalgard, 2009). In

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a study from Heidelberg, 343 of a sample of 2,540 adults, or 13.5 percent, reported
chronic itch, 72 percent of whom said they itched every day. These were people taken
at random from the community. Half did not know the cause of their itch, and most
found any relief from itch elusive. On closer analysis, the people with chronic itch
also said that their quality of life was worse when the itch was severe (Matterne et al.,
2011). Relationships, leisure, and sleep were affected on a measure of quality of life for
patients with itch (Matterne et al., 2009).
Measuring quality of life is one way into thinking about experience, but it is often
an unsatisfactory snapshot of that experience. Anja Bathe from the Heidelberg team
led a more thorough investigation by interviewing 16 patients with chronic pruritus
who were seeking treatment. The researchers asked about the labels and language
used; ideas about cause, consequence, how controllable it felt; and for more detail
about its consequences in wider life. Sleep disturbance often emerged as a major
complaint that extended to fatigue and lack of concentration. They also reported an
interesting finding not discussed elsewhere: the difficulty patients had in settling on
an appropriate language for itch. Available language was considered inadequate by
patients who wanted to communicate the extent of the misery of itch. Language of
bites and other external agents such as cutting were used, but were very not thought
satisfactory (Bathe et al., 2012).
The language of itch is peculiarly limited. For example, the itch severity scale uses
only six descriptors: stinging, stabbing, burning, annoying, unbearable, and worrisome
(Majeski et al., 2007, p. 672). This measure was developed from a previous clinician-
administered measure, itself was taken from the famous McGill Pain Questionnaire.
Of course both pain and itch share neuropathic qualities, as captured by these
descriptors, but this is surely only a small part of the experience. Missing is any con-
tent relating to the interruptive and urgent qualities, and to the wider experience of
emotional distress. This gap has been recognized, and plans are underway to produce
more thorough methods of assessment of the broader impact of chronic itch. In a
consensus paper from the International Forum for the Study of Itch, the importance
of assessing not just the felt experience was clearly stated (Weisshaar et al., 2012).
The cognitive, motivational, and wider emotional aspects of itching and scratching
are important when considering the person attempting to cope with itch. It is useful to
think of people living within an affective-motivational cycle that starts with the inter-
ruption of attention by itch, coupled with the overwhelming desire to scratch, which is
followed by concerted attempts to not scratch, the failure of those attempts, and then a
flood of negative self-appraisals, including shame, embarrassment, and self-criticism.

Attending to itch

Itch, like pain, functions primarily to interrupt. This attention-grabbing aspect has
attracted some interest. Andrea Evers from Lieden in the Netherlands leads the study

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 if you h av e a n i tch, don’t scr atch

of psychological influences in itch perception. In her laboratory she and her col-
leagues showed that attention to bodily sensations increases sensitivity to induced
itch, implying a central attentional involvement (Van Laarhoven et al., 2010). But what
happens when you do attend to itch? Evers reminds us of the role of anxiety, expressed
with itch as worry about symptom exacerbation, stigma, and the subsequent loss of
social relations; she stresses the possible role of specific beliefs, such as believing in
the onset of catastrophic outcomes because of unbearable itch (L. Verhoeven et al.,
2006). For Evers, the crucial cognitions are of perceived lack of control over the itch
and scratch. She argues that for those who develop a pattern of helplessness, worry,
and catastrophic beliefs, the impact of disease—its course and the subsequent need
for treatment—increases (E.W.M. Verhoeven et al., 2008).
The importance of beliefs about itch is only beginning to be understood. Patients
have long discussed the challenge of control, but how far one’s beliefs are auto-
matically invoked and what part they play in our behavior is not well investigated,
even though Andrea Evers has argued the case very well. In addition, in other fields
of psychology, there has been a growth of interest in cognitive biases, in how our
attention, labeling, and interpretation of sensations can be altered by fear of those
sensations. In many ways itch would be a much better candidate for the identification
of automatic cognition. Unlike other physical sensations, itch has a direct link with
a broader hygiene response, making the social cues for itch concrete and specific in a
way that they have failed to be for pain, suffocation, fear of falling, and fatigue. If atten-
tion or interpretation biases can be identified for itch, it would open a novel avenue
of discovery for the psychological treatment of itch and the behavioral modification
of scratch.

If you have an itch, don’t scratch

Once itch has interrupted, how easy is it to not scratch? Health and behavioral
psychology are replete with examples of how difficult the extinction or modification
of behavior can be. Habit reversal when habits are under social control is difficult
enough to achieve. Consider the plethora of lifestyle advice and the fate of good inten-
tions to change complex behaviors such as smoking, drinking alcohol, and physical
activity. Success in sustained behavioral change is elusive. Behavioral extinction of
conditioned behaviors such as scratch is particularly difficult to achieve. Itch is almost
hardwired to deliver scratch. Is it possible to resist?
One study attempted to model this resistance in the laboratory. Elisa Filevich and
Patrick Haggard developed a novel paradigm in which to study inhibition of urgent
action, using itch. They were particularly interested in cases of what they call internal
inhibition, by which they mean the decisions we make to inhibit habits (as opposed
to external inhibition, meaning instructions from others to change): it is the diffe-
rence between resolving to change and being told to change. Filevich and Haggard

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developed a task in which people were exposed to itch and could move to avoid it,
but instead endured it. Their principal finding was that internal inhibition, or per-
sonally initiating self-control (willpower), has a stronger neural consequence than
responding to instruction. Now, interpreting exactly what this stronger pattern of
brain signals means will be important, but at this level of description there is evidence
that when we try not to scratch an itch, it is an event of greater neural significance.
They speculate that this neural involvement is about the decision making. Because we
could have avoided the negative consequences, so the effect is stronger (Filevich and
Haggard, 2012).
This interesting line of research into willpower and the consequences of resisting
or enduring extreme urges and desires is very promising because it comes close to
the experience of the battle with itch described by patients. It opens various avenues
for further investigation. First, what governs the ability to resist, and under what
circumstances is it difficult to resist the urge to scratch? Second, what are the con-
sequences of planned decisions to inhibit or to resist? In a non-itch study from the
same laboratory Filevich and colleagues found that immediate decisions to inhibit
were less costly in terms of brain activity than planned resistance. Is this willpower
in action? If so, such self-generated inhibition is costly, likely to be fatiguing, and will
have consequences (Filevich et al., 2013). Finally, it would be interesting to know the
consequences of repeated attempts at inhibiting scratch while experiencing an itch.
We do not know, for example, whether the deliberate inhibition of scratch leads to
increased intensity of the itch, as in an alarm ignored. It is also possible that inhibiting
scratch will lead to an amplification of itch on its next occurrence, known as a hang-
over effect. What is needed is a science of resistance to scratch.

Social emotions

The fate of most attempts to inhibit scratch is that they fail. For many people with
chronic itch the failure of control can be as worrying as its consequences. The itch
severity scale includes annoying and worrying as part of the emotional experience. And
of course chronic itch can be both of these things. However, when interviewed by
Anja Bathe, patients didn’t stop at annoying and worrying. They went far beyond:

Many participants feel guilty after scratching their skin in an attempt to cope with the
unbearable symptom: “One realises afterwards, oh gosh, couldn’t you have kept your
hands off. But then it’s too late” (female aged 26: pruritus of unknown origin). Guilt
also appears in the form of chronic pruritus to be constructed as punishment for com-
mitted sins: “Why am I punished again, what have I done . . .” (female aged 31: pruritus
of systemic origin). Again this imposes substantial strain on the patient. The inability
to withstand the urge to scratch and the resulting guilt constitute major psychological
problems. Participants also said that they were highly embarrassed about scratching in

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 sh a m e a nd disgust

the presence of others as this constitutes a taboo. However, the urge in the person can
still be felt and they need to come to terms with it. The perception that others can see
secondary skin lesions (resulting from scratching) causes substantial feelings of shame
and embarrassment. In one participant, who was not experiencing pruritus at the time
of the interview, the thought of reappearing pruritus evoked strong emotions of fear,
anxiety and helplessness as the association of pruritus and scratching and its ensuing
consequences are not easily forgotten.1

Particular to the experience of itch is the prominent role of social emotions, in

particular, guilt, shame, and embarrassment. Social emotions are the class of emo-
tions that we feel in the context of relationships, so are sometimes called relational
or self-conscious. Unfortunately, the management of itch involves the inhibition of
a largely automatic behavior of scratch, which, although it can provide relief and
momentary pleasure, causes damage and can further exacerbate itch. Therefore
at the heart of the experience of itch are two intimately related psychological chal-
lenges: first, trying not to do something you really want to do, an immense motiv-
ational challenge of enduring and inhibiting desire; and second, when one fails to
endure or inhibit and one scratches, this scratching can be accompanied by a pro-
found sense of failure and shame. These two aspects of motivation are core to the
psychology of chronic itch.

Shame and disgust

The problem with failure to control scratching is that for people with chronic itch,
this failure can become psychologically toxic, leading to extensive patterns of
self-destructive beliefs. There is not enough study of this aspect of self-punishment
caused by the failure of attempts to control scratch. That experience tends to be lost in
the broader discussion of shame of the visual manifestations of altered skin or overt
scratching behavior.
For many people the context of chronic itch is the presence of skin disorders that,
when aggravated by scratch, can be unsightly, and lead to social isolation and stigma.
Part of the experience of skin disorders is fear and embarrassment at the thought
of public display of wounds. People often report feeling unattractive and likely to
attract attention that can be embarrassing (Hrehorów et al., 2012). In an interesting
sociological analysis of stigma, 18 people with psoriasis, a common systemic disease
that causes skin lesions, were interviewed about being socially “marked.” One person
exemplified the dominant theme of separation:

The worst thing with psoriasis is that it is visible and I cannot make it disappear. I feel
restricted to loneliness, neither starting a new relation with a man, nor looking for a
new job. (Woman, onset at age 18; Uttjek et al., 2007, p. 367)

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Exploring lives lived with psoriasis reveals that everyday life is different in subtle
ways; it is both more planned and routinized. Where there is skin there is groom-
ing, and the practices of grooming for the person with marked skin involve elaborate
hygiene and clothing routines that become an important part of life. Participants
described the lengthy deliberations about clothing, about its use in hiding markings,
and about the many embarrassments of leaving flaked skin behind. The researchers
say of everyone interviewed:

All participants said that psoriasis had some impact on their quality of life. They never
felt fresh; instead they felt messy, unclean, and/or restricted in their life and that the rash’s
scales made their clothes and spaces around them look untidy. (Uttjek et al., 2007, p. 369)

In this study, however, shame was never openly discussed, and when raised the
topic was quickly changed. However, if asked directly, patients with psoriasis do
report shame. In a large study from Rome, 936 patients with psoriasis were asked
to report on the emotions they felt. Forty-eight percent said they sometimes, often,
or always felt humiliated. Embarrassment, anger, and shame were similarly frequent
features for more than 60 percent (Sampogna et al., 2012). Parker Magin, a primary
care physician from Australia, has led extensive research into the experience of social
emotions. In a variety of studies, he asked patients with psoriasis to describe in more
depth their experience. For many, the experience of shame and humiliation comes
back to a social understanding of hygiene and disease transmission that is part of
the social meaning of skin. Patients report feeling not only dirty, but of others’ per-
ceptions of them as carriers of infectious disease. This is captured well in one study
in which a 42-year-old woman said, “People tend to back away from it or think that
it might be contagious. That seems to be a big factor, ‘Can I catch it?’” (Magin et al.,
2009, p. 157).
The social emotions of shame, embarrassment, and anger operate freely in the con-
text of itch. Scratching is a visible sign of potential skin attack and functions to make
others skin-vigilant. Visible skin disorders and recognizable scratch behavior also
trigger skin hygiene beliefs. The stigma that is central to the experience of those with
chronic skin disease and pruritus is part of a broad set of protective behaviors that
rely on disgust as a primary driver of avoidance. In their massive global study of dis-
gust, Val Curtis, Robert Aunger, and Tamer Rabie had over 30,000 people worldwide
make judgments about how disgusting certain pairs of images were. In one image, a
man “was sprayed with a water mist and photo-morphed to look feverish and spotty-
faced.” As a consequence, “the respondent average disgust score more than doubled,
from 1.5 to 3.1.” (Curtis et al., 2004, pp. 131–132).
Another pair of images included skin lesions. Both were judged to be disgusting,
but the less disgusting one was of a healing wound. A further set of images was of
ectoparasites. Of the seven images judged to be disgusting, three were directly

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 pair disease irrelevant disease relevant

(a)

– –
x = 1.6 x = 2.6

(b)

x– = 1.5 x– = 3.1

(c)

x– = 1.2 –
x = 2.0

(d)

x– = 1.6 x– = 3.9

(e)

– –
x = 3.6 x = 4.6

(f)

x– = 3.7 –
x = 3.8

(g)

x– = 2.8 x– = 3.5

Fig. 8.2. Stimuli used in the paired disgust sensitivity task (x̄ is the average disgust score out of
5 as the most disgusting). (Plate 2)
Reproduced from Val Curtis, Robert Aunger, and Tamer Rabie, Evidence that disgust evolved to
protect from risk of disease, Proceedings of the Royal Society of London (1800–1905), 282 (1804),
S131–S133, Figure 1 © 2004, The Royal Society.
 i tch

scratch-related—two of skin changes and one of ectoparasites—and one other was

indirectly scratch-related: an image of a crowded subway train. Disgust, Curtis and
her colleagues argue, “is an adaptation designed to prevent the acquisition of infec-
tious diseases” (p. 132). Figure 8.2 reproduces the pairs of images used in the study
together with their mean disgust scores.
It would be interesting to discover whether just knowing that another person is
itching, or the observation of another scratching, is sufficient to communicate disgust
and fear of infection, or whether it is only the direct observation of possible causes of
infection (like parasites and broken skin) that function to promote hygiene by stimu-
lating disgust.

Formication

The close relationship of itch and scratch to hygiene behavior and parasite load is at
its most pronounced when people actually experience the feeling of insects on or
under the skin. Formication can usefully be thought of as an extreme form of the itch-
scratch phenomenon. It is not extreme in the sense of high intensity, but extreme
in its function of signaling potential infection, first by mimicking the experience of
insects crawling on and under skin, and then generating a strong belief of infestation.
Formication, as the actual paresthesia sensation, can be distinguished from the rare
delusional state of parasitic infection. In delusional parasitosis, patients believe that
they are infested with parasites, which drives behaviors such as attempting to remove
the offending insects (Levin and Gieler, 2013). Nancy Hinkle gives a good summary of
Ekbom’s variation of delusional parasitosis. She makes the point that “although ES
[Ekbom’s syndrome] is a delusion that the body is infested by bugs, it is almost always
accompanied by tactile hallucination of a crawling sensation, or a feeling of biting or
stinging” (Hinkle, 2011, p. 178). She also briefly discusses the folie à deux phenomenon
that occurs in many delusions in which a close person can come to share the delu-
sional belief.
In order to provoke scratch, all that is normally needed is itch. Beliefs about the
cause and consequence of itch do play a role in predicting defensive and hygiene
behavior, but are more relevant in chronic pruritus caused by skin disease. Formica-
tion, however, is a specific phenomenon that should be explored further because it
may hold the key to understanding how bodily senses are interpreted. It is not clear
why such a specific paresthesia has evolved. One can speculate that it may be a last
line of defense when itch-scratch fails, in digging out a burrowing parasite from the
skin, but it is clear that when formication appears what becomes important is not
the sensation but the belief. What distinguishes simple formication paresthesia from
delusional parasitosis is the role of belief. In the former, one knows that it only feels like
insects crawling under the skin; in the latter, one believes, and can convince others to
believe, that there are insects crawling under the skin. Beliefs about itch, its causes and

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consequences—even rare beliefs like this—are at the heart of the experience of itch
and are also the main targets of psychological treatments of chronic itch and chronic
scratch.

Psychodermatology

The causes of itch are not always skin-relevant. But for patients the skin is the prin-
cipal observable organ involved. Whether or not skin is implicated in the cause, it
is nearly always involved in the consequences when itch-scratch behaviors take
hold. The recognition that skin is psychological has led to the development of the
field of psychodermatology that covers the treatment of skin disorders in psychiatric
populations, the co-presentation of skin and psychological problems, and the role
of psychological factors in the experience and adjustment to primary dermatological
problems, such as psoriasis, atopic dermatitis, and acne (Bewley et al., 2014). Primary
psychological treatments have been developed that focus specifically on itching and
scratching, and broader treatments have been developed with the goal of changing
beliefs and behaviors to promote the self-management of symptoms and improve
quality of life.
In a meta-analysis of psychological treatments, 23 studies of psychological inter-
ventions were identified. The studies are varied and cover outcomes that range from
itch frequency to shame. In general, the outcomes are promising (Lavda et al., 2012). A
few studies focused specifically on the management of itch. Andrea Evers’s team have
published the most comprehensive study. They undertook a group treatment for
adults with atopic dermatitis, which included content on itch management (in par-
ticular, techniques of habit reversal) and a focus on beliefs. They used a three-pronged
approach: teaching skills to reduce the urge to scratch, building belief in the ability to
control and change (self-efficacy), and reducing catastrophic beliefs and worry. Com-
pared to patients who were waiting for treatment, treated patients experienced less
itch and scratched less. Treatment was also effective in increasing self-efficacy and
reducing worry on an itch-catastrophizing scale (Evers et al., 2009). This is a promis-
ing study; it shows that altering scratch behavior is possible.
The psychological treatment of itch is still in its infancy. We lack tools and tech-
niques. Assessment tools are borrowed from other areas and methods are attempted
but not yet well specified. Advances in behavior therapy have been slow to transfer to
psychodermatology, probably because of the small number of researchers focused
on this area. However, the specificity of the itch-scratch behavioral loop makes it an
extremely promising target for psychotherapeutic intervention. Given that 10 per-
cent of the population report that itching and scratching are unpleasant and unwel-
come in their lives, the development of successful self-management treatments
could have far-reaching benefits. First, Evers pioneering work should be built upon.
In addition, research into four novel areas could be promising. First, it is important

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to demonstrate the extent to which scratch can be reduced by graded exposure to

itch-inducing stimuli. Second, research into goal planning and motivation to stop
scratching is needed. Critical in this will be the study of dealing with setbacks, which
many patients report as catastrophic and can generate a wave of self-defeating cogni-
tion. Third, negative social emotions are a core part of the experience of chronic itch.
Unexplored is the effect of promoting positive social emotions in treatment, in par-
ticular of self-compassion, empathy, and pride. Finally, we need to know more about
the beliefs that occur in different contexts associated with itch. Many of the studies of
cognition in chronic itch have relied on advances in other fields, such as pain, or from
general theory. Specific itch theory should guide research. To help, there are quali-
tative studies of the experience of chronic itch, although more of these studies are
needed, especially if they can sample the content, valence, and strength of cognition.
To explore the experience of living with chronic itch, I talked with Neil Carrier
(Box 8.2).

Box 8.2. Neil, living with itch: “it is hard for me to imagine what it is like not to itch”
Neil is an anthropologist and an expert on East Africa; in particular, the ethnography
of drug use. For as long as he can remember, he has had a constant itch in all of his face,
which is temporarily relieved by contact—in particular, moving, touching, or rubbing.

______________________________________

Chris: Can you describe for me the sensation of itch?

Neil: That is a difficult question. It seems an obvious sensation. It is just an intensity of
feeling. Gosh, it is tricky to describe. It is the intensity of a feeling that is urging me to
put pressure on my face to take that feeling away. It is uncomfortable. A tickling, but
with moments of real intensity—almost like a rush of it, almost like a piercing itch that
demands attention straight away. But other times it is more dull. Sometimes, when it is at
its worst, there is an intensity of it. Yes, I wish we had a better language to describe it, really.
Chris: Why don’t we have a better language to describe itch?
Neil: It would be easier if we did. To most people an itch is an itch is an itch. But it isn’t; it
is so much more than that.
Chris: What would happen if you could not move and you could not touch yourself?
Would the sensation change?
Neil: It would get much worse—the feeling that I have to do something. I am not sure
how I would cope with it if I could not have my hands near my face. I would probably
contort myself trying to do something. I would probably tense up to try and take some
pressure away. If I could not move I would probably try and do it within me. So probably

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Box 8.2. Continued

internalize it. I have never got to the point of testing it. Probably I should try that. I have
never got to that stage. I always feel it so intensely that I have to respond.
Chris: How do you respond to the itch? Do you scratch?
Neil: I don’t really scratch my face. I manage it by putting pressure on different points. If
I scratched, then it would just irritate it more in the long run. My strategies have always
been to touch my face in a way that puts pressure on it to take away the itch, or caus-
ing pain elsewhere for distraction. It is not really scratching. I wonder if I ever really
scratched. I used to be more aggressive with pushing my face, and I think I have missha-
pen my nose through that. But now it is more just putting pressure.
Chris: So is it fair to say that it is experienced through your whole body?
Neil: It is only recently that I begin to realize more and more how much it has affected
my life, and how it is lived more and more in my body. I have even damaged my left eye
now because I have been rubbing it too much. Because it relieves me a bit. I suspect I
might have damaged it. I have pushed that side of my face in a bit with rubbing so much.
Chris: How else does it change your body?
Neil: I am always trying to find ways to keep my hands close to my face. I will always be
sitting in a way that keeps my hands in reach of my face. It looks casual but it is deliber-
ate. There are a lot of small things. I will be in seminars and there is a moment when you
are not quite ready to ask a question, but the way I sit communicates that I have my hand
up. It has happened a couple of times recently when I am not ready to ask a question and
I am called upon. I should never go to an auction!
Chris: Does needing to keep your hands near to your face change what you can do
socially?
Neil: Yes, I become a lot more aware of it around other people. If I am alone doing my
writing then I can sit in whatever position I need to. I always write one-handed, so I have
my other hand up to my face. But, yes, when I am around other people in a social envir-
onment, then I become more aware of what I am doing that is different from others. It
does make me more antisocial than it would otherwise. Depends on the situation. If it is
somewhere where you have to stand around, like a drinks reception, I don’t like those,
because my hands will be full and I won’t be able to free them easily.
Chris: Is it itch or embarrassment?
Neil: It is the itch. Some of these receptions can be laborious, but it is definitely some-
thing about knowing that I am going to be uncomfortable and itchy. And even when
you talk to someone and you realize that you are not giving your best because you are
so focused on how to cope. I think, “I am not comfortable, I am feeling really itchy,” but
I have to keep on talking. My mind starts to focus on the itch rather than engaging with
the person. Yes, it definitely makes me uncomfortable in these situations.

(Continued)

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Box 8.2. Continued

Chris: Are there times of embarrassment?
Neil: Going back quite a long way, when I was younger. If you are constantly touching
your face it is noticeable. I just went into my shell about it and didn’t want to talk, it was
too embarrassing a thing to speak of, really. I just felt so different, and obviously you
would get teased about it at school. So over the years I really didn’t want to talk about it.
Whereas nowadays, I understand partly that I will never improve these things if I don’t
discuss them. Now I find it quite interesting myself. Intellectually interesting: about how
these sensations are embodied. Or perhaps I am just getting older and realize that it is
something I have got and there is no reason to be embarrassed about it, as I was when
a teenager.
Chris: Has it changed who you are and what you can do?
Neil: Who knows? If I had not had the itch I might be doing something completely differ-
ent. But I suspect that is putting too much determinism onto the itch. I don’t know. I love
what I do and the contribution I can make.
I have no idea what life would be like without itch. I wonder what life must be like for
people who don’t itch. It is a factor every day of my life: how to cope with it, how to
adjust, what social things I don’t want to go to because I will be uncomfortable. So, yes,
it is hard for me to imagine what it is like not to itch.

______________________________________

We think of itch as related to scratching of the skin. Neil’s account is fascinating because
three ideas dominate. Some we have discussed and others are new. The qualities of itch
as urgent and interruptive are reported, and the strange ability of itch to escape descrip-
tion is pondered. But also, we are reminded that scratch as a category should include vari-
ous forms of counterstimulation in response to itch. Novel was Neil’s recognition that
itch has a whole-body effect. Itch has an effect on Neil’s posture, physical poses, habits,
and lifestyle choices. And lastly, the extreme of itch, unlike the extreme of dyspnea,
pain, or fatigue, was avoided. Any derealization was avoided. Itch is never allowed to go
unscratched.

Summary

Itch it is intimately related to the specific behavior of scratch. It operates in the sym-
bolic context of possible external attack to the skin, and it functions to promote a
range of hygiene and grooming self-protective behaviors. In a chronic state, much of
the suffering of people with itch is about living with constant distraction, personal
loss, fear of social rejection, and being different, all of which are expressed as negative

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social emotions in embarrassment and shame. Itch has a preoccupying attentional

quality that makes an external motivational focus difficult. The psychology of itch
could provide novel understandings of embodied protective behavior, and there is a
very strong case for a growth in psychodermatology, focusing on how to change the
lived experience of itch.

Note

1. Reproduced from Chronic pruritus—more than a symptom: a qualitative investigation

into patients’ subjective illness perceptions, Anja Bathe, Elke Weisshaar, and Uwe Matterne,
Journal of Advanced Nursing, 69 (2), p. 321, doi:10.1111/j.1365-2648.2012.06009.x Copyright
© 2012 Blackwell Publishing Ltd.

References

Bathe, A., Weisshaar, E. and Matterne, E. (2013). Chronic pruritus—more than a symptom:
a qualitative investigation into patients’ subjective illness perceptions. Journal of Advanced
Nursing, 69, 316–326.
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 CHAPTER 9

TEMPERATURE

W e need help when it comes to managing body temperature. Although we have

good physiological mechanisms of thermoregulation, they are not perfect.
There are limits to our unconscious ability to automatically adjust body temperature
in response to a changing environment. Human core temperature is approximately
37°C but we can only operate safely within a narrow range: with hypothermia starting
at 35° and hyperthermia at 39°, if not earlier. Before we get to these temperatures, or
stay at them for too long, we need to intervene and engage in a variety of exogenous
thermoregulatory behaviors. Or to put it more simply: we need to know when to put
on or take off a hat. Effective thermoregulation needs thermoperception.
This chapter is about our experience of perceiving temperature, of being hot and
warm, cold and cool, and everything in-between. The physiological mechanisms of
thermoperception occur at the periphery of skin and centrally in the brain. How we
perceive and make sense of the temperature of the outside world and at the same
time maintain our own temperature is a remarkable achievement. It is so important
that the language of heat and its loss extends far beyond the simple judgment of body
temperature, with hot and cold being used to refer to emotions, characters, situations,
and actions. Is the tendency to describe anything and everything with reference to
temperature more than just linguistic laziness? Perhaps this is how cognition works,
grounded in everyday base realities like temperature.
Equally intriguing is what I think is one of life’s great puzzles: why don’t people put
on a hat when it gets cold? I admit it might not seem the most pressing challenge of the
human condition. But the decisions we make to protect ourselves, and how they go
wrong, are what hide behind the statistics on winter deaths; life and death decisions in
response to environmental pressure. One answer of why people behave in particular
ways is a social one: we make thermoregulatory decisions, like hat wearing, in a social
context. Shivering or sweating in public, for example, communicate more than body
temperature, and sweating in particular can be very challenging. Body temperature is
one of the primary vitals sign of health, measured repeatedly and often, everyday, all
across the world. Exactly what meanings temperature acquires and how it is experi-
enced in specific health contexts teaches us a lot about the psychology of bodily
perception. I close with an examination of a primary disorder of thermoregulation
known as Raynaud’s phenomenon. It is a good test of whether psychology can be
useful, and go beyond observation and explanation.

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 t he r mor egu l at ion

Two people helped me explore the experiences of temperature. First I spoke with
Alex who is a blacksmith. He spends his working life in high ambient temperatures
and close to white hot metal. He has thought carefully about the effects of heat on
his body. Euphemia was also kind in talking to me about what it is like to live with
Raynaud’s phenomenon. An awareness of temperature, temperature change, and the
importance of clothing are never far from her thoughts.

Thermoregulation

The skin is the main sense organ for temperature:

Thermosensation . . . is one of the sensory modalities of the skin. It provides (1) a

thermoregulatory afferent signal for homeostatic mechanisms which keep the body at
an optimal working temperature, (2) the capability to detect potentially noxious ther-
mal stimuli that pose an immediate threat to the integrity of the integument (i.e., nox-
ious cold and heat stimuli) (3) afferent signals which contribute to the identification of
objects and materials through touch, e.g., metals are easily discriminated from wood
because metals feel colder than wood.1

This rather neat summary shows the various functions of temperature perception
in the skin. It functions to do three things simultaneously: to promote biological
homeostasis, to protect the organism, and to support haptic exploration.
Neurophysiological studies have now shown a relative specification in cold and
warm fibers that function only in response to their temperature ranges, and do not
operate as mechanoreceptors or as nociceptors. These dedicated afferents also pro-
ject spinally, in the thalamus and to the cortex, relatively intact. Joris Vriens and his
colleagues give a clear summary of the current state of research in the peripheral and
central mechanisms, discussing the progress in our understanding of ion channels,
which they describe engagingly as “molecular thermometers that translate envir-
onmental and internal thermal cues into electrical activity in the somatosensory
system” (Vriens et al., 2014, p. 586). Thermoreceptors are also found outside of the
skin: in muscle, viscera, and particular organs including the eye, the mouth, and the
trachea.
Sensory neurons have their cell bodies clustering in either the dorsal root gan-
glia for the body, or in the trigeminal ganglia for innervated structures of the head,
including the face. Neuroimaging studies of temperature challenges show the
involvement of both the thalamus and hypothalamus, as well as cortical structures
such as the somatosensory cortex. As with other interoceptive states such as fatigue,
pain, itch, hunger, and thirst—which all require behavior to alter h ­ omeostasis—
older regulatory structures such as the hypothalamus that drive urgent behavior

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are implicated (Egan et al., 2005). Physiologically, what is remarkable about tem-
perature is the maintenance of core body temperature within an extremely tight
temperature range, despite major fluctuations in environmental temperature. The
system is best thought of as an integrated pattern of multiple looping feedforward
and feedback sensory and effector systems, with conscious experience emerging as
a by-product that provokes behavioral regulation only when autonomic regulation
fails (Romanovsky, 2006).
Primary regulation is achieved physiologically by changes in heat output and
changes in the movement and flow of blood. Increases in core heat will lead to blood
moving heat away from the core, flushing near to the skin (hence the change in skin
color) where heat is lost from the skin in sweat. We tend to think of the movement
of blood in terms of oxygen carriage; however, blood circulation also functions suc-
cessfully as part of the temperature regulation system, transporting heat. Similarly,
in preserving core temperature blood is transported centrally, and muscle activity is
increased in an attempt to increase heat production. The most observable examples
are shivering and teeth chattering.
Secondary regulation, by which I mean behavior aimed at changing body tem-
perature (seeking shade or sun, or adjusting clothing), is often invoked only after
primary regulation reaches its limits. However, it operates to support the same
functions of temperature regulation by attempts to either insulate from or pro-
mote heat loss, and/or by attempts to produce or conserve heat. We don’t think of
the choices we make in dressing as a form of secondary behavioral thermoregu-
lation, but that is exactly what they are. When we decide to put on a coat we are
assisting the three functions of temperature: maintaining biological homeostasis,
protecting the self, and allowing touch to be more discriminating when we explore
the world.
However, as we have come to understand, our psychology of the body does not
always follow simple physiological rules. It misbehaves. The decisions we make about
temperature are not very straightforward and are open to a variety of influences. The
distinction I made between primary and secondary is maybe too simple, too dualistic.
Secondary regulation does not operate slavishly in response to a failure of primary
regulation. Consciousness gets in the way. Consider that we can be planful, putting
on clothes in preparation for cold temperatures; willful, taking off a shirt in −5°C at a
soccer game in celebration; or just fashionable, wearing branded wellingtons in a 35°C
New York thoroughfare.
Let’s explore this interplay of primary and secondary regulation. There are two
specific cases that demonstrate how the perception of temperature has a strong influ-
ence on our behavior and how behavior has a strong influence on our perception of
temperature. The first is in how body temperature affects our judgment of others’
character. The second is in how far our emotions can actually change our judgment
of temperature, and influence our thermoregulatory behavior.

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Blowing hot and cold: judging others’ character

The language of temperature has been very useful for describing a broad range of
human behaviors. Consider, for example, that we often describe people who show
anger as hot-headed or fiery, and those whom we consider to be calculating and less
influenced by emotion as cool under pressure or cold-hearted. Perhaps this may be
because emotional arousal can often look like thermoregulation (e.g., turning red).
But this goes beyond arousal. When I reject you I can be said to give you the cold
shoulder, but if you accept me, you might give me a warm welcome. Away from the
extremes of hot and cold, we can unfavorably describe those who appear incon-
sistent as intemperate, implying that we cannot tolerate their extremes. These are
people who blow hot and cold, implying they are unpredictable. Linguistically, at
least, it seems that we value certainty, control, and order, and that metaphors that
refer to basic features of life such as hot and cold work well for us. But language
is fundamentally metaphorical. We consistently talk about things in reference to
other things. It is not that surprising that temperature is used metaphorically. Law-
rence Williams and John Bargh, however, suggested that the association between
temperature and the judgments of others’ character goes beyond metaphor, is more
than linguistic coincidence. In two intriguing experiments, they adapted a well-
established test of this idea and exposed people to warming or cooling prior to
making judgments.

Please hold my coffee

In a classic social psychology deception study, an experimenter met the student sub-
jects at the entrance to a university building and they took an elevator together to
the laboratory four floors up. While in the elevator the experimenter asked the sub-
ject to hold either a warm coffee or an iced coffee for them while they wrote notes.
After this warm-cold exposure, the students underwent what they thought was the
experiment, which involved making judgments about many things, including peo-
ple’s character. Those exposed to the warmth judged the characters of strangers to
be warmer (more trustworthy and likable) and those exposed to the cold judged the
opposite. In a second, improved experiment, they replaced the outcome of a judg-
ment of character with a behavior of whether they would act more prosocially (less
selfishly) toward another person after feeling warm. Again, they found that people are
more egocentric following a cold experience. The researchers concluded that “experi-
ences of physical temperature per se affect one’s impressions of and pro-social behav-
ior toward other people, without one’s awareness of such influences” (Williams and
Bargh, 2008 p. 607). This finding has been replicated and also extended to judgments
of how close one feels to other people, as an attempt to explore social warmth (Ijzer-
man and Semin, 2009).

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Cold and lonely: a Bridget Jones effect

Is it really possible that one’s perception of physical temperature directly affects a

judgment of another’s social warmth? If so, then the opposite might also be true: that
emotions directly affect a judgment of temperature and liking. Chen-Bo Zhong and
Geoffrey Leonardelli asked just this question in two experiments. Specifically, they
were interested in whether rejecting somebody led to them judging the temperature
of a room as colder. In one experiment they simply asked students to recall a time
when they had been socially excluded, with another group recalling a time of social
acceptance. After this remembering, the participants were asked to judge various
aspects of their environment, including room temperature. Real room temperature
was held constant. Those who thought about being rejected gave an average room
temperature of 21.44°C compared to those who thought about feeling accepted, who
judged the room to be an average of 24.02°C. A small difference, perhaps, but not a
chance difference. And when it comes to temperature, a difference of 2.5°C can be a
life-or-death matter (Zhong and Leonardelli, 2008).
Taking these ideas further, John Bargh and Idit Shalev were interested in those
who feel chronically rejected, not just by an experimenter. In their own words, they
hypothesized

that people (implicitly) compensate for the lack of social warmth in their lives with
increased physical warmth experiences. Specifically, we hypothesized that chronic or
“trait” loneliness . . . of our participants would be positively associated with the fre-
quency, duration, and preferred water temperature of the showers and baths that they
take. (Bargh and Shalev, 2012, p. 156)

The first study was with students and the second with people from the community.
The researchers’ methods were simple. They masqueraded as undertaking a survey
about everyday habits, and included questions about frequency, length of exposure,
and water temperature in bathing habits, which they combined into a measure of
how much heat is taken. They then measured loneliness. In both samples, signifi-
cant correlations were found between loneliness and heat extraction. Bargh and
Shalev concluded that social exclusion leads to physical comfort behaviors: if you feel
rejected you will seek out physical warmth.
That we seek comfort when we are lonely is perhaps a simpler explanation for such
effects. We could usefully call it a Bridget Jones effect, after Helen Fielding’s popular
character who is unlucky in love and becomes expert at self-comforting (Fielding, 1996).
However, investigators propose more specific effects. For example, in one study using
similar experimental methods, social rejection was not only associated with the judg-
ment of body temperature, but with skin temperature measured objectively. In a perhaps
unforgivable pun the authors call this effect cold-blooded loneliness (Ijzerman et al., 2012).

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 m a d dogs a nd e ngl ishm e n

The extent to which such effects are robust and specific to temperature need to be
properly established, because attempts at replication are proving elusive (Lynott et al.,
2008; Wortman et al., 2014). This research is only at its beginning, but the trail may
already be going cold.
The idea that the linguistic coding of social and personal judgments using a lan-
guage of temperature is more than metaphorical is a form of embodied cognition, in
which experience can directly affect and be affected by sensorimotor processes. In a
weak form, there is the idea that moral, social, and relational thoughts and emotions
are played out on and in the body. If we are disgusted by a thought, do we want to
wash? Similarly, if we are given the cold shoulder of rejection, do we seek out comfort-
ing warmth? In this weak form, the shared language is just a metaphorical clue. But
in a stronger form, embodied cognition holds that physiology and psychology are
inextricably linked: that perception—in this case, the perception of t­ emperature—
can make sense only within its social and personal environment, and as such, “the
environment is part of the cognitive system” (Wilson, 2002, p. 626).
The possibility that being cold can lead to less generosity or social sharing, or that
being rejected makes one feel cold and seek warmth, can be interpreted within the con-
text of the broader function of self-protection. For a social animal such as a human, rejec-
tion can indeed lead to isolation and possible exposure. If you are going to be cast out
from a group, you are going to be exposed to the elements, and so better find protection.

Protecting ourselves from the elements: secondary regulation

How successful are we at avoiding the extremes of temperature and taking action to
protect ourselves from exposure to the elements? In part the answer depends on what
experience we have of living exposed to those elements. Many people live in extreme
climates. I am writing this chapter in a country with a famously temperate and wet
climate, but even here in the UK, we have recorded a highest temperature of 38.5°C
in August 2003, and a lowest temperature of −26.1°C in January 1982 (http://www.
metoffice.gov.uk/). We need to behave to protect ourselves from the elements.
Secondary regulation operates in exactly the same two modes as primary regula-
tion. When cold, we act to preserve the heat we have and generate new heat, and when
hot, we act to lose the heat we have and prevent new heat from building: a simple,
well-mapped functional system. Except this means we need to have a good under-
standing of how to behave to support these two mechanisms. And, of course, we need
to behave in accordance with good thermodynamic and physiological principles.

Mad dogs and Englishmen

Psychology teaches us repeatedly and often that humans are just not rational. We do
not behave in line with thermodynamic principles, however much it would be in our

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interest. Frances Ashcroft, in her engaging and entertaining study Life at the Extremes,
discusses how different approaches to secondary thermoregulation have been
attempted. The Noel Coward observation that only mad dogs and Englishmen go out
in the Indian midday sun, says Aschroft, was due to a mistaken belief that vigorous
exercise in the sun protected against tropical disease. A more simple error can be seen
in the removal of clothing in the sun believing it cooling, when people who live in
hot climates often do the opposite, wearing loose-fitting ventilated clothes. It is the
difference between sun-basking tourists and shade-seeking locals (Ashcroft, 2001).
Climate-driven behavior is particularly interesting and only rarely studied at a psy-
chological level. For example, we know that deaths from both hot and cold weather
are common. A recent study of cold-related mortality, or excess winter deaths, gave
an estimate of over two million deaths in Europe in 2002–2010 (Fowler, 2015). Older
people are significantly more at risk, a finding also reported for heat-related mortal-
ity (Baccini et al., 2011). At a population level, it seems we are unprepared for these
extreme temperatures. Perhaps our secondary regulation is failing; we are not mak-
ing good decisions.
A hint of what may be happening was found in a landmark study by the large
Eurowinter research team. They explored differences in the decisions that individuals
make about temperature. People respond very differently to the same temperatures:

Outdoors at 7°C, people living in regions with warm winters were less likely to wear a
hat (13% Athens, 72% south Finland), an anorak, gloves, or trousers (among women),
though total clothing area was similar; they were more likely to wear a skirt (women),
an overcoat, or a sweater, and more likely also to stand still and to shiver, and less likely
to sweat.2

What seems to matter in the decision to put on a hat is not whether it is cold but
whether the cold temperatures are out of the ordinary for your normal climate. They
conclude, “Although we know that the middle-aged and elderly should wear pro-
tective clothing and keep active in cold weather outdoors, our surveys show that in
relatively warm countries they often fail to do so.”3 We don’t seem to be heeding the
advice of our grandmothers (Sperber and Weitzman, 1997), perhaps worried about
the impression that “old-fashioned” behaviors might have on our social standing
(Day and Hitchings, 2011).

“The apparel oft proclaims the man”

Shakespeare was aware that clothes matter. But perhaps he should have written,
“Ignorance of apparel oft undoes the man.” Clothing can be a matter of life and death.
Psychology has not been very interested in clothes as protection. There is a rich psy-
chology of clothing; however, virtually none of it concerns human decision making

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about the thermal properties of different garments. Perhaps that is unsurprising. If

we take heat for granted, then clothes serve a variety of functions more interesting to
the social scientist: for body adornment, for bodily satisfaction, in communication,
and in establishing social status, role, and desire. For example, in a study of 223 young
women in the United States on how fitted they liked their clothes to be, the various
benefits of the clothes they liked were examined, with “fashion innovativeness”
coming out top (Alexander et al., 2005). Perhaps we should expect this from young
women in a warm California. So what about older women in Helskinki? The same.
In an in-depth qualitative study of ten women in Finland, comfort was mentioned
but fashion and cut were the highest concerns (Holmlund et al., 2011). Perhaps when
it comes to clothing, in affluent societies at least, we take the thermal properties of
clothing for granted. The challenge in temperate climates is in knowing when to pay
attention to changes in temperature that require changes in clothing behavior.

Entering the extremes

There are places where extreme conditions demand more careful consideration of
temperature—where survival would be measured in minutes and seconds if you didn’t
think about temperature. Some people, and all of us some of the time, are motivated
by more than keeping warm. We have goals that threaten thermoregulation, whether
in pursuit of work, sport, play, or adventure. But overriding thermoregulation with
another goal puts us at risk: homeostasis may be compromised, the ability to protect
ourselves sacrificed, and our ability to explore the world challenged.
Humans make mistakes when temperature-stressed. For example, in one study
of helicopter pilot accidents, the number of accidents increased proportionally with
the heat of the helicopter cab (Froom et al., 1993). Vigilance and attention to change
are at particular risk in higher temperatures. In one well-controlled study in which
cognitive performance was measured at 0°C, 23°C, and 40°C, it was only at 40°C that
vigilance failed and errors increased. What seems to matter, however, is not ambient
external or even skin temperature, but changes in core temperature. Only when pri-
mary regulation is insufficient and homeostasis fails does attention fail (Faerevik and
Eidsmo Reinertsen, 2003).
Firefighters are particularly at risk of challenges to decision making. In the specific
environment of fire, rescue motivation may be high, but critical decisions need to
be made: decisions about harm, in environments defined by danger; decisions about
time, when duration of exposure to high temperatures and thermal radiation mat-
ters; indeed, decisions about survival itself. Unfortunately, the psychological study
of real-world heat stress has been limited. There are general effects of exposure to
extreme heat, nearly all showing decrement. Most studies are undertaken in con-
trolled environments with specific cognitive tasks (Pilcher et al., 2002). It has not been
possible to recreate the emotional and motivational contexts that would teach us how

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temperature affects life or death decisions. In the case of firefighting, for example, we
don’t know whether a motivationally rich and extreme environment of rescue will
impair or improve mental performance, or have no effect at all. (Barr et al, 2010)
Similar findings of exposure to cold have been reported. Mathew Muller and col-
leagues explored the effects of cold on cognitive performance. They measured atten-
tion, memory, and aspects of decision making when acutely exposed to 10°C for two
hours, and on re-warming. Working memory—the attention and updating aspect
of cognition—was particularly impaired in cold temperatures (Muller et al., 2012).
Although this study was very well controlled, the findings need replication, in par-
ticular to determine how important the losses are in complex, real-world decisions.
Field studies of people living and working in extreme cold environments suggest that
such cognitive changes are at worst just temporary (Paul et al., 2010).
There is a gap to cross between controlled experiments showing that extreme tem-
peratures can affect psychological function and the fact that many people appear
to function in those environments (Burke and Orlick, 2003). Not only do they func-
tion, but they are motivated to put themselves into those extreme temperatures. The
data from the winter mortality studies suggest that we are not good at making the
necessary adjustments when the temperature changes, that we have low “situational
awareness.” Perhaps those who choose to live or work in extremes of temperature
are better prepared, more reactive, or have learned the warning signals. Those who
expect and prepare for extreme temperatures may do better than those who do not
expect and fail to prepare for minor changes. How do we notice when the danger
creeps up on us, or when secondary regulation of temperature is sorely needed?
To explore the ideas of how one can live or work in extremes of temperature, mak-
ing decisions in the moment, and whether heat changes one’s world-view I talked
with Alex Coode (Box 9.1).

Box 9.1. Alex, the heritage blacksmith: “you have a holiday from your body”
Alex is a blacksmith who works now on heritage projects. He has a passion for iron and
its use in restoration work, and just how far nature can be represented in forging. He has
three forges situated in a historic foundry in the UK. Alex describes himself as single-
minded and stubborn. He knew he wanted to work with iron and said of forging, “It is
so physically and mentally demanding. I love it. In several lifetimes I would never master
it. There would always be more to learn.” In this interview it will help to know that the
word forge has multiple referents. It is confusingly used as a verb to mean working the
metal, as a noun to describe the fire, and as the building that houses the forges and where
the forging is done. So Alex forges at a forge in a forge.

______________________________________

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 e n t e r ing t he e x t r e m e s

Box 9.1. Continued

Chris: How hot does it get in a forge?
Alex: The ambient temperature in the workshop can get up into the late 40s, which is
hot. You can tell it is hot because you have to drink a lot.
Chris: In working the metal how close to the heat do you need to get?
Alex: There are a lot of processes where you need to be seeing what is happening in the
fire and so being quite close to it. The nature of forging is that it has to be accurate with
the right amount of force and done quickly. Because what you have taken out of the
forge is at the right temperature, then it is immediately trying to cool down. The second
law of thermodynamics is doing its very best to make everything the same temperature.
Chris: So speed matters?
Alex: Not just speed but accuracy. Forging is technical and physical. You want to be
working the metal when it is white hot, or orange, preferably light orange; otherwise it is
too late. They say that there are two ways for a blacksmith to go to hell: one is underchar-
ging and the other is working the metal when it is too cold. While a piece is in the fire,
resource is going into making it ready to work. If you don’t work fast and accurately, and
you don’t have the right equipment to hand, then you will waste that resource.
Chris: Do you get used to the heat?
Alex: Sometimes the heat can be quite shocking, but it does not last long. Once you have
established that it is not going to hurt you. You don’t worry about it. You just ignore it.
Chris: How do you know it is not going to hurt you?
Alex: Because after the first few times you have not been hurt. It is a bit like hot sauce on
food. If you were not expecting it and you didn’t know it was safe, your mouth would be
telling you that you are injured. But you learn from experience that it is not harming you.
One of the most important reflexes you build up as a blacksmith is the one that makes
you let go if you feel any residual heat in what you have just picked up. If something is
white or orange or even red heat. If you pick it up you will very rarely get burned because
you sort of know. There will be a hissing noise and a slight smell of bacon. I have a theory
that the hiss does not have far to go to get to your brain. Burns happen when you get hold
of something that is black and does not make a hissing noise when you grab it. By the
time the message has reached your brain that there is danger, that you are being burned,
it is too late and you have a nasty burn.
Chris: Is discomfort a necessary part of being exposed to heat in forging?
Alex: No. The opposite is true. Because the work itself is so absorbing, you don’t notice
the discomfort and the small injuries like burns. You can finish a session at a forge and
realize that you have strained something or burned something. That twisted ankle that
bothered you in the morning you have forgotten about. Because you have to work so fast

(Continued)

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 t e m pe r at u r e

Box 9.1. Continued

and hard it takes your full attention. So you don’t feel the heat. You tend not to notice
it. The activity of forging itself is so absorbing, it requires your complete focus so you
switch off anything that is unrelated to what you are doing.
Chris: I can’t work out whether being so absorbed is good or bad. Do you see it as a bene-
fit or a danger?
Alex: I would say it is a benefit. You have a holiday from your body. When you repeat it
again and again it liberates you to a large extent from your perceived limitations. You
realize that you can do more. And so I think it does alter the way you think about your-
self, the way you interact with the world and with your own body. If you can so easily
forget, completely forget, about whatever you thought was so important that morning,
then it is obviously a choice.
Chris: Have we become too aware of discomfort, too ready to avoid too much or too little
heat?
Alex: The heat of forging is not comfortable—I wouldn’t say that. I am aware of it but
just choosing not to address it. I do think in general that people’s comfort zones have
shrunk. On a hot day we go from air-conditioned house to car to office. People can iso-
late themselves from discomfort. For many people a lot of things that are uncomfortable
are not worth considering. Anything that involves extremes of physical labor or tem-
perature have all been cushioned. I think that is the challenge of modern life. What is the
point of complaining about the heat? It is what it is.

______________________________________

For Alex, living with the extremes of heat appeared to be unusually edifying, not some-
thing much discussed in the psychology of temperature studies. It will be interesting to
know the extent to which those who routinely live or work outside of normal ranges
of temperature believe that this confers benefits in general self-preservation, self-­
determination, or grit. Being absorbed was also seen here as positive, allowing freedom
from restriction or challenge from one’s body.

The paradox of sweating

Not everyone wants or is able to escape their physical experience. For many people,
the experience of being hot can be overwhelming and come to dominate their lives,
especially when it results in the observable forms of primary regulation such as
sweating.
Sweating is normal, and a useful mechanism of heat loss. However, despite this
normal, functional, and highly useful mechanism, it is not often personally enjoyed
or socially celebrated. In fact, for many people it is experienced as unpleasant,

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unwelcome, and even disgusting. In part this may be due to the ability of thermo-
regulation to be shaped by influences other than its primary functions. Autonomic
arousal in anxiety can be thought of as highjacked thermoregulation: in sweating,
in blushing, and in trembling (Harker, 2013). For some people, sweating that serves
no obvious thermoregulatory function is a clinical problem seen in dermatology as
a major limiting factor on people’s lives. Paradoxically, anxiety about sweating can
create further sweating, leading some to explore whether a primary treatment might
be psychological: to alter the unhelpful and anxiety-exacerbating beliefs people hold
about sweating.
One measure of common cognitions in hyperhidrosis (excessive sweating) captured
the range of negative beliefs commonly expressed. In the main they relate to fear of
embarrassment, negative evaluation of self-competence, and social rejection (e.g.,
“people will think I’m incompetent if I sweat”); but also a belief that sweating is asso-
ciated with poor personal hygiene (e.g., “people will think I didn’t shower because
I’m sweaty”); and its social consequences (e.g., “people are disgusted by my sweat”)
(Wheaton et al., 2011). These items show how sweating, perhaps because it often hap-
pens with fever, is so often associated with illness and disease, and therefore with the
protective reactions of fear and disgust (Curtis, 2001).
The treatment of fear and loathing of sweating is lost within the wider constructs of
social phobia and fear of social rejection. For many people with such a fear, blushing is
often the primary focus because of its autonomic immediacy and its visibility. Sweat-
ing takes a secondary position. However, for those who develop an emotionally main-
tained hyperhidrosis, specific beliefs may well be important. For a well-cited example,
Agnes Scholing and Paul Emmelkamp explored a typical cognitive therapy approach
of addressing the reality of dominant self-statements such as “blushing means that
you hide something.” (Scholing and Emmelkamp, 1993, p. 159). They step-by-step
helped people to test these beliefs and found them to be largely without evidence. The
problem that is often unexplored in standard cognitive therapy for social phobia is
that sweating does actually elicit disgust and avoidance. It is not an irrational belief.
People don’t like it. It is not clear how far the challenging of the veracity of beliefs
that have a strong basis in reality is helpful. Exploring the specific fear associated with
sweating—be it unwelcome scrutiny, public disapprobation, loss of personal control,
or even a fear of the consequences of heat loss—will be important (Moscovitch, 2009).
In some situations, however, sweating is considered normal. In exercise, for
example, sweating connotes hard work and application. In one qualitative study
using a group-memory technique, women discussed positive experiences of sweat-
ing within a context of mastery, control, and physical effort, an example of which is
worth repeating in full because it is a rare and rich evocation:

I start to pedal my exercise cycle and I feel comfortable and under-stretched. Push-
ing the pedals feels boringly easy and I’m convinced that I could continue at this pace

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indefinitely. After about ten minutes or so, I start to feel hot and a bit out of breath and
I can feel the sweat collecting on my forehead and my upper lip. The action of pushing
the pedals feels more difficult and I want to stop but I force myself to think of the good
it must be doing me. As I grip the handlebars I start to feel the sweat seeping between
my fingers and although this feels uncomfortable I take it as a sign that I am exercising
properly. I wipe my hand on my jogging pants, lift my tee-shirt and check my back for
sweat. I feel quite disappointed because it only feels damp and so I carry on at a faster
rate. Eventually I feel trickles of sweat running down my face and my back and I remind
myself again that this discomfort is worthwhile. When I check my back for the second
time it feels slippery wet and I experience a mixture of satisfaction and disgust. When I
stop cycling I head straight for the shower and enjoy the feeling of my heart beating fast
as I wash away the sweat.4

Unfortunately, for some, the disgust of sweating wins over the potential satis-
faction and benefits of exercise. For many people, in many communities, sweating
on exercise is seen as highly undesirable and something to be avoided (Lucas et al.,
2013). For example, in their review of barriers to exercise among older people, Karen
Schutzer and Sue Graves suggested that “sweating, labored breathing, and muscle
soreness typical during exercise is believed by some to do more harm than good.
Older women, in particular, were often raised to believe exercise is not ‘ladylike’”
(Schutzer and Graves, 2004, p. 1057).
The researchers do not provide evidence for this assertion, although I think it is a
commonly held view, often anecdotally reported. In a recent qualitative study one
woman remarked, “Some of us ladies were born at a time where girls didn’t sweat”
(Bethancourt et al., 2014, p. 15). A better understanding is needed of exactly why
sweating is experienced as undesirable for so many people, why it was constructed as
“unladylike,” how these narratives persist, and how stable they are.
As Val Gillies and her colleagues showed, it is possible for sweating to be con-
structed positively as socially and personally rewarding, but for many people “get-
ting hot and sweaty” may be a primary source of avoidance, not only of exercise
but even of the contemplation of exercise. Gordon Waitt argues that to understand
what is acceptable for bodily experience is dependent upon the place it happens.
He calls this, rather engagingly, “a geography of sweating.” The social meaning of
sweating matters, and the meaning is in part determined by its location. Sweating
during garden work, after sex, and in the gym, were all acceptable to his partici-
pants, whereas socially and at work it was the subject of disgust and horror (Waitt,
2014). The physiology of human sweating does not change very much. However,
the psychology of sweating is in constant flux. Sweating can be experienced as
intensely positive, coming at the apogee of human endeavor and success; it can
also be experienced as dirty, filthy, bestial, and disgusting, at the nadir of human
misery.

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 t he psychologic a l a m bigu i t y of he at

Hot flushes

The idea that sweating is not “ladylike” is odd when one considers the common
experience of menopause, in which sudden, unbidden changes in temperature and
sweating are signature features. Alterations in primary thermoregulation lead to
unwanted heat retention. Symptoms can last for many years and, although a normal
part of life, can have far-reaching detrimental effects (Politi et al., 2008). Symptoms of
menopause go beyond the classical hot flush, often extending to include pain, anxi-
ety, emotional lability, cognitive loss, and unwelcome bodily changes. But overheat-
ing and sweating, especially at night, are common complaints (Pimenta et al., 2012).
Myra Hunter has championed the view that the attitudes and beliefs that people
hold about menopause—its meanings, cause, consequence, controllability, and
social acceptance—are all at the heart of women’s experience. For example, with
colleagues she developed the Hot Flush Beliefs Scale as a tool to capture experience.
The final instrument has three subscales that concern negative emotion and social
acceptance (e.g., “When I have a hot flush I look stupid in front of others”), beliefs
about coping with hot flushes (“Other people seem to manage their hot flushes better
than I do”), and beliefs about how to cope with sweating at night (“When I have night
sweats, it is harder to cope the next day”) (Rendall et al., 2008, p. 164).
Like much health psychology, the focus can be on the negative. There is some evi-
dence that those who have a dominant belief of menopausal symptoms as negative
do experience worse symptoms. In a thorough review of the role attitudes toward
menopause play on symptoms, Beverley Ayers and colleagues found that holding
negative attitudes about menopause seemed to contribute to worse experience,
and vice versa (Ayers et al., 2010). Mind you, when you look at the list of symptoms
reported by Pimenta and colleagues, it is hard to find a positive story to tell. Lotte
Hvas did find some, although none were related to symptoms. When asked for the
positive, women in her studies reported the lack of anxiety over sex and pregnancy,
the absence of menstruation, and general aspects of confidence gained in older age
(Hvas, 2001, 2006). Being hot and finding it difficult to regulate body temperature
were uncomplicatedly negative.

The psychological ambiguity of heat

The psychology of temperature, at least as it relates to heat, is intricately linked with

the psychology of arousal. Many of the physiological systems of thermoregulation
serve multiple alternate functions in arousal, flight, and the social communication of
danger. Growing red in the face could signal anger, embarrassment, or re-warming
on a cold day. Sweating profusely could signal fear, menopause, or cooling. People’s
experience of being hot emerges directly from the social context of the heat. Because

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of the ambiguity of the communication of heat, it will demand scrutiny from others.
If I see you red-faced and sweating, I will automatically attend more closely to gather
further information on your needs, and determine whether I need to protect myself
from disease or aggression, or come to your aid. At times, the functions of thermo-
regulation can compete: in altering the movement of heat to and from the periphery
to maintain physiological homeostasis, one may expose oneself to undue attention
and negative social judgment, challenging self-protection.
The public display of thermoregulation will always, therefore, be a site of social
scrutiny and negotiation. The challenge for those who want to encourage people
to get hot and sweaty—for example, in public health campaigns of promoting
­exercise—will be to communicate positive contexts for physical sensations. For
many people, being encouraged to exercise means being encouraged to confront
physical self-disgust. Much of the health promotion and exercise encouragement
literature focuses on the science of motivation; it is interested in how to instill and
maintain goals of self-improvement and make concrete the abstract reward of
future benefits; it is dominated by theories of self-regulation and self-­determination
(Teixeira et al., 2012). Missing is a concern for the psychology of the body; in par-
ticular, for the thermoregulating body. We will need to understand how to con-
struct a positive framing of heat and sweat as nondisgusting, natural, and part of a
healthy response to movement and activity. Of course, this will mean countering
the significant marketing investment spent encouraging us to think the opposite.
The size of the global market in antiperspirants is in the order of US$13 billion
(Statista, 2014).

Being cold

For many people, however, sweating is not a daily concern. Staying warm and avoid-
ing the cold are basic human motivations. The cold kills. In England and Wales, for
example, there were 31,100 preventable winter deaths in 2012–13. Many of these were
due to cold stress, and, as shown in Figure 9.1, there is a clear relationship with tem-
perature drop (ONS, 2013). The main culprits, unsurprisingly, are cardiovascular and
respiratory compromise. Average winter temperatures in the United Kingdom rarely
go below 0°C for long, although in other countries this would be a mild winter. Inter-
view and lifestyle data from eastern Russia, where average winter temperatures are
around −7°C, show how important cold stress can be. Mortality below 0°C increased
by 1 percent for every −1°C (Donaldson et al., 1998).
For some people, however, cold can strike when the temperature falls well within
a normally comfortable range. There are many people who live feeling constantly
challenged by disorders of thermoregulation that throw them into sudden, often
unpredictable, episodes of being cold.

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 r ay nau d’s phe nom e non

Mean daily °C
deaths
Deaths in 2012/13 Five-year average deaths
2,000 20
Mean monthly temperature Five-year average temperature
1,800 18
1,600 16
1,400 14
1,200 12
1,000 10
800 8
600 6
400 4
200 2
0 0
Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul

Fig. 9.1. Average daily deaths and monthly temperatures in England and Wales in 2012/13 and
a five-year average. (Plate 3)
Reproduced from Office of National Statistics, Excess Winter Mortality in England and Wales,
2012/13 (Provisional) and 2011/12 (Final), 2013, p. 5, Figure 2, http://www.ons.gov.uk/ons/
dcp171778_337459.pdf © Crown Copyright 2013. This figure is published under the terms of the
Open Government Licence (http://www.nationalarchives.gov.uk/doc/open-government-licence/
version/3/).

Raynaud’s phenomenon

One of the most common vascular disorders related to the perception of cold tem-
perature is known as Raynaud’s phenomena, named after Maurice Raynaud, a French
physician who first described cold extremity damage and its relationship with gan-
grene. Today, it is often referred to as a disease, but is more accurately a phenomenon
associated with many diseases. Janet Pope, summarizing for the British Medical Journal,
defines Raynaud’s phenomenon as

an episodic, reversible vasospasm of the peripheral arteries (usually digital). It causes

pallor, followed by cyanosis and/or erythema, which can cause pain and, at times,
paraesthesia. On rare occasions, it can lead to ulceration of the fingers and toes (and,
in some cases, of the ears or nose). Primary or idiopathic Raynaud’s phenomenon
(Raynaud’s disease) occurs without an underlying disease. Secondary Raynaud’s
phenomenon (Raynaud’s syndrome) occurs in association with an underlying
disease—­usually connective tissue disorders, such as systemic sclerosis (SSc; sclero-
derma), systemic lupus erythematosus, rheumatoid arthritis, Sjogren’s syndrome, or
polymyositis.5

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 t e m pe r at u r e

The causes of primary Raynaud’s phenomena are often unknown but are thought
to be either genetic or environmental, with prolonged exposure to cold stress or
vibration. It is a surprisingly common problem. Pope (2013) reviewed the prevalence,
which varies between countries but could be as high as 6 percent, and is higher in
women than men.
The experience of secondary Raynaud’s is often buried within the challenges of the
primary disease. For example, Bernadet Sutanto and colleagues reviewed 46 studies
of the experience of people living with systemic lupus erythematosus. Temperature
changes are rarely explored in these studies (Sutanto et al., 2013). Perhaps because
of the dominance of other physical symptoms in the adjustment to a life-changing
polysymptomatic long-term disease, concerns about how to manage thermoregu-
lation are rarely, if ever, addressed. Dealing with cold temperatures is banished from
research consideration. However, if one specifically asks about temperature, people
do discuss it as a problem. For example, in one study of the unmet needs of 112 patients
with systemic lupus erythematosus, after pain and tiredness came the problems of
managing temperature changes. Sixty-seven percent of patients reported having
some or a moderate-to-high level of need when it came to coping with the cold, and
as many as 80 percent reported a similar level of fear that all symptoms would worsen
(Danoff-Burg and Friedburg, 2009).
Primary Raynaud’s is a classic case of an idiopathic disorder. It is common, unpleas-
ant, not generally very disabling, diagnostically relevant in only a small number of
cases, but a significant nuisance for many people who find the attacks of vasospasm
painful, worrying, and disabling. These types of high-prevalence, subclinical, idio-
pathic problems can be the cause of major if rarely calculated burden.

Cold comfort

What little psychological study there is of possible interventions for people with
Raynaud’s has focused on either specific aspects of symptom management or on the
broader issues of adjustment to, and support of life with, a chronic condition. In these
studies, Raynaud’s is only one part of another disorder.
In the early 1980s both cold and stress were identified as playing a role in trigger-
ing an attack (Freedman and Ianni, 1983). It became clear that emotional experience
seemed to matter, but it was not clear whether it precipitated an attack, or whether
emotional control could mitigate an attack. Kathleen Brown and her colleagues
explored this idea of stress further in their study of 313 people with primary Raynaud’s
and found that anxious thoughts were more relevant to triggering events in warmer
temperatures. Worry and anxiety were risk factors, but they may be hidden in studies
that focus on multiple risk factors in cold environments (Brown et al., 2001). There
was then both a physiological and a psychological case emerging for the role of

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 col d com fort

treatments that teach mastery of a possibly learned vasomotor response to arousal.

In short, biofeedback looked like it should be successful.
This population of 313 patients remains the largest study of patients with Raynaud’s.
These patients were entered into a randomized, controlled, multicenter trial of tem-
perature and EMG biofeedback. They followed a tradition of biofeedback studies in
which patients were taught methods of identifying when temperature changes were
happening in advance of an attack through observable changes in the skin. The idea is
to condition peripheral vasomotor function by either reducing the onset of vasocon-
striction or increasing vasodilation, often with the use of hand-warming.
Unfortunately, no treatment effects were found. It didn’t work. Or, to be fair, the
treatment was not able to work because people with Raynaud’s disease could not
master it. The authors reported that “the Temperature Biofeedback group . . . not only
had problems with learning basic hand-warming skills, but also had problems apply-
ing hand-warming skills to reduce RP [Raynaud’s Phenomenon] attacks” (Middaugh
et al., 2001, p. 274). The authors speculate on the possible reasons for biofeedback
failure.
Indeed, the literature on psychological interventions for people with Raynaud’s
phenomena has continued in this speculative vein. In a narrative review of the ten
available studies, all of which are small, except for the Middaugh study, the effects of
biofeedback are at best inconclusive, and more likely missing (Karavidas et al., 2006).
Research in this important area has stopped. A large negative trial may well have the
effect of closing a field of research, but unfortunately no further avenues of research
have been developed to replace it.
Although it needs to be further explored, the apparent inability of patients to mas-
ter biofeedback is intriguing. Middaugh and colleagues suggest that part of the prob-
lem with the failure of the treatment lies with the patients who approach it negatively:

A negative strategy, Denial, predicted less successful learning and early drop out with
temperature biofeedback (e.g., I act as though it hasn’t even happened). This suggests
that learning may be enhanced by instruction on coping skills to foster positive engage-
ment and counteract denial-associated withdrawal. (Middaugh et al., 2001, p. 272)

I suspect this interpretation misses the point. Given what we know about the modern
psychology and physiology of thermoregulation, it may just not be possible or even
feasible to learn how to control bloodflow in the periphery.
Nevertheless, there are at least three avenues of investigation needed before aban-
doning hope—or trying to change the patient to fit the treatment. First, what matters
in the movement of blood (and hence heat) to and from the periphery is not skin
temperature so much as core temperature. Temperature biofeedback that makes use
of changes in core temperature is potentially more relevant. Second, the overlapping
and interwoven relationship between thermoperception, emotion, and embodiment

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is only just being explored (Moseley et al., 2008). Central mechanisms that drive vaso-
motor function associated with bodily threat are a promising target for investigation.
Third, we have not really covered first base, in that we do not understand the experi-
ence of sudden loss of heat from hands and feet and when it is noticed. What is really
meant by denial? Perhaps what is meant is closer to what we saw with Alex Coode—a
state of being absorbed and an uncomplaining attitude. Qualitative investigation is
needed into the experience of people with Raynaud’s phenomenon and how bodily
sensation is interpreted.
To explore the idea of how the sudden onset of an attack of cold temperature feels,
I talked with Euphemia Graham (Box 9.2).

Box 9.2. Euphemia, living with Raynaud’s: “I guess I am learning all of the time”
Euphemia works in a large telecommunications company in a corporate leadership role,
but she worked originally in physiotherapy. She has had Raynaud’s disease, as she thinks
of it, for the last 12 years. I was particularly interested to learn more about her experience
of the onset and offset of an episode, and about how it has changed her attitude to life.

______________________________________

Chris: How long have you had Raynaud’s?

Euphemia: I first noticed it about ten years ago. I was working in an air-conditioned gym.
When I left and got into my car I started to have bad attacks. I knew about Raynaud’s
because I had worked with patients with it, but I didn’t really think about it for myself
until those first attacks when I was driving home. Now my Raynaud’s is quite bad.
Chris: What does “quite bad” mean? Talk me through an attack.
Euphemia: It means that my fingers lose all their sensation and go white and I can’t feel
them. I just have total loss of sensation. I don’t really know where they are in space. What
“bad” to me means is that I can’t feel them. If I go for a shower, it is as if they are not mine.
I can’t wash or scrub my hair or do anything. I can move them around my body but I
can’t feel them in the same way. And then after an attack it takes quite a long time, about
20 to 30 minutes, before it starts to get better. If I want to go onto my computer and start
working, there is no chance of that happening because I can’t type. It feels like I have very
fat fingers so it just feels like I am slapping the keyboard.
Chris: How disabling can it be?
Euphemia: It is disabling in the instant because you can’t do the things you want to do. It
feels like you’ve got somebody else’s hands. It is odd. There is no way I can do anything
intricate. I also don’t trust myself because I don’t know the temperature of things, so

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Box 9.2. Continued

there is a risk involved. One of the things I want to do when I am cold is run a nice warm
bath, but I couldn’t tell with my hand whether the bath is hot or not.
It can be very annoying, but at least I know it is going to go away. Other people have
much worse things to deal with. And I tend to think it was my own fault because I did
not look after my hands when I was younger. I know I didn’t. When I was younger I used
to ride horses a lot, but that would be more difficult now. Not just the riding, but looking
after the horses. Simple tasks like undoing the buckles on the bridle or loosening the
girth, would be really hard and sometimes impossible if I could not feel my hands.
Chris: Are there times or occasions that make it worse?
Euphemia: Almost you can say that it is the twilight of each season—that is the danger
because you don’t notice the change in temperature. When you are in the season it is
fine. I probably get more bad attacks in autumn on a sunny bright day when it is cold but
I still think it is summer and I am not wearing my gloves, whereas once I have got into
the middle of winter I wouldn’t dream of going out without gloves. I like the seasons to
change; I just have to try and get better at it.
Chris: Has it changed the way you think about clothes?
Euphemia: Yes, I am very aware. I really like to look nice, but the overriding decision is
that I have to either be warm or not get too hot. So if I am going to a summer wedding, I
would hate to be sweaty and hot, and I don’t like to get too cold. So I do now pay much
more attention. So now for example at work I only have to get from the car to my office
five minutes away, but I would always get a coat to make that small journey because
otherwise I know I am risking having an attack when I get into the building. So I try to
be sensible.
And I have gloves everywhere, everywhere I go, in the car, in my bags, everywhere. I have
got so many pairs. And I now think about what clothes are made of. I buy cashmere if
I can because I know it is going to keep me warm; man-made fibers don’t keep you as
warm.
Chris: Some people think of being spontaneous as romantic. Is that spontaneity denied
to you?
Euphemia: It is just planning. Once you start having the attacks regularly, and you lose 20
or 30 minutes of your life at a time, it is quite annoying because you can’t do what you
want to do for quite a while so you start to think, “What can I do to prevent it?” So this
romantic spontaneity you speak of is not worth the disability.
Chris: Is there anything positive that has come from your experience?
Euphemia: I don’t think of it as negative. We are all going to get something and if this is it,
then that is fine. I do try and tell people to look after their bodies when they are young.
Not just around hand care. We joke about young people thinking they are indestructible.

(Continued)

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 t e m pe r at u r e

Box 9.2. Continued

I am sure I was like that. I try to tell my daughter that you should look after your hands
because you are going to need them for the next 70 to 80 years. Nobody ever said that to
me. They were just there to be used. I just took them for granted that they would always
be there. It is also positive, I think, when it comes to clothes. I definitely have more hats
than I ever thought possible. And it has given me the confidence to wear them. It is not
a fashion statement because I am wearing them to get warm, but I get to wear some
great hats.

______________________________________

Living with the possibility of sudden severe cold stress for Euphemia at least is partly
controlled by a new regime of secondary regulation that is based on detailed planning,
situational awareness, and clothing choice. Not spontaneous but effective. Not men-
tioned, however, is any strategy of thinking about bodily sensation and how warm one
is. Denial? No. I would call it a determination to plan and to not let the cold matter. We
need a new psychology of chronic thermoregulatory disorders that accounts for beliefs
about temperature, how we naturally adapt to challenges of heat and cold—one that is
sensitive to the social meaning of heat and cold in context.

Summary

Secondary thermoregulation has been largely ignored in psychology. A psychology

of temperature is needed that seeks to explain how protection from cold and heat
stress is achieved. This psychology will range from the psychology of clothing to
embodied cognition. Deciding to adjust clothing can be a life-or-death decision, but
we know very little about this common behavior. Equally, we know very little about
the uncommon behaviors, such as how firefighters make decisions. We can learn a lot
from people who inhabit extreme temperature environments, and from those who
struggle every day to regulate their temperature. Psychology has neglected thermo-
regulation. We are constantly making decisions that change our body temperature.
Needed is a practical psychology that can improve health interventions both to pre-
vent excess winter and summer deaths, and to treat those struggling with seemingly
out of control extremes of body temperature.

Notes

1. Reprinted from Neuroscience & Biobehavioral Reviews, 34 (2), Raf J. Schepers and Mat-
thias Ringkamp, Thermoreceptors and thermosensitive afferents, p. 177, doi:10.1016/j.
neubiorev.2009.10.003 Copyright (2010), with permission from Elsevier.

196
 su m m a ry

2. Reprinted from The Lancet, 349 (9062), The Eurowinter Group, Cold exposure and winter
mortality from ischaemic heart disease, cerebrovascular disease, respiratory disease, and
all causes in warm and cold regions of Europe, p. 1344, doi:10.1016/S0140–6736(96)12338–
12,332 Copyright (1997), with permission from Elsevier.
3. Reprinted from The Lancet, 349 (9062), The Eurowinter Group, Cold exposure and winter
mortality from ischaemic heart disease, cerebrovascular disease, respiratory disease, and
all causes in warm and cold regions of Europe, p. 1345, doi:10.1016/S0140–6736(96)12338–
12,332 Copyright (1997), with permission from Elsevier.
4. Reproduced from Women’s collective constructions of embodied practices through mem-
ory work: Cartesian dualism in memories of sweating and pain, Val Gillies, Angela Harden,
Katherine Johnson, Paula Reavey, Vicki Strange, and Carla Willig, British Journal of Social
Psychology, 43 (1), p. 109, doi:10.1348/014466604322916006 Copyright (c) 2004, John Wiley &
Sons, Inc.
5. Reproduced from Janet Elizabeth Pope, Raynaud’s phenomenon (primary), BMJ Clinical Evi-
dence, 10, p. 1119 © 2013, BMJ Publishing Group Limited.

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 CHAPTER 10

APPETITE

W e need fuel to live. As a general guide, each adult needs to source more than
2,100 kilocalories each day to sustain function. For many people, 2,100 kilo-
calories of energy are extremely difficult to achieve and daily life is spent in hunger. To
be more precise, according to the United Nations World Food Programme the num-
ber of people in food poverty is 805 million or 1 in 9 people (World Food Programme,
2014). Hunger is typically defined as both a physical discomfort caused by lack of food
and the drive to find food. Appetite is best thought of as the embodied urge, want,
need, drive, or desire to consume food and drink.
Appetite is perhaps an unusual choice for a focus on neglected physical sensations.
After all, there is no shortage of academic and popular discussion about wanting for
food and drink. In fact, today our relationship with food and drink is a major source
of debate. What has been neglected, however, is a focus on the experiences of needing
and wanting. What does it feel like to be distracted by the physical pull toward food?
I review briefly the physiological and anatomical mechanisms of appetite, and then
discuss the broader social and political expression of appetite in a world in which
food and water are scarce resources. Next, I consider the psychology of appetite
with a focus on how appetite functions in the normal case, and in a variety of abnor-
mal cases. Throughout, I deliberately avoid any consideration of taste and smell. Of
course taste and smell are important, but I judged them less neglected in terms of psy-
chological research. They are already well studied. My focus is on this felt experience
of the desire to consume.
I sought the help of two people who are experts in appetite. First, I spoke with Jean
Christophe. He is a chef and restaurateur who lives surrounded by the objects of his
desire. Second, I spoke with Tom. Tom is a professional jockey. In order to ride he
needs to make a weight of under 150 pounds, which means that he must regularly stay
undernourished and reach a body mass index of 18.5. For him appetite is a complex
subject, a balance between the desire to eat and drink and the desire to win.

Appetite regulation

Appetite is only one part of a complex set of conditions that structure how we eat and
drink, including habit, emotion, availability of food, and other people. All of these
influences determine what and when we consume. In particular, appetite functions

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sometimes as a signal to seek food and drink. At other times it operates as a check
during eating or as a signal to pause or stop altogether: these stop signals can then
provoke food avoidance even when there is more that could be consumed.
There are peripheral sensory mechanisms that operate in specific phases of eating,
from olfactory preparation triggering local changes in mouth and stomach, to the
experience of stomach pressure discussed in Chapter 4. However, unusually for the
physical senses, more research attention has been paid to the involvement of endo-
crine and central nervous systems. Appetite is best considered as a function of two
related systems that involve the peripheral, central, and psychological influences.
These two appetite systems can be described as homeostatic and hedonic.
Homeostatic appetite manages biological energy reserves. This system operates
outside of awareness to manage the storage and release of energy. Critical to this
system is the signaling from adipose tissue. Emerging as particularly important in
the homeostatic drive to consume are the hormones leptin and ghrelin, which are
in constant circulation (Lutter and Nestler, 2009). As with other aspects of urge, the
hypothalamus is centrally implicated in the regulation of appetite. Neuropeptides
released by neurons in the hypothalamus underpin homeostasis in promoting or
reducing feeding behavior (Parker and Bloom, 2012).
Hedonic appetite, as its name suggests, is also under the control of neural mecha-
nisms; not those that drive need, but those that drive reward and pleasure. This
hedonic system is attracting more research interest because of its prominent role
in theories of food consumption and obesity in societies where dense and energy-
rich foods are plentiful. Eating beyond any homeostatic benefit is thought now to
be reward-based, operating partly under the influence of both the opioid and dopa-
mine systems. Hans-Rudolf Berthoud summarizes the two dominant theories of
overeating. The first he pejoratively calls the gluttony hypothesis and refers simply to
overeating, producing more dopamine-mediated pleasure. The second he called the
deficiency hypothesis: that one’s appetite drives overconsumption due to a pleasure
regulation strategy of increasing dopamine through repeated stimulation (Berthoud,
2011). There is evidence that fits both hypotheses but none currently that discrimi-
nates between them.
Homeostatic and hedonic influences on appetite do not operate in isolation; a
rich area of research investigates how they interrelate. Maximizing signals used in
homeostasis may be essential in counteracting hedonic drive, and likewise a bet-
ter understanding of what governs hedonic drive could be enough to “override
homeostatic control” (Harrold et al., 2012). The extent to which these two systems
interact at a psychological level has not been well investigated. Berthoud argues,
perhaps simplistically, that by physiological definition, eating past the replacement
of energy supplies has to be hedonic as it no longer functions to maintain homeo-
stasis, and may actually put an organism at risk. However, these dual evolved sys-
tems of appetite mean that we are living with many paradoxical effects of appetite.

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 pow e r

The world is replete with examples of how appetite can operate in a nonrational
or illogical way. The case exemplars are of the reports of loss of appetite in starva-
tion, and the report of great hunger in the obese. To understand appetite we need
to understand the core experience of hunger and thirst—the experience of being
driven to consume.

Power

Unique to appetite as a neglected sense is its relationship with power. Appetite func-
tions to promote a search for food and drink. But food and drink are scarce resources
that are not universally available. In general, our access to gravity, space, and breath-
able air are not under central economic control; similarly, avoidance of itch, pain, and
fatigue are not rationed among us. None of the targets of these urges are as scarce,
potentially unobtainable, or socially mediated as nourishing food and clean drink-
able water. Imagine a world in which gravity was a scarce resource to be shared, or in
which breathable air was available only to eight out of nine of us. Imagine the political
significance they would take on, and the economy that would develop around them.
A useful definition of power is the control over a shared resource. In this sense, appe-
tite is always an expression, however unwittingly, of power in action. The provision
and consumption of food is always under political influence, often the macro polit-
ical, but also the micro political of everyday negotiation.
From the day we are born appetite ties us to others, to those who can choose to feed
and water us, or choose not to. The relational aspect of appetite is core to its experi-
ence. And the idea that one can choose to satisfy appetite is part of that experience
of power. The choice to feed oneself or to feed another is a political and social act.
We can see this in evidence in extreme and abnormal cases. For example, starvation
is a common form of torture; it is used to debase, as a means to dehumanize. Ray
Tallis, for example, argues in his philosophical discussion of hunger, that although
we appear more bestial in starvation, it is the knowledge of our behavior, even in self-
observation, that grounds us. Reflecting on accounts of survival of Nazi death camps
in Auschwitz, he says:

What happens to us when we are savagely hungry seems to be a kind of critique of all
those aspects of ourselves we take pride in as human beings. The knowledge that one
would fight to protect one’s full plate while others have empty ones, that one would
hoard food while others around one are dying—glossed as prudence—remains as a
guilty shadow at the heart of one’s self-esteem.1

Withholding food and drink with the aim to starve is torture. However, resisting
or refusing food for oneself is also a political act, one that is highly challenging to

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others. Often it arises within a context of reduced options for control, as in the case
of a hunger strike. The political power of the hunger strike comes from its transgres-
sion, from its social defiance, from its visibility. In the language of social science, it is
performative, acted, and communicated. It must be visible and known.
In rare cases, self-starvation is not constructed as a political act but instead as an
abnormal psychiatric act. For an interesting example, Fiona McNicholas and her col-
leagues in Ireland described an unusual and extreme case of “pervasive refusal” in
which an eleven-year-old girl, “J,” ultimately became hospitalized as her homeostasis
was put at risk:

After a total of 18 months in hospital J had shown no response to any intervention pro-
vided. During the latter nine months of this admission she had refused to eat, drink,
engage in self-care or communicate in any way with staff, other patients or family. (Mc-
Nicholas et al., 2013, p. 140)

J eventually had a “flight into health” when presented with a referral to a foreign spe-
cialist unit. The case is interesting in itself, but here the very fact that food refusal can
be used in such a way emphasizes its political role in social control when there are few
avenues of independent control. These are extreme examples of a common feature of
appetite—the suppression of appetite for a higher goal. But for a psychology of appe-
tite, it is important to remember that embodied desire is always a social expression of
human interdependence; it is always relational.

Setting priorities

Like being tired, cold, or in pain, appetite imposes a motivational priority. When we
are hungry or thirsty, or are presented with the option of feeding, appetite can win
out over all other drives. What governs that priority and what predicts eating behav-
ior are major preoccupations in psychology. The literature is mostly concerned with
modern dilemmas of hedonic or controlled eating. Chief among them is the current
concern for eating disorders, the most common of which is obesity. The prevalence
of obesity in adults in the United States, defined as a BMI over 30, is now 35.5 percent
in men and 35.8 percent in women (Flegal et al., 2012). Similar prevalence data have
been reported in Europe (Gallus et al., 2015). The psychology of appetite has become
important as never before. When food is scarce, overconsumption is only a fantasy.
However, when energy-rich foods are easily within reach, mass obesity may become
a reality. Jo Harrold and colleagues state the nature of the problem very well:

We occupy a world of abundant and heavily promoted highly palatable and energy
dense food. In this situation obese individuals possess an over responsiveness to the

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pleasures of eating which appears not to be quenched by the physiological conse-

quences of ingestion. In effect their appetite system appears overwhelmed. (Harrold
et al., 2012, p. 3)

For psychology to be relevant to the study of obesity, we need to offer explanation for
the role of wanting, desiring, and craving in the promotion of food search.
Less common, but also often seen in food-plentiful societies, is the problem
of food avoidance or refusal, clinically presenting as versions of anorexia dis-
orders. Appetite or craving may actually be diminished in those with anorexia
who restrict all food intake (Veensta and de Jong, 2011). But, anorexia is not really
about appetite. Appetite is merely a casualty of attempts at control and perfec-
tion. For example, Sarah Williams and Marie Reid analyzed how people with
self-defined anorexia nervosa relate to food and their sense of self. They found
that people were mainly concerned with personal control and with perfection.
In general, people with anorexia framed hunger positively as a form of experien-
tial avoidance: they talked about hunger being useful because it stops one from
thinking about the pain of rejection and loss (Williams and Reid, 2012). It may
simply be that the meanings of craving, desire, want, and need are altered to sig-
nify broader personal challenges. Hunger becomes less about food and is instead
captured—kidnapped, if you like—and used to function as a vehicle of denial and
control. In this sense resistance to appetite serves an overall emotional purpose
of self-protection.
These are abnormal cases. Extreme, deliberate undernourishment or overnour-
ishment fall at the limits of the distribution of food and drink behavior. Perhaps
more common, but less investigated, are the interesting everyday expressions of
appetite in those who don’t have an eating disorder. What role does appetite play,
for example, in those who manage hunger and thirst as a pleasurable desire, and
those who resist the urge to ingest as part of a regular strategy of diet or weight
control?

The pleasures of desire

Hedonic appetite—the desire for food for pleasure, beyond homeostasis, beyond
the provision of fuel and hydration—is a core part of modern eating and drinking in
wealthy societies. Hedonic it may well be, but it is not at all clear that we understand
what the pleasure of appetite is. David Mela has tried to explore exactly this ques-
tion by proposing a stronger distinction between food “liking” and food “wanting.”
He reflects that most animal studies, and many human studies, don’t study pleasure
but actually study preference. Typical paradigms involve a choice between competing
rewards, from which one assumes liking from the choice that is labeled a preference.

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For humans, the hedonic question is whether one is motivated by the pleasure of lik-
ing or by the wanting of food. This distinction may be crucially important, because
the wanting of food is under the control of a range of learned cognitive and emotional
associations, which are different to those for the liking of food. These associations are
those most used in marketing and advertising. Rather engagingly, in this argument
Mela allows himself a moment of criticism of the moralistic tone that he believes per-
vades the science of eating behavior, and in particular the science of obesity:

There is a subjective element of Calvinism colouring even professional discussions of

food pleasure, an unstated expression of the view that “If it tastes nice, it must be bad for
you.” Valid or not, from the perspective of evolutionary biology this is certainly a mod-
ern and unnatural view of the mechanistic links between food selection and nutritional
requirements. More worrying is that this also positions pleasure as a foe, rather than a
potential ally of healthy eating behaviours. The corollary, “In order to be good for you,
it cannot taste nice” will assuredly get us nowhere in making progress toward attracting
consumers to a healthy, balanced food choice and intake.2

How we come to decide whether we want or like certain substances is a source of

much psychological interest. There is clearly huge variability in our appetites and
we are used to expressing our like or dislike of certain foods. Consider the broad
differences in diets across the world. In China, for example, the staples are rice and
noodles, while in northern Europe it is the potato, although for most of the world
it remains maize. But there are some foods that people actively avoid, even when
others seek them as a delicacy. For example, how fond are you of fried cricket or
the protein-rich pupae of the silkworm? The Western rejection of insects, many
of which are commonly eaten across the world, has been a stubborn population
avoidance that has so far resisted any public policy attempts at change. Alan Yen, for
example, reminds us that “apart from Europe and North America, approximately
1500–2000 species of insects and other invertebrates are consumed by 3000 ethnic
groups across 113 countries in Asia, Australia, and Central and South America” (Yen,
2009, p. 290). Attitudinal barriers to the selective consumption of insects in the West
are well established, and Alan Yen does a good job of explaining the many benefits of
voluntarily introducing insects into our diet. He accepts that it is going to be a hard
sell. As Mary Roach puts it in her excellent book Gulp, “Culture writes the menu”
(Roach, 2014, p. 53).

Eat your greens

How do you encourage people to eat and drink things they judge unappetizing or
even disgusting? Many of us have had the experience of attempting to persuade

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a reluctant child to eat something they don’t want to eat. Indeed, many of us were
those reluctant children—and some of us remain reluctant adults. For a dominant
example, eating adequate amounts of fruit and vegetables is considered protective
against vascular diseases (Steffen, 2006). Despite many public health campaigns on
the value of eating fruit and vegetables, the average consumption remains low. In an
American survey undertaken in 2000, the percentage of people meeting the WHO-
recommended level of consumption of five 80-gram portions of fruit or vegetables a
day was 40 percent. Adolescent boys achieved the lowest consumption—at a remark-
able 0.7 percent. This figure means many consumed none (Guenther et al., 2006).
This is a stubbornly stable finding, not changing very much over time, geography, or
generation, and has been repeated in a variety of U.S. studies. The State of the Plate
review in 2010, for example, showed no change: “Fruit and vegetable consumption
has remained quite stable at just under 2 cups per person per day across the total
population since 1999” (State of the Plate, 2010, p. 11). An interesting observation of
those interested in obesity prevention is that figures such as these often include fruit
juice and fried potatoes. These data are not peculiar to the United States. Global data
show similar patterns, with countries such as Pakistan having diets that are almost
vegetable-free (Hall et al., 2009).
There are many studies of the potential reasons for fruit and vegetable avoidance.
The factors implicated range from social and economic barriers to ethnic and cultural
history, social modeling, and habit. In a systematic review of all of the psychological
attempts to change eating behavior and increase the consumption of fruit and veget-
ables, it was judged that it is possible to increase self-reported consumption of fruit
and vegetables. However, the changes achievable are quite small: across all of these,
fruit and vegetable consumption increased by an average of one serving a day. This
modest increase shrinks to below half a serving a day for adolescents (Thomson and
Ravia, 2011).
So children don’t eat their greens, and it is hard to make them. Perhaps that is
hardly news. Parents have a significant role in shaping the context in which food
attitudes and beliefs are developed. The purchasing, carrying, storing, preparing,
and consuming of food are all modeled repeatedly and often in the home (Birch and
Fisher, 1998). What doesn’t positively influence behavior is direct assertive parental
­instruction—saying “Eat it!” in a shrill or loud voice. Julie Lumeng and her colleagues
at the University of Michigan, as part of a larger study in child development across
ten sites in the United States, videotaped children and mothers discussing a snack
that was introduced. They observed 1,218 young children (15, 24, and 36 months old)
and their mothers for ten minutes, and coded all of the mothers’ interventions, from
encouragements to instructions. The researchers found that the use of “assertive”
and “intrusive” eating instructions were associated with greater adiposity in the
child (Lumeng et al., 2012). Although there was nothing green in the snack offered
in this study, the general findings are rather startling when it comes to nutritional

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awareness. It seems that knowledge and skills in motivating, directing, encouraging,

or negotiating positive eating are not common. In fact, the State of the Plate study
even argued that these are in decline, with generation-Y mothers in the United States
less knowledgeable than ever about the appropriate portions of fruit and vegetables
recommended for their children.
Conspicuously missing from the forest of papers on public health and psycho­
logical interventions aimed at altering eating behavior is any consideration of what
David Mela (2006) called liking and wanting. It is almost as if the psychology of eat-
ing has lost sight of the importance of the experience of consuming, not only taste,
but its effects on appetite, on desire. Psychological theories tend to focus on social
and personality determinants of behavioral choice within a specific context. The few
studies there are on pleasure show that when it comes to answering the dominant
social question—“Do you like this?”—the answers do indeed revolve around beliefs
about texture and appearance, as well as taste (Zeinstra et al., 2007). Hedonic experi-
ence and how it can be altered with information hold the greatest interest for those
who are trying to influence our consumption, those who are trying to get us to switch
to their products and consume more.

Lipsmackinthirstquenchinacetastinmotivatingood­buzzincooltalki
nhighwalkinfastlivinevergivincoolfizzin Pepsi

Significant investment goes into influencing our hedonic judgments about food
and drink, with advertising drawing on qualities that go well beyond the taste. This
commercial from the 1970s is an iconic example of the trade. One could describe a
carbonated flavored sugar drink in simpler terms, but this innovative and humor-
ous approach packs in multiple associations that accentuate both the characteris-
tics of the drinking experience (fizzin) and prime desirable social attributes (fastlivin).
Aradhna Krishna has led this field in studying the use of sensory characteristics
outside of taste to promote consumer experience. She calls it “sensory marketing.”
The experience of purchasing and consuming is a multisensory one. From the
unwrapping of a chocolate to the crackle provided by carbonation of water in a
soda drink, all, she argues, are crucial to the experience of consumption inasmuch
as they give structure, purpose, and focus to appetite, and guide purchase or con-
sumption behavior (Krishna, 2012). She is beginning to unravel how the founda-
tional metaphors, such as height, weight, and temperature, discussed in studies of
embodied or grounded cognition, can be used in consumer psychology (Krishna
and Schwarz, 2014).
The efficacy of such marketing strategies in influencing consumption is not
in doubt. Less clear is whether the experience of food information can actually
change the experience of the food, including one’s hedonic appetite. In other words,

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marketing can clearly change our wanting behavior, but can it change our liking
behavior? Important here is not just the influence on taste but also the influence on
the desire for more, and on judgments of satiety.
Jeffrey Larson and his colleagues took a novel approach to studying the influence
of marketing on appetite. They recognized that there had been very little interest in
the potentially saturating effects of the high volume of food and drink advertising we
are exposed to on a daily basis. In two experiments, they asked students to actively
consider and evaluate images of food. One group viewed 60 images and another only
20. All of the students evaluated how much they liked the food, and how appetizing
they found it. The idea was that those exposed to three times as much “considering
and evaluating” of food images would behave differently when faced with that food.
Immediately following the image evaluation, the participants were given three pea-
nuts and asked how much they enjoyed them. Intriguingly,

as participants evaluated more salty foods in pictures, their enjoyment decreased when
subsequently eating a different salty snack of peanuts. This happened even though par-
ticipants never saw a picture of peanuts, and they were never instructed to think about
consuming peanuts (or any other food). (Larson et al., 2014, p. 190)

Perhaps an unintended consequence of overexposure to food images is the stimu-

lation of satiety. If food is thought plentiful, wanting is reduced. Equally speculative
is the idea that this is simply a function of scarcity. The value of the peanut is reduced
because it is presented in a salted food–rich context. Larson and colleagues argue,
with a supporting second experiment, that what matters is that participants had to
actively imagine food, and that this operates through provoking judgments of satiety
and so reduced pleasure.
How you describe food, and how often you are exposed to and consider those
descriptions can matter. As well as making recommendations to marketers about
possible counterintuitive effects of communication, Larson and colleagues offer
advice to all of us. Perhaps, they suggest, people “might benefit from limiting their
sensory simulations before eating with the potential result that food may become
more enjoyable” (Larson et al., 2014, p. 193). Too much research on a food blog or
restaurant review website might reduce your pleasure. An optimal “hedonic strategy”
for food is to spend as little time considering it as possible until the moment of food
choice.

What’s on the menu?

That moment of food choice is critical to those who want to provide the best pos-
sible experience of eating and drinking, to chefs, restaurateurs, and food writers.

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Brian Wansink and colleagues focused exactly on the moment of food choice in a
restaurant. They were interested in whether the description of food on the menu
could affect not only the wanting but also the liking—in other words, whether see-
ing something more extensively described makes any difference to the pleasure
of its consumption. In an interesting field experiment, Wansink and colleagues
manipulated menus in a canteen. Some people had menus that were merely descrip-
tive, whereas others, on different days, had menus that were more expressive. The
choices were:

Traditional Cajun Red Beans with Rice (vs. Red Beans with Rice), Succulent Italian Sea-
food Filet (vs. Seafood Filet), Tender Grilled Chicken (vs. Grilled Chicken), Homestyle
Chicken Parmesan (vs. Chicken Parmesan), Satin Chocolate Pudding (vs. Chocolate
Pudding), and Grandma’s Zucchini Cookies (vs. Zucchini Cookies). (Wansink et al.,
2005, p. 395)

The diners were asked three questions about their experience: how good the food
tasted, how sated they felt, and how appealing the food looked. The first finding was
that more words produced more words. Twice as many positive comments were
received about the meals that were described expressively. Diners also reported that
the expressively described food was more appealing and tasted better, but did not
report it as more filling (Wansink et al., 2005).
Once we are in the realm of hedonic appetite, it seems that the exact experience
is highly sensitive to external cues, and can be manipulated by information and
expectation. Perhaps the best scientific expression of this was given by Martin Yeo-
mans, working with the chef Heston Blumenthal. Together with Lucy Chambers
and Anthony Blake, they created what they hoped would be everybody’s favorite
new dessert: smoked salmon ice-cream. They were interested not so much in
whether one can enhance experience by describing it in a more evocative way, but
what exactly the role of food expectation was. They used a method of priming for a
sweet experience by describing something as “ice-cream” and providing a conflict-
ing and countercultural (at least in England) experience with a “salted fish” ingre-
dient. The results are shown in Figure 10.1. When the same food was described as
“smoked salmon ice-cream,” it was rated as less pleasant and more salty than when
it was described as “frozen savory mousse.” In repeated experiments this finding
held strong. We expect ice-cream to be sweet, and we don’t like it when it is not
(Yeomans et al., 2008).
The food and drink industries are getting more interested in the idea that percep-
tion can be influenced by the cognitive and emotional context in which the food
is presented. We are only just beginning to explore how the description, labeling,

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A) Pleasantness B) Salty
250 500

200 400
Rated pleasantness

Rated saltiness
150 300

100 200

50 100

0 0
Ice-cream Frozen savoury Ice-cream Frozen savoury
mousse mousse
Food label Food label

C) Flavour strength D) Bitterness

500 350
300
400
Rated flavour strength

250
Rated bitterness

300 200

200 150
100
100
50
0 0
Ice-cream Frozen savoury Ice-cream Frozen savoury
mousse mousse
Food label Food label

Fig. 10.1. Rated characteristics of salmon-flavored food presented as either “ice-cream” or

“frozen savory mousse.”
“Rated pleasantness (A), saltiness (B), strength of flavor (C) and bitterness (D) of smoked salmon
ice-cream depending on whether this was labelled as frozen savory mousse or ice-cream. Data are
mean ± SEM.”
Reprinted from Food Quality and Preference, 19 (6), Martin R. Yeomans, Lucy Chambers, Heston Blu-
menthal, and Anthony Blake, The role of expectancy in sensory and hedonic evaluation: The case of
smoked salmon ice-cream, pp. 565–73, Figure 1, Copyright (2008), with permission from Elsevier.

presentation, and other nontaste characteristics of consumption can be used to alter

appetite and consumption. Can we stimulate desire or increase avoidance with the
simple use of an adjective such as succulent or the presentation of a dessert menu at
just the right time?
To explore the idea of how we manage expectations around food and drink, I talked
to Jean Christophe Slowik (Box 10.1).

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Box 10.1. Jean Christophe, the restaurateur: “I love what we serve

and we serve what I love”
Jean Christophe is a celebrated chef who lives surrounded by the objects of his desires.
He is passionate about food and about the social experience of eating and drinking. We
talked at his restaurant L’Absinthe, in Primrose Hill, North London

______________________________________

Chris: Is there a difference between eating because you need to and eating because you
want to?
JC: I think so. We see it often in the restaurant. Because of the size of portions we serve,
when people have two courses they have more than their share of what they need. Then
the pudding [dessert] becomes interesting. One out of three times we give the pudding
menu and people say, “No. But maybe I will just look.” They are not hungry anymore.
Then they look at the menu and see something they are interested in. Then they will find
the space. They do not need it. But most of the time it is, how can I say, they are interested
and want to experiment a bit more. They want to try something they have wanted for
a long time, or something they have an urge for. So pudding is always more to do with
desire than need. I don’t think anybody ever really needs pudding when it is part of a
three-course meal, not in the way you mean “need.”
Chris: How do you influence that desire? Does description matter?
JC: I don’t like to overdescribe. You go to some restaurants and there are four lines
explaining where the potatoes come from, where the garlic they use in the sauce comes
from, and they are all fancy names from fancy farms. Because of the school of thought
from my upbringing, my training, I believe that you cannot have a restaurant if you do
not deal with good produce to start with. So there is no need to go into the detail of
source, because the bottom line is: if you are passionate about your job, you are only
going to get the best.
I understand that the label matters, but I have decided that we do not need to do this.
The restaurant will do the talking. There is no point of fancying it all up. It is about the
substance. If you do all that and there is no substance, then you fail anyway.
Chris: But doesn’t expectation matter?
JC: I have thought about expectation a lot. The lower the expectation then the greater
the pleasure. The higher the expectation the lower the pleasure. Most of the time people
come in and discover us and then come back. We have a higher rate of return on walk-
ins than on bookings. Because the bookings have read about us or researched us, or a
journalist has sold a specific experience, and they expect exactly the same. People who
walk in from the street are more interested in what they find.
Chris: Do you experiment with the menu?
JC: I try to experiment, but once you are on a path it can be very difficult because it is
hard to twist. You want to twist, but every time you twist you have to twist back. So we

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Box 10.1. Continued

very rarely change the menu, because for us quality comes in repetition. The more you
do the dish the better the dish becomes. If you change the dish every day, it is very hard
for the chef to do that well. But we change three or four times in the year. We can’t have a
long menu. The only way you get quality out of a small kitchen is to have a small menu.
Sometimes people ask for what is not on the menu. I can’t do that, because I cannot
guarantee the quality. We will get lost. I always find a long menu very suspicious in a
restaurant because you have to ask: how is that possible?
Chris: Have you tried to offer a wider French cuisine, for example, with the use of offal?
JC: We tried. We wanted to do French cuisine with British produce. So we tried to bring
some offal on the table. And it was a disaster. We made andouillette—tripe sausage.
Try to get a British person to eat tripe sausage! Or tripe, full stop! It is not produce that
British people eat.
Chris: We used to eat offal. Who sets these cultural expectations on what is possible?
JC: It must be a slow process of revolution of the generations. We are the middle gen-
eration where some of us eat offal and some do not anymore. Maybe in 20 years time
it won’t be seen. People will think us strange. Perhaps people think they have bettered
themselves. We all want to better ourselves. So they do not need to eat that sort of food.
You have gone up one notch in society and now you can afford to have the pork chop.
This probably is a class issue, more so in this country.
Chris: So it is not about the taste or about appetite.
JC: No, completely not. No: it is the idea. If I said to someone, You can have a plate of
tripe, it is irrelevant to how it is going to be prepared. He will not like it.
Chris: You are surrounded every day by the food and wine of the highest quality that you
have chosen. Is that a temptation?
JC: Oh, no, it is very easy. It is like when you start in a chocolate shop. They make sure
you eat as much chocolate as you can. Once you are sick of it you don’t touch it any
more. In the restaurant, professionalism takes over very quickly. We have to eat before
the service. So we eat at 11:30 in the morning. And 5:30. So when you are providing the
food, you are either not hungry or you are too busy to eat.
Chris: Does working with food and wine change your desire and pleasure?
JC: No, it doesn’t. What it does change is your standard. It goes up and up and up. Take wine.
So if I started at the bottom of the range: I used to drink house wine and I thought that was
quite good. Then maybe I shifted to the Côtes du Rhône. Now that has become my norm.
Now the Gevrey-Chambertin has become the norm. So my taste has gone up. Now my
everyday wine has become a higher standard. I can afford it. I don’t mean financially—I
mean I can now appreciate it, appreciate the difference. Obviously I still try different things.
But once you get used to something you have to go to the next level. I love what we serve and
we serve what I love. Same with the wine. Everything we serve has to be excellent.

(Continued)

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Box 10.1. Continued

Chris: Can you go back down a level?
JC: No, I cannot drink bad wine any more. I am too old for that!
______________________________________

JC has an expert understanding of the relationship between wanting and needing and
the role that description and expectation can play on the choice and enjoyment of food
and drink. In support of Jeffrey Larson’s ideas, it is interesting that JC believes that less
information increases the possibility of pleasure. In reducing any prior influence by not
reading reviews, not thinking about the farm that produced the produce, and simply
trusting chefs to know their business, one can allow an appetite to be expanded through
discovery. Also interesting and not explored in the scientific literature, is an adaptive
response to food plenty: a change in preferences. When surrounded by objects of desire,
one’s preference becomes more particular, nuanced, and discriminating.

Personal responsibility

The expert appetite of an expert chef is an extreme example of how appetite can
be shaped and tamed. This is something JC takes for granted. He is in control of his
desires. The issue of control, however, is at the center of arguments over how indi-
viduals and societies should respond to the obesity pandemic. For many people it is
simple: if you are overweight, then exercise personal responsibility and consume less.
Kelly Brownell and colleagues discuss the fraught issue of personal responsibility in
the context of the American discourse on obesity. They argue as follows:

The notion that obesity is caused by the irresponsibility of individuals, and hence not cor-
porate behavior or weak or counterproductive government policies, is the centerpiece of
food industry arguments against government action. Its conceptual cousin is that govern-
ment intervention unfairly demonizes industry, promotes a “nanny” state, and intrudes on
personal freedoms. This libertarian call for freedom was the tobacco industry’s first line of
defense against regulation. It is frequently sounded today by the food industry and its allies,
often in terms of vice and virtue that are deeply rooted in American history and that cast
problems like obesity, smoking, heavy drinking, and poverty as personal failures.3

This combative discourse gives a good flavor of the current battle over our appetites.
The regulation and control of the social drivers of appetite are being fought over, in
particular when it comes to sugar (Lustig et al., 2012). However, it is worth remember-
ing that the personal is always social. When I decide to eat a snack, I can bring to

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mind its surface characteristics, and my perception of want and need. What I cannot
access are the influences over time in shaping my perceptions, or the ingredients and
their effect on my subsequent appetite and behavior. Other people, people I don’t
know, are involved in my choices. The involvement of others in our personal respon-
sibility for food is becoming better understood, at least by academics and policy mak-
ers (Swinburn et al., 2011; Roberto et al., 2015).
This knowledge has, however, barely transferred to any clear public understanding
of appetite. When I choose to eat a snack it feels like solely personal choice, and other
people treat me like I am making only a personal choice. If I “lose control” and eat ten
snacks the consequences will be physical and social. Where there are judgments of
responsibility, there will be judgments of irresponsibility. Stigma and discrimination are
core to the experience of obesity (Puel and Heuer, 2009). Overweight and obese people
are often considered to be unattractive, lazy, and lacking in willpower and self-control.
In obesogenic environments characterized by the oversupply of energy-dense, nutrient-
free food and drink, people are described as simply having lost control of their appetites.
Not everyone believes that we have lost control. Biology is perhaps not so easily
beaten. Ruud van den Bos and Denise de Ridder offer an interesting challenge to the
dominant idea that our appetite system is no longer fit for purpose. Instead, they argue
that the defining feature of evolved human adaptivity is the existence of conscious
control, of our ability to override otherwise automatic systems. With consciousness
and language comes self-regard. We are able to question our physiology rather than
slavishly respond to it. Self-control, in their view, allows for temporal planning and
the prioritizing of longer-term outcomes against immediate rewards (van den Bos
and de Ridder, 2006). This is exactly what we are doing when we deliberately attempt
to change our diet. But just how easy is it to individually change a behavior so funda-
mentally social, relational, and shaped by external forces?

“I’m on a diet”

Most of us have tried at some point to change our dietary habits, typically to lose
weight, but often for other health or social goals. It is hard. Denise de Ridder and her
colleagues were interested in why we decide to calorie-control diet, what happens
when we do, and in particular what it means when someone declares themselves to be
on a diet (de Ridder et al., 2014). The answer might seem obvious. Surely people who
say they are on a diet are those who are overweight or want to lose weight. However,
the answers to the questions posed by de Ridder and colleagues are not so straightfor-
ward. They observed that the declaration of being on a diet, or the social label of being a
dieter, is unrelated to weight loss. In fact, the chances are that if you declare yourself on
a diet, you will not lose weight. In a relatively large sample, they identified that dietary
restraint was common (van Strien et al., 1986). However, dietary restraint is highly
related to negative perceptions and concerns about food. The researchers discovered

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that “dieting and concerns go hand in hand while both leave actual consumption
largely unaffected” (de Ridder et al., 2014, p. 106). In plainer words, worrying about
food and attempting to control diet have nothing to do with subsequent weight loss.
Perhaps we need help. Dieting alone appears to be just too difficult. There is no shortage
of commercially available help in the form of weight loss programs, many of which are
either prescribed or provided within formal health care systems. Studies of such dieting
programs show that modest short-term gains are possible, although even the studies show-
ing modest gains may be flawed by biases toward positive evaluation (Mann et al., 2007). A
recent systematic review of therapist-delivered weight loss programs also showed a mixed
picture. They were not effective when delivered in primary care, although they may be
effective when delivered commercially by people who are specialist trainers (Hartmann-
Boyce et al., 2014). Weight loss is possible, then, with behavioral intervention; in particular,
when delivered by behavior change specialists, but self-dieting may be closer to an anxiety-
or impression-management strategy, operating in the context of food-plentiful societies.
“Diet talk” is more of a ritualistic performance of mild self-punishment that may
serve only to manage the negative impact of shame and worry. Self-initiated dietary
restriction has now lost its power to function as part of a weight-management strat-
egy, but instead has taken on a new role as defense of self-respect. The behavior of
expressing an intention for change has become totally decoupled from the behav-
ior of food search or of eating: it operates free of any planning or implementation
(de Ridder et al., 2014). Intriguing though these ideas are, what’s missing from this
developing view of the psychology of appetite is a discussion of changes in food want-
ing when people attempt to restrict food intake and declare themselves “on a diet.”
What role does appetite play in food restraint or its failure?

Hungry behavior

There are surprisingly few qualitative studies of the actual experience of dieting, of
what it feels like when one is hungry. Perhaps food and drink restraint is so com-
mon a behavior that it escapes serious investigation. There are studies of specific
­populations—in particular, those with an eating disorder—but there is less interest in
the ordinary. Social scientists appear to be more interested in core subjects of identity,
body image, and choice. However, hunger—an increase in the salience of physical
discomfort and attentional bias to cues for possible food—has a number of effects on
behavior. Principally, hunger acts to raise awareness to possible food, motivates one
to forage, broadens the category of what might satisfy, and increases exposure to our
own core behavioral tendencies. In other words, hunger disinhibits.
Anne Hammarström and colleagues undertook a trial of a weight loss interven-
tion. They chose 12 women from the trial and interviewed them in more detail about
their experience of dieting. The results are quite revealing. The women were not inter-
ested in any technical aspects of energy consumption, nor with the overall purpose

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of dieting. And they did not talk much about food liking. No. What they talked about
were the demands of food wanting and its assault upon the self, and about their battle
for self-respect, self-determination, and change. They talked about their inner bat-
tles with food and drink, with desire and craving; with the challenge of self-loathing
and self-respect. One woman described her hunger in terms of a “craving” for sugary
foods that was similar to the trials of being an alcoholic:

I cannot buy sweets, which is why I call myself an alcoholic because I’m like them in
that they can’t buy themselves a bottle of alcohol. And I have to eat all sweets at once.
Nothing else is possible. I wish the sweets were as far away in the shop as possible.

Another spoke of how she felt when failing to resist eating sweets: “Afterwards when
I have eaten it I feel sick and I think—hell, why did I eat it . . . when I know that I should
not and that I feel bad afterwards.”4

Craving

At its extreme hunger becomes craving, which is a highly intense desire accompanied
by thoughts that are intrusive, hard to ignore, and hard to control. The same word is
used for a range of motivational disorders for all substances of abuse, including food,
drugs, and alcohol (Pelchat, 2002). Food craving, as was seen in the example from
Anne Hammarström’s study, is often experienced negatively as abandonment to an
external force or as a character weakness. But the psychology of craving in appetite is
not very well understood. It is dominated by models borrowed from addiction, which
are more relevant to a craving for a specific, often illegal or illicit substance, such as
drugs of abuse. Craving for normal, everyday food and drink is different. Craving is
likely to be highly context dependent. Three different contexts of food denial and crav-
ing exemplify how important context can be. The first is a study of dieters; the second
is a study of craving in pregnancy; and the last is a different context of food denial:
those deliberately avoiding food in order to achieve a positive, often occupational goal.
Andrew Hill in the UK has done much to develop a psychology of craving and appe-
tite. For example, in a study with Anna Massey, he introduced two important meth-
odological developments to the study of diet and craving. First, the investigators made
a distinction between those who are restricting their diet to lose weight and those who
are restricting their diet to maintain their weight. They call the first group “dieters” and
the second “watchers.” Second, they went back to basics and captured detailed obser-
vations in diaries of each craving target, intensity, and emotion over a seven-day period
by 129 women. In all, they captured 393 records of craving in the week. They found:

Chocolate was the most frequent target of cravings (37% of episodes), followed by sa-
voury (31.6%), and sweet foods (22.4%). Savoury food cravings included crisps (potato

217
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fries), bread, cheese, and meal foods, while sweet food cravings were most commonly
for biscuits, cake, desserts, and confectionery.5

And without any hint of irony, they report that “the majority of cravings were fulfilled
by eating the craved food (70%), a proportion that did not differ by dieting group.”6 The
context of food restraint was important. Self-defined dieters had more frequent and
stronger cravings than both watchers and those not on a diet. Furthermore, “Dieters
rated their cravings as slower to disappear and their mood to be lower in hedonic tone”
(Massey and Hill, 2012, p. 783). In this context, defining oneself as a dieter was associated
with increases in craving, decreases in positive mood—and no sign of changed behavior.
A different context of craving was explored by Natalia Orloff and Julia Hormes
from New York. They were interested in the experience some women have of crav-
ing during pregnancy. Appetite often changes during pregnancy. For example, the
incidence of pica, the ingestion of non-foods, is thought to increase. And craving,
often for sweet substances such as chocolate, increases (Orloff and Hormes, 2014).
The researchers argue that craving is largely due to a pattern of approach and avoid-
ance around socially sanctioned denial of desired food. The more one self-denies, the
more likely it is one will crave. In pregnancy the social meaning of eating is changed
and the social sanctions on satisfying one’s craving by consuming are relaxed. This is
an intriguing idea, although it certainly needs further study. However, the position-
ing of a highly motivated and specific behavior so squarely in the realm of the social
context is welcome. A psychology of appetite needs to be relational in understanding
the meaning of self-denial and the social costs of the failure of attempts at self-denial.
Approaching the question of context and appetite from a different angle is the
third interesting case of occupational dieting. For some people diet is constructed as
an occupational requirement, either in what is becoming known as “aesthetic labor,”
as in aspects of the hospitality industry (e.g., flight attendants, reception workers), or
in modeling, acting, or sport. Take acting, for example. In one study, both student and
professionals were asked what lengths they would go to in order to secure a “dream
job.” Figure 10.2 gives the results of twelve body alterations. Most agreed that losing
and gaining weight is a body modification they are willing to undertake to achieve an
acting job. One young male actor captured this well when he said:

I am the kind of actor who diets ridiculously, goes through binge diets of “I’m going to
not,” you know, “I’m going to cut major food groups out of my diet.” In order to achieve
something . . . Equally, I’m also the kind of actor who [will] go to the place of transform-
ing my body to the extreme by putting on weight to play a part.7

Another common example is professional jockeys. Using diary methods, Eimer

Dolan and colleagues studied jockeys’ nutritional habits prior to racing. All jock-
eys reported a range of weight-loss practices, not least dieting, dehydration, use of
saunas, and excessive exercise. According to the researchers, “It appears likely that

218
 90
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% willing to undertake each modification, out of 40 professional actors

Fig. 10.2. Body modifications student and professional actors would undertake to achieve
their “dream job.”
Reproduced from Seen but not heard: an embodied account of the (student) actor’s aesthetic
labour, Roanna Mitchell, Journal of Theatre Dance and Performance Training, 5(1), p. 65, doi:10.1080/194
43927.2013.868367 (c) 2014, Taylor & Francis. Reprinted by permission of the publisher (Taylor &
Francis Ltd, http://www.tandfonline.com).
 a ppe t i t e

a substantial proportion of jockeys remain in a state of chronic energy deficiency”

(Dolan et al., 2011, p. 796).
To explore appetite in the context of a higher motivational goal of sport, I talked to
Tom Strawson. Tom is 26 and a jockey (Box 10.2).

Box 10.2. Tom, the jockey: “the discipline comes from an ambition to succeed”
At 6 feet, 2 inches (188 cm), with size-11 feet, being a jockey is not the easiest of life
choices for Tom. He has to make a race weight below 147 pounds (66 kg). This involves
reducing his food intake to between 600–700 calories a day, effectively making him
hungry all the time.

______________________________________

Chris: How would you describe this lifestyle you lead?

Tom: It is a challenge. You have to constantly manage your weight. I think I am now
getting better at it.
Chris: How do you achieve it?
Tom: You have to have a really good regime and a well-planned diet. Generally you are
meant to eat in the region of 2,000 to 3,000 calories a day, but I get down to 1,000 cal-
ories, and when I am dieting hard, 600 to 700. Your body has to get used to it, and adapt
to it. You have to learn to eat the right things. This year is the first time I have consulted
a professional dietician who has helped me eat the right things. I have probably been
starving myself a little bit too much. And now I have a bit more of a protein diet. More
meat. I don’t eat bread any more. I eat protein. It is one constant battle, but you have to
try and make it easier.
Chris: Do you keep a constant weight or does it fluctuate?
Tom: Yes, you do fluctuate. The more rides you get the easier it is. I think getting your
weight down is the hardest thing. Keeping it down is easier. In the summer I can put
weight on, this summer I got up to 12.4, even 12.8 stones [172, 176 pounds]. I fluctuate a
bit at this time of year.
Chris: What else do you do to achieve weight loss?
Tom: I have to do a lot of exercise. I have to be physically very fit, and that involves riding
five or six days a week. Then I live a life on an exercise bike in front of the TV at home or
working harder at the office, then going to the gym at lunchtime, swim a kilometer, bike
15 kilometers, then go back to work feeling refreshed. Your body gets used to it.
Chris: Your body gets used to it, but does your mind? Are you still hungry?
Tom: Oh, yes, you are hungry the whole time. That does not change.
Chris: Does the desire for food change?

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 cr av ing

Box 10.2. Continued

Tom: Desire? Yes, it does. Yes. For example, there are some things I will never touch. In
the last five years I have not eaten a McDonalds burger. Before I would happily have had
a burger or a pizza or a fry-up. I look at that now and think of the calories. For the whole
time I am thinking of calories.
Chris: Is it the calories that stop you or has the wanting changed?
Tom: I don’t desire it anymore. It is not something I want. My diet has changed a lot. I now
eat a lot of fish and fresh vegetables.
Chris: Marathon runners say they have thoughts about stopping all the time. Do you
have thoughts about eating?
Tom: Oh, gee! Yes, you do get that. It happens all the time. I don’t say it out loud but I do
think about it all the time. But you get better with it. I just keep reminding myself of the
achievements. I achieved more than I wanted to achieve last year and I just keep remind-
ing myself of that. That is exactly why I do it: to achieve. I just have to man-up and get on
with it. I don’t find it particularly easy to fast in the week, but to me it is all about succeed-
ing. And whenever I question myself, which I do the whole time, I think, “Well, what else
would I be doing?” I put everything into what I do and I want to be the best at what I do.
Chris: What is the biggest challenge?
Tom: It can get you down. At one point nothing was going well, but in the last eighteen
months it is all getting better and I feel like it is now moving forward. The success helps
you cope with feeling hungry all the time, and starts to justify why you are doing it.
Chris: It sounds like a life that is defined by discipline. Are there positives from being so
disciplined that transfer to the rest of life?
Tom: Of course. Massively. Discipline is organization. You have to be organized and
determined. I am all about trying to achieve something. I will work until I get there. I
might fail at first, but I will get there. You get out of life what you put into it. That is my
motivation. The discipline comes from an ambition to succeed, and finding a way to
make it all happen.

______________________________________

For Tom as a jockey, dieting is still difficult, still challenging, and something that
requires tremendous personal discipline. Interestingly, his motivation is indirect. He
is not dieting to lose weight; he is dieting to lose weight so he can compete and win.
Perhaps in this way jockeys escape the failure discussed by Denise de Ridder. Appetite
does not seem to alter: the being hungry and wanting of food remains intact, regard-
less of the motivation. However, there are changes in the targets. Just as Jean Chris-
tophe’s appetite changes with experience, in demanding higher-quality foods, so Tom’s
appetite changes with the loss of desire for high-fat, high-sugar foods from fast-food
restaurants.

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Summary

The experience of desiring, wanting, and craving to eat and drink is oddly neglected
in psychology. Appetite is always relational: consuming too much or too little can
always be explained by power relations. The role of power can be observed in food
refusal and avoidance, but is also at play in “diet talk” and in the lengths the food
industry will go to shape and influence our choices. A psychology of appetite will
need to understand the limits of personal choice when it comes to availability of
food and drink. Egocentric explanations of self-determination focused on “personal
responsibility” will fail, as will wholly sociological explanations of social determina-
tion. Individuals repeatedly exercise choice in the very specific contexts of their own
goals and values. Needed is a psychology of desire that takes account of the physical
experience of appetite, of wanting and needing, of the desire to consume.

Notes

1. Reproduced from Raymond Tallis, Hunger, 1e, p. 32 © 2009, Routledge.

2. Reprinted from Appetite, 1 (8), David J. Mela, Eating for pleasure or just wanting to eat?
Reconsidering sensory hedonic responses as a driver of obesity, p. 16, Copyright (2006),
with permission from Elsevier.
3. Reproduced from Kelly D. Brownell, Rogan Kersh, David S. Ludwig, Robert C. Post, Rebecca
M. Puhl, Marlene B. Schwartz, and Walter C. Willett, Personal Responsibility And Obesity:
A Constructive Approach To A Controversial Issue, Health Affairs, 29 (3), p. 379, doi:10.1377/
hlthaff.2009.0739 (c) 2010, Project HOPE. The published article is archived and available
online at http://www.healthaffairs.org.
4. Reproduced from Anne Hammarström, Anncristine Fjellman Wiklund, Bernt Lindahl,
Christel Larsson, and Christina Ahlgren, Experiences of barriers and facilitators to weight-
loss in a diet intervention—a qualitative study of women in Northern Sweden, BMC Wom-
en’s Health, 14 (59), p. 5, doi:10.1186/1472–6874–14–59 © 2014 Hammarström et al.; licensee
BioMed Central Ltd. Quotation used under the terms of the Creative Commons Attribution
License (http://creativecommons.org/licenses/by/2.0).
5. Reprinted from Appetite, 58 (3), Anna Massey and Andrew J. Hill, Dieting and food craving. A
descriptive, quasi-prospective study, p. 783, Copyright (2012), with permission from Elsevier.
6. Reprinted from Appetite, 58 (3), Anna Massey and Andrew J. Hill, Dieting and food crav-
ing. A descriptive, quasi-prospective study, p. 783, Copyright (2012), with permission from
Elsevier.
7. Reproduced from Seen but not heard: an embodied account of the (student) actor’s
aesthetic labour, Roanna Mitchell, Journal of Theatre Dance and Performance Training, 5 (1), p. 65,
doi:10.1080/19443927.2013.868367 (c) 2014, Taylor & Francis. Reprinted by permission of the
publisher (Taylor & Francis Ltd, http://www.tandfonline.com).

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 CHAPTER 11

EXPULSION

T he final consideration is of the sensation of expulsion, the removal of gas, liquid,

and solids from one’s body. I explore a group of ten physical experiences, most
of which are associated with proprioceptive actions whose principal operation is to
separate matter from the body, to move it from inside to outside. These are the senses
that function to expel, expunge, make matter other to oneself; these are the sensa-
tions we experience as we literally dis-embody.
The removal senses of interest in this penultimate chapter all share a common phe-
nomenological feature: once they start they are difficult to stop. Most involve a
limited and defined set of physical parameters (effector systems or triggering events)
and have very different hedonic qualities. But they all share this principal feature of
needing to run their course; a quality of being almost semi-automatic. One is often
relegated to the role of observer, travelling with the sensation, but held responsible for
it and for what happens next.
Removal and separation are achieved either through the action of air or the
action of fluids and semi-solids. The air removal senses include sneeze (sternutation)
cough (tussis), hiccup (singultus), burping (eructation), and farting (flatulence). The fluid
and semi-solid removal senses include defecation, urination (micturition), vomiting
(emesis), menstruation, and ejaculation. Physiologically, most involve a set of muscles
that operate for the specific purpose. Some are arced reflexively through the spinal
cord—the best examples being perhaps hiccupping and vomiting—whereas others
have more central control, if only over sphincters, such as in urination.
There are very different sets of social understandings and practices that each of
these senses operates within, which are at least partially determined by their physio-
logical character. In what follows I explore first the air removal senses in two parts.
The two senses of sneeze and cough are dominated by discourses of disease, conta-
gion, and protection. The other three air senses of hiccup, burp, and fart escape this
disease association, but are instead constructed within a discourse of manners, of
social propriety. Next, I explore the fluid removal senses in three parts. First, defeca-
tion and urination are discussed as the routine removal of bodily waste—as the final
stage of digestion. Vomit is an interesting case because it involves the specific expul-
sion of ingested but potentially toxic material before digestion. Finally, the last two
fluid removal senses are reproduction-related with the vaginal discharging of blood
and tissue, and both male and female ejaculation.

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 e x pu l sion

Each of these ten removal senses has a clear and well-defined physical function.
However, how they are experienced depends on their social context and personal
meanings. Across all of them, there is a public-private dynamic at play. Always
at stake with these senses is how far one is physically or socially able to publically
remove air or fluid from the body, made more complicated by their aural, olfactory, or
visible qualities. And always with this public-private dynamic is the need to control,
plan, manage, or mitigate the consequences of the public display of physical removal.
Two people helped me explore expulsion. In failing to understand from the aca-
demic literature why some air removal senses are funny and others are not, I sought
the advice of a professional comedian, Arthur, who talked to me about why farting is
funny. Later, intrigued by how the fluid removal sense of vomiting can change depend-
ent upon its place and time, I talked to Connie about voluntary vomiting. Vomiting
for her is a method of controlling the consequences of alcohol consumption.

Human jets

Both coughing and sneezing function to defend the airway from irritation or block-
age. We inspire air and explosively propel it through the airway with force. For cough,
there is much debate as to its separation from breathing and its unique characteris-
tics, not least its repetitive and rhythmic character (Bolser et al., 2006). Adult human
coughing and sneezing can be seen as a form of human jet propulsion. Both coughing
and sneezing velocity can be as fast as 4.5 meters per second, and sneeze has recently
been measured as reaching at least half a meter (Tang et al., 2013). It is an effective sys-
tem for projecting a foreign body or internal blockage away from the body, and may
also function to promote mucus secretion triggered by pharynx and buccal pressures
(Burke, 2012). Increased buccal mucus secretion itself also functions to remove debris
from the airway by swallowing.
It is exactly our success in jet propelling mucus away from the body that causes
social concern because it is a highly effective way of transmitting disease. Much of the
mucus sharing is done indoors and in confined spaces. In simulation studies, both
position in a room and the quality of the ventilation influence personal exposure to
mucus droplets from another’s sneeze (Seepana and Lai, 2012). Sneezing indoors is by
far a more effective way of transmitting disease than sneezing outdoors.
The explosive and projectile qualities of these human jet propulsions also commu-
nicate to others that one may have a blocked airway and need assistance, or that the
air may itself be dangerous (e.g., smoke). It may also communicate potential illness
and possible infection. Sneezing, however, is also known to occur with other triggers.
For example, there are reports of sneeze on exposure to direct sunlight, on overeat-
ing, after orgasm, or simply brought about by thoughts of a sexual nature. The causes
of orgasmic sneezing are unknown but are likely to be centrally mediated. Early theo-
ries of cause were often psychogenic, especially psychosexual. But it is more likely

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 com mon a nd pu bl ic

that a better understanding of the evolution of sneeze and the relationship of vestigial
cortical sharing of nasal and genital projections will provide an explanation of these
seemingly unrelated phenomena. Because it causes embarrassment, sexual sneeze
is thought to be underreported. When it is reported, the descriptions are often of
distress rather than pleasure (Bhutta and Maxwell, 2008, 2009).

“Coughs and sneezes spread diseases”

Murat Songu and Cemal Cingi discuss an interesting hypothesis about our preoc-
cupation with sneeze and disease. They suggest that sneezing has always attracted
beliefs around health, morality, and even prescience. It is still common for people
to think that when someone sneezes it is a sign that others are thinking of them, or
that the number of sneezes can bring good or bad luck. The meaning of sneeze has
changed since the occurrence of great European pandemics such as plague and the
more recent major flu epidemics: sneezing is now always symbolically related to
infectious disease and illness (Songu and Cingi, 2009). Whatever the cultural history
of the place of coughing and sneezing as methods of transmitting infection, this idea
is now well embedded, perhaps best captured by the 1940s UK Ministry of Health
campaign declaring that “coughs and sneezes spread diseases” (see Figure 11.1). These
health promotion campaigns were unflinching in their positioning of the person who
does not use a handkerchief as stupid, a public menace, and deserving of prosecution
(Welch, 2013). This campaign is still used in the United Kingdom, although the use of
the handkerchief has become confused and lost from this message, being a less popu-
lar practice. Other barrier methods are emerging, such as the wearing of face masks
(Suess et al., 2012). Wearing a face mask is a public display of infection concern and
may mark a shift away from the 1940s public health attempts to control transmission
by changing the behavior of the carrier. The focus now is on individual attempts to
protect oneself from others.

Common and public

Upper respiratory tract infections (the common cold) are the most common diseases
we know, with most adults experiencing more than two a year, and children having
more (Eccles, 2005). Chronic cough, typically one lasting for longer than eight weeks,
is thought to affect one in five of us (Morice et al., 2004). Although possible causes
and treatments are well documented, the experience of chronic cough is not. Exactly
how people experience persistent cough and make sense of it as part of their lives is
not well described.
Measuring cough severity is challenging but not impossible. In one study of 22
people with chronic cough, frequency and intensity were reported as being very

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Fig. 11.1. Coughs and sneezes spread diseases. Circa 1960. (Plate 4)
©The British Library Board, B.S.81/19.

important to the experience. But as important was the discussion of the consequences
of the public display. Coughing is not easy to hide. It is often a public activity because
it is interruptive. It signals distress, raises the question of proximity to disease, and it
might quickly transfer into a call for help. However, it does not always produce help.
In a study of the experience of cough, one participant talks about coughing and the
experience of mucus being stuck in the throat:

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 hicc u p

And that then trickles down here, and then I cough like the devil. . . . I get—it sticks
here, great big chunks of it will stick here—can’t get it out. And I cough, and cough,
and cough, and then if you go to a restaurant and start coughing, they throw you out.1

Both coughing and sneezing publically display personal distress and social threat.
Despite their ubiquity, there are few considerations of the public experience of
coughing and sneezing, and fewer still on the stability and influence of beliefs about
coughing and sneezing and their relationship with hygiene behavior. For example,
how do people change their behavior when others cough and sneeze near to them?
Also unclear is how easy it is to change behaviors that are so common, and whether
public health campaigns, like that shown in Figure 11.1, have any effect on mass
hygiene behavior. A psychology of sneeze and cough will need to understand lay per-
ceptions of disease transmission, beliefs about sneeze, the social control of sneeze
within specific knowledge communities, and why health practices such as wearing
a mask, using a handkerchief, being temporarily isolated, and using vitamin supple-
ments move in and out of popularity, dominating in some but not other societies.

Hiccup

Hiccups are the “repeated spasms of the diaphragm followed by sudden closure of the
glottis” (Krakauer, 2005, p. 822). Functionally they appear to have no physical or pro-
tective role and play no part in disease expression or management. They are thought
to be only a vestigial reflex, one that has no adaptive value (Kahrilas and Shi, 1997).
Typically we experience hiccup as sudden and hard to control. They are often judged
to be loud and socially disturbing. In fact, they are named after their sound: consider
the English hiccup, the French hoquet, and the Spanish hipo. Hiccups are, then, aural and
public. They are normally short-lived and the source of humor and mild frustration
or consternation. Consider that the word hiccup is often used metaphorically to mean
a minor problem, or a pause for correction in a process. When we say, “There has
been a hiccup,” we generally mean to downplay a problem as minor, temporary, and
manageable.
Chronic hiccup, however, is a serious problem and can cause severe distress, dis-
ability, and anxiety. It is anything but minor and is often not manageable. Thankfully
it is not common, but it does occur more with advanced cancers and can be a major
challenge in end-of-life care. There is a surprisingly large literature on potential phar-
macological treatments for persistent hiccup in palliative care, although little guid-
ance on their effectiveness (Moretto et al., 2013).
Patients with persistent hiccup often experience it as challenging in the extreme.
For example, I know of only one study that looks in detail at the experience of people
with chronic hiccup. Alvisa Palese and her colleagues took five years to undertake a

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study of adults with cancer-related persistent hiccup. It is a very challenging envir-

onment in which to do research, research that has to be done sensitively and with
clinical expertise. In this study, five adults talked in detail about their experience of
symptoms from neurological cancer and in particular of hiccup. Their narratives
were dominated by a sense of despair at being powerless, at being unable to control
unpredictable and automatic experiences, without any known trigger or mechanism
for stopping them. The longer-term prospect was equally challenging as the patients
reported fighting each hiccup, but eventually shifting to managing the frequency:

Patients’ attitude started to modify radically. With the growing understanding of the
malign nature of the symptom, and its invincibility even against pharmacological treat-
ments, over time, patients learned to lengthen pauses between one hiccup and the next
and to reduce the number of spasms. (Palese et al., 2014, p. 399)

The study of psychological treatments for hiccup is sparse. There are case studies
of highly unusual problems such as in hiccup associated with compulsive fluid con-
sumption (Thomas et al., 2001), and there have been attempts at using biofeedback.
For example, there is one clinical case with the successful use of respiratory control
and heart rate biofeedback in a young woman with persistent hiccup (Hurst et al.,
2013). The lack of consideration and treatment development for hiccup reflects badly
on psychology as an applied and clinical discipline. We are only at the very beginning
of considering treatments for these distressing conditions.

Releasing gases

Coughing, sneezing, and hiccup all require a respiratory inspiration phase in which
air is taken and used to create a force. The final two air removal sensations relate to
the release of gases from physical cavities, sometimes actively, often passively. There
is a specific case of the release of air trapped in the vagina, typically during or after
penetrative sex. It may be common, although its incidence is unknown, but in the
normal case is virtually always medically benign. For some women, however, it can
be embarrassing and in rare cases worrying and socially disabling (Allahdin, 2011). By
far the more common cases of the buildup of bodily gases to be released are at either
end of the digestive tract, in the burp and fart.

Burping

Burping is thought to occur approximately twenty times a day. It is a normal mecha-

nism for returning swallowed air, but can become a concern when its frequency
increases, it becomes associated with food regurgitation (rumination), or its social

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 bu r ping

display creates embarrassment or fear of embarrassment. Gastrointestinal distur-

bance is an everyday occurrence and perhaps to be expected when we consider the
complexity of normal human digestion. But for many people, dysfunctional diges-
tion, or dyspepsia, is also common and sometimes troubling (Wallander et al., 2007).
One interesting household survey showed burping to be a common gastrointestinal
event across the world (Enk et al., 1999).
For most people, burping is not a worry but a form of gastric self-management.
Uncontrolled and sudden burping in an inappropriate social setting is often consid-
ered rude because it is associated with slovenly, uncouth, and poorly disciplined eat-
ing behavior. Modern eating involves various practices of distancing oneself from the
immediacy of food and the urgency of appetite, such as the regular timing of meals,
the use of cutlery and dishware, and the habit of eating in a slow and considered man-
ner. These are forms of restraint that operate as marks of civilization, and signal our
separation from the bestial. Because burping is often caused or exacerbated with
swallowing air on eating rapidly, it can be an unwelcome reminder of physicality. The
public burp operates often as a social challenge to finely crafted and fragilely main-
tained social mores. Shakespeare understood this well in his invention of Sir Toby
Belch, who appears in Twelfth Night to crudely deliver basic truths, offering a chaotic
alternative to order. To deliberately burp is to challenge. A burp rarely goes unjudged.
It says: Reject me as uncouth, or accept us all as animal.
The humor in burping arises exactly from the social transgression of manners and
the positioning of the dominant concern as suddenly ridiculous. The burp operates
in humor bathetically. In other words, it challenges the pompous and over-serious.
One of the most successful ever clip-television shows in the United Kingdom is called
TV Burp. It operates exactly as its name suggests. Short clips of life (at least TV life) are
presented out of context and their seriousness undermined as a reminder ultimately
of our shared human ridiculousness (Leggott, 2010).
For some people, however, burping is neither funny nor socially useful. It is a
menace. For those with advanced cancer, for example, gastrointestinal symptoms,
including burping, can be challenging (Komurcu et al., 2002). Others suffer from a
primary belching disorder that can occur either with or without excessive air swal-
lowing (aerophagia) (Tack et al., 2006). Also problematic, although not as commonly
mentioned, is the inability to burp.
There are no developed psychological interventions for chronic and severe burp-
ing. One can find case studies that give some insights. Although there are historical
studies showing how gastrointestinal and muscular changes can be altered psycho-
logically, this area of research never flourished (Kamolz and Velanovich, 2002). There
were flirtations with hypnosis and relaxation training, but burping has escaped any
concerted psychological attention. There is a sign that interest has not completely
collapsed. Case studies are beginning to emerge that discuss burping as a serious area
of clinical interest. One proposes a role for simple education and reassurance (Disney

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and Trudgill, 2014); another discusses a first case of burping as relief of distress (eruct-
ophilia) in the context of an eating disorder (Jones and Morgan, 2012). Nobody has yet
described a case of the fear of burping either privately or publically, which logically
must exist, and could perhaps be called eructophobia.

Farting

Farting is the removal or release of intestinal gas, most of which is produced in the
intestine itself, although it can be caused by the excessive swallowing of air. It helps in
the study of flatulence to recognize three principal features that are worth exploring
separately: the volume of gas produced and hence released (including a concern for the
frequency and duration of flatus); the noise associated with the release; and the smell.
Fabrizis Suarez and Michael Levitt provide an excellent review of intestinal gases
including flatulence, and give normal figures for farting at “400 to 2500 mL of gas per
day . . . with a frequency of ten passages per day (upper limit of normal is 22 times day)”
(Suarez and Levitt, 2000, p. 416). They argue that many people are unaware of the
normal rate; some present clinically with self-perceived excess but can be effectively
counseled that 22 times or less a day is within normal limits. For some it is intimately
associated with hygiene, and thoughts of uncleanliness can become a ruminative
concern. Reassurance is not always helpful but there are case studies showing success
with “paradoxical intentions,” a psychotherapeutic technique in which one attends
very closely to the source of anxiety until one habituates to it (Milan and Kolko, 1982).
Studies of exposure to the fearful thoughts (such as “I am going to fart”) and the
places where the thoughts occur are also promising (Ladouceur et al., 1993). Just as
fear of flatulence can be concerning, so can excessive flatulence. In the palliative care
context, flatulence is a very common complaint, more so than hiccup and burp. In
one study of home vs. hospital palliative care for advanced cancer, flatulence was the
third most common complaint for those at home, after pain and fatigue (Peters and
Sellick, 2006).
The public display of flatulence is formed of sound and smell. All of the removal
senses operate across a divide of the private and the public. Like burp, but per-
haps even more than burping, public flatulence also functions to remind people of
their physicality. In his book on curious human behavior, Robert Provine reports
an analysis of the sound of flatulence and explores how controllable that might be
(Provine, 2012). There are cases of people reporting high levels of control over flatu-
lence. Provine discusses the famous case of Le Pétomane who was a professional fart-
ing entertainer, able to play wind instruments with his flatus.
Although farting can be a form of entertainment, for the vast majority of us it is a
fairly mundane and uninteresting act. One is supposed to control flatulence. Failure
to control it can, however, cause social unease or challenge. Two studies explored this

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 fa rt ing

failure of control. In a large study of adult fecal habits including flatulence, Martin
Weinberg and Colin Williams from Indiana interviewed people about the sudden loss
of control when farting. Typically people expected to be judged for a failure of control
or for lacking social manners. One interviewee said:

It’s not so much the action itself, as it is the reaction that passing gas gets from people. I
guess the most embarrassing thing about it is the loss of control in holding your gas. It
just seems like in social situations . . . that you’d be able to hold your gas.2

That uncontrolled farting is embarrassing is not very surprising. However, what is

unusual about the findings is just how personal people’s sense of failure is over some-
thing that happens as often as 22 times a day, every day, in all contexts, even when
asleep. The power of this everyday form of social control is what makes farting easy
to assign other meanings to, for either a strong identity position or as a vehicle for
deviance. For example, in the same study, a different male interviewee boasted about
what people would say if they were party to his malodorous flatus: “Guys would say
it’s raunchy and then say ‘Nice one,’ because if it’s strong it’s more manly. You know,
because women would not try to clear a room with a fart.”3
Michael Reisig and Travis Pratt took a very different approach to this question of
the social uses of flatulence. They were interested in how low social control finds an
outlet in the personal deviation of socially controlled manners. They chose three
common minor social offenses in American society: telephoning people when
drunk, swearing in public, and, relevant here, “publically expelling digestive gases.”
There are very few studies like this that ask people to disclose social transgressions,
perhaps for obvious methodological reasons. As Weinberg and Williams discussed
in some detail, we like to control the impression other people have about us in regard
to fecal hygiene, including flatulence. They surveyed 502 university students and
explored what supported these different minor deviant behaviors. They found that
admitting to public flatulence was more likely in men, and more likely in those who
generally have low social control, although they also found that “much of the effect
of low self-control on public flatulence was mediated by peer flatulence” (Reisig and
Pratt, 2011, p. 613). It appears that for men, at least, flatulence made public is gendered
and more acceptable in the company of other men.
In terms of our social practices of distancing ourselves from our animalism, all
aspects of digestion are subject to great social pressure (Roach, 2014). They are to
be hidden, personal, and often denied. However, this private-public dynamic is
gendered. Just as sweating is seen to be undesirable and unseemly in women, and
by many women themselves (see Chapter 9), so the public display of digestion in the
social control of flatulence is equally gendered. Women are held to more demanding
standards than men for control over flatulence.

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Why is farting funny?

James Spiegel, a professional philosopher, investigated this question in his paper

entitled “Why Flatulence Is Funny?” The answer lies in part in its function to disturb.
Speigel argues that flatulence has all of the requirements of humor because it operates
as different from the norm and it punctuates everyday life with a sudden reminder of
the basic. It can make us feel superior by acting as the social transgressor, highlight-
ing pomposity, and at the same time it can provide a relief from the effortful work of
being civilized (Spiegel, 2013). Spiegel’s philosophical account is erudite but for me
does not get to the heart of why farting should be enduringly funny.
To get a different perspective on how and why we find gas escaping or being
propelled from our bodies funny, I talked to Arthur Smith. Arthur is a professional
comedian (Box 11.1).

Box 11.1. Arthur, the comedian: “we are hardwired to laugh at farting”
Arthur and I met for lunch at Café Boheme in Soho and both ordered the artichoke. We
sat outside.

______________________________________

Chris: Have farting and burping always been funny?

Arthur: Burping is the younger brother of farting. Not quite up there in the funny stakes.
Farting is much funnier than burping. I think we are hardwired to laugh at farting, which
is not true of all bodily functions. Spitting isn’t funny, but farting definitely is. I wonder
if cavemen found each other’s farting funny.
Chris: Perhaps. But we seem to have elevated farting to have other functions.
Arthur: Well, there is nothing quite as funny as a fart in an elevator. Especially when no
one admits to it. It provides an added mystery, like Farting Cluedo [Clue].
There have been many farting acts across the ages. Henry II had a court jester called
Roland the Farter. He was effectively the top comedian in the country. He was given
a house and estate and was required to do his farting act for the king. He would come
on and do a leap, a whistle, and a fart, which I think would still work now. He and Le
Pétomane are by far the most famous farters. At the moment there is a great performing
farter called Mr. Methane (http://www.mrmethane.com).
Chris: How does the fart joke work?
Arthur: The best person to do a fart and make you laugh is a proud and important man.
Now if the prime minister launched a big fart during his speech at the Conservative

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Box 11.1. Continued

Party conference, that would be funnier than me doing one now. It is like Greek tragedy:
a proud man brought low. The greater the man, the bigger the fall, the bigger the drama.
The prouder the man, the funnier the fart.
Chris: Why do you think we use bodily functions to challenge the pompous?
Arthur: It announces that in the end you are just an animal. It is a leveller. In a world
where we are all pretending to be sophisticated creatures, it tells people that we are ani-
mal. We have all of these elaborate rituals and carapace to try and pretend that we are
something beyond a belching, farting creature. Also, done properly, farting can be an
act of defiance or deliberate challenge. If, for example, as you shook hands with Prince
Charles you launched a huge fart, that would be funny. People should consider farting
as a tool in politics.
Chris: When is a fart joke not funny?
Arthur: Well, you won’t get any fart jokes at the Royal Variety Awards. Farting is a low
form of wit. But low matters. I can imagine a long-winded setup that leads you to expect a
clever punch line, and then you just deliver a fart. Farting can be used to change the story,
to throw people off track, and bring them down to earth.
Chris: Do female comedians use farting?
Arthur: I am sure if you watched 50 female comedians and 50 male comedians there
would be more fart jokes from the men. Women do tell fart jokes, but it would be a more
radical thing to do. Potentially more funny, though, as we are used to men talking about
farting. Yes, a woman making a fart joke—that offers more opportunity for comedy.
Women have a harder time farting. Imagine you are on a date with a stunningly beautiful
woman and she launches a big fart—does that make her less attractive? These are the
important questions . . .
Chris: Mmmmm!
Arthur: In the end, we are basic animals. Base is funny, and it does not get more base
than farting.

______________________________________

Farting is funny not in and of itself, but because of how it can be used. Compare, for
example, the uninvited sharing of mucus by sneezing over someone. That is rarely
humorous because of its relationship with disease. Spitting buccal mucus at someone
is also socially disturbing (hard to ignore), but spitting is typically a sign of aggression
because it is controllable, and therefore a deliberate act of challenge. Both are socially
interruptive. However, as Arthur discussed here, well-timed flatulence is socially disrup-
tive because it is a highly effective form of bathos. Farting reminds us of our bestiality
and of the flimsiness of the manners and mores that operate to distance us from that
reality.

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Continence psychology

Normal defecation and micturition should be thought of as continence. We learn to

control or respond continently to the urge to defecate or micturate within certain
limits. The physiology of continence is relatively well-described, although there are
some gaps in our knowledge, such as what should be considered normal (Palit et al.,
2012). For example, paradoxically, most people do not consider themselves normal
when it comes to bowel function. At least that was the conclusion of researchers who
in 1992 explored the regularity of bowel function and found that “only a minority of
adults enjoy conventionally normal bowel function and a little more than half pass
normal stools” (Heaton et al., 1992, p. 823). In one U.S. survey of over 1,000 adults, a
quarter reported loose stools or diarrhea (Sandler et al., 2000). We probably need to
let go of the idea that there is a normal when it comes to defecation. Frequency, tim-
ing, stool solidity, and the ability to control urge are all highly variable across people,
situations, dietary habits, and time.
The psychology of continence will involve the cognitive science of physical mas-
tery and control, and a social science of what governs private behavior in a public con-
text. I find it helpful to think of continence psychology in three broad domains. The
first is how we initially achieve continence and respond to the urges to open bowel
or bladder with restraint—how we train the developing child to be continent. The
second is the experience of incontinence, either through injury, illness, or frailty. And
the third is on the temporary disturbance of learned continence in otherwise normal
life; in particular, the role of emotion.

Toilet training

Failing to resist the urge to urinate or defecate is socially restrictive. Soiled clothing,
discomfort, social disapproval, avoidance, rejection, and an increased risk of infection
are just some of the very good reasons why we have a large number of socialized toi-
leting behaviors. Most children are toilet-trained in the second to third year, although
there is interesting discussion on why both the manner of training and when one
starts seems to have changed. In the last 50 years there has been a trend toward start-
ing children on toilet training later. This has little to do with the child, their physiology
or their psychology, and is instead about parental preference (Vermandel et al., 2008).
Starting too early or waiting too long to toilet train are often the causes of major
parental anxiety and parental pressure. Sometimes there is also parental punishment
or violence due to the misplaced belief that the lack of continence is a willful act of
deviance (Alpaslan et al., 2014). Toilet training, however, is more of a social marker of
child development and maturity, and a rite of passage for both parent and child. When
parents make the decision to toilet train, the judgment of child willingness or readiness
may actually be a proxy for parent readiness. In a study of parent experience of toilet

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training, parents reported exactly this sense. Making the decision and making time were
critical factors, as was the desire to avoid being judged as different by peers. The rite of
passage was captured well in this study by one parent’s enthusiastic and positive display
of child development: “If she urinated a little in the potty it was fantastic, we showed it
to the whole family, took a picture, and made it a fun thing” (Jansson et al., 2008, p. 474).

Managing incontinence

Inevitably, losing the ability to control the urge to defecate or urinate is distressing.
For example, one study of German women with urinary incontinence captures very
well the themes that appear frequently across similar studies. The women reported
shame and embarrassment not only at possible episodes of incontinence but at even
discussing them. Despite how common urinary incontinence is, it remains for many
people a private burden. Also interesting was the description of a life altered, and
for some people defined, by incontinence. Women discussed having developed a
quite comprehensive “city map” of all public and semi-public toilet facilities in their
locality. They had memorized the tram timetable and the opening times of cafés with
facilities, and had a good understanding of how much they should drink and what
they should drink (e.g., coffee) when planning a trip:

If I go from here into town—when I go by tram—I’m in town in five to seven minutes,

so I’ve reached the first point in a quarter of an hour. Yes and then I go there, I go for a
coffee. Because the other toilets aren’t open yet, but the cafés are open, so I go there and
it’s nearest to the tram stop.4

This sort of technical planning and organization is the lived reality of those with
incontinence. In medicine, one is perhaps more used to describing disability by func-
tional impairment, but disability for the individual is more often defined by the limits
imposed by environment, be it the geography, weather, or even town planning. The
public provision, or rather lack of provision, of toilets is an interesting challenge to
modern living. The lowly public toilet is a site of major social and cultural debate. Clara
Greed argues eloquently and comprehensively for why public toilets matter so much
(Greed, 2006). In the United Kingdom, as in many other countries, there has been a
steady reduction in the provision of nonproprietary toilets. They have also become
the site of private, often secret, behaviors (hygiene, cosmetic, sexual, illicit drug use),
so much so that public toilets are now widely seen as a necessary evil. Innovation in
toilet provision is urgently needed. The psychology of toilet behavior, both use, and
planning and provision, is a public policy imperative (Anthony and Dufrense, 2007).
A psychology of continence will perhaps be less about training individuals in tech-
niques of control and more about encouraging policy makers, planners, city officials,
and business leaders to ensure the adequate provision of toilets.

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Emotion and incontinence

Sudden incontinence can be caused by laughter, coughing, lifting a heavy weight,

infection, or drug and alcohol poisoning. More curious, however, is the ability of
fear—in particular, of extreme fear (terror or panic)—to cause incontinence. It is not
clear what the function of this fear response is. The fear of loss of bodily control is a
common concern for those with a panic disorder. In an interesting study involving
both chart review and patient interview, Sheryl Green and her colleagues in Ontario
asked an unusual question. They wanted to know whether what patients fear most
has ever happened. Much of the clinical psychology of the body assumes that patients
have unrealistic beliefs about potentially catastrophic events. Are such catastrophic
fears always unfounded, or is it possible that fainting, vomiting, and incontinence
can happen? Nineteen patients were interviewed and four reported incontinence dur-
ing an attack. The incontinence was described as sudden, involuntary, and without
warning. Patients during panic can experience exactly what they fear most (Green
et al., 2007).
This relationship of fear and incontinence may also extend beyond the extreme case
of panic disorder. There is a well-documented observation in learning psychology that
animals defecate and urinate more frequently when stressed. And in popular culture,
we recognize that extreme fear is associated with sudden incontinence. Andrew Solo-
mon describes just such an occasion when he was experiencing the onset of severe
depression, presaged by panic and terror, when he was having a breakdown:

On the way home from the store, I suddenly lost control of my lower intestine and soiled
myself. I could feel the stain spreading as I hastened home. When I got in, I dropped
the grocery bag, rushed to the bathroom, got undressed, and went to bed. (Solomon,
2001, p. 49)

Stress and emotional dysregulation have also been implicated in explanatory mod-
els of irritable bowel syndrome, where chronic, broad-spectrum gastrointestinal com-
plaints are the signature feature (Kennedy et al., 2012). But most discussions of the role
of emotion and physiological stress markers tend to be gut-focused (Allen et al., 2014).
Perhaps a “continence psychology” will allow for the serious study of the possible
role of higher-order cognitive and emotional functioning on the specific behaviors
involved in defecation and urination, their control, and their control failure.

Vomiting

Swallowing (deglutition) involves both voluntary and involuntary components. The

primary phase functions to prepare food into a manageable bolus that can be shaped

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 vomi t ing

and softened, then moved to the back of the tongue which triggers the involuntary
movement of the bolus to the pharynx, including the closure of the nasal passage. The
final phase is marked by the passage of the bolus into the esophagus and the invol-
untary automatic transfer of the bolus to the stomach (Matsuo and Palmer, 2008).
Vomiting (emesis) is more than the reverse of swallowing. It is often described as hav-
ing two distinct phases (retch and expulsion), although from a phenomenological
perspective it may be better to think of it as three phases. The first is nausea, which
acts as a warning of vomit. Nausea may or may not progress to the second phase of
retching, characterized by sudden involuntary abdominal and diaphragmatic con-
tractions. Retching may or may not progress to the third phase of expulsion, in which
multiple muscle groups are recruited all with one purpose: the projection of stomach
contents as far away from the body as one can achieve (Pleuvry, 2012).
Most people have experienced vomiting either from a food-related infection,
motion sickness, pregnancy, neurological disturbance (such as migraine), or as a
reaction to treatment—in particular, anesthesia- or chemotherapy-induced vomit-
ing. What is common across these settings is the rather complicated phenomenol-
ogy of vomiting. It is often experienced as unpleasant and distressing, but in some
contexts it can be associated with a positive post-vomit feeling of being purged, a
relief from retching, and even of euphoria. The incidence of self-induced vomiting
in the general population is quite low (Hilbert et al., 2012), but may be disturbingly
high in some populations. For example, almost 60 percent of a sample of 107 women,
students at a New Zealand university, said they had made themselves vomit after
drinking alcohol (Blackmore and Gleaves, 2013). The context of vomiting can change.
It could be a method of weight control, a side effect of a leisure pursuit such as sailing,
a symptom of a disease, or an adverse effect of a treatment.
Nausea, retching, and expulsion (the vomiting) are typically described as involun-
tary, uncontrollable, and unpleasant. In the context of palliative care, these are difficult
symptoms to manage, and there is rarely anything positive about vomiting (Maguire
et al., 2014). In this and other contexts, however, it is the battle for control and the
fear of sudden uncontrolled vomiting that can lead to distress and social handicap.
Unlike the expelling of air in burp, hiccup, or cough, the expelling of partly digested
stomach contents is socially unacceptable and met with disgust and social rejection.
For example, patients with gastroparesis—a disorder of failed gastric clearance leading
to bloating, fluid retention, nausea, and vomiting—often go to great lengths to avoid
the shame and distress caused by the public witnessing of a private suffering. In one
study, the efforts patients went to in order to conceal vomit was described:

They put much thought and effort into managing short-term control of symptoms usually
by being overly prepared. One participant always carried plastic bags to vomit in; several
timed their food intake very carefully so as not to risk vomiting in awkward places; one par-
ticipant lobbied her boss for just the right desk at work so that she could vomit unobserved.5

239
 e x pu l sion

Shame and self-loathing are often part of the complex experience of vomit-
ing. The physical experiences are relegated behind the social-emotional experi-
ence of embarrassment, shame, guilt, failure of bodily control, and beliefs of
personal ­inadequacy—all of which are brought to the fore in the psychopatho-
logical expression of vomiting as deliberate purging (Tasca et al., 2012). These
beliefs are also prevalent at the other extreme, in the little-researched anxiety disorder
emetophobia, fear of vomiting. In emetophobia, the dominant drivers are a morbid fear
of infection and disease, patterns of avoidance of food and food preparation, worry,
and a heightened awareness of normal gustatory sensations (Veale et al., 2013).

Voluntary vomiting

The pathological case is always interesting and useful in thinking about how disor-
dered cognitions can emerge to support abnormal gastrointestinal behavior. One can
come to live in fear of a normal bodily function, or have it highjacked for use by other
psychological functions. Missing for me, however, is a psychological consideration of
vomiting that might emerge in normal, everyday contexts. A comprehensive psych-
ology of the body will need to address how changing food environments will affect
normal weight control. For example, in specific environments of food plenty—when
combined with the almost impossible task of trying to control the abundance of
calorie-dense foods discussed in Chapter 10—do new practices of vomiting appear?
When Natalie Blackmore and David Gleaves discussed their finding that 60 percent of
students reported self-induced vomiting after drinking alcohol, they did so within a
context of possible individual psychopathology. Voluntary vomiting, however, is not
a new phenomenon; it has been described before. For example, in his study of Mozart,
Andrew Steptoe quotes the Baron Riesbeck describing an eighteenth-century Vien-
nese dining practice in which

it is customary when an entertainment is given, to provide doses of tartar emetic, and set
them in an adjoining room; thither the guests retire when they happen to be too full, emp-
ty themselves, and return to the company as if nothing had happened. (Riesbeck JC. Trav-
els through Germany, trans Revd Mr Mary (London 1787), quoted in Steptoe (1988, p. 25)

Perhaps what Blackmore and Gleaves have discovered is a modern variant of vol-
untary vomiting in the context of a twenty-first-century generation. Alcohol and
alcohol poisoning are part of many young people’s lives in societies where alcohol is
cheap, available, and where overuse can become the norm.
To understand the practice of voluntary or deliberate vomiting better, I talked with
Connie Webber (Box 11.2).

240
 volu n ta ry vomi t ing

Box 11.2. Connie, on modern vomiting: “we are putting more alcohol in so
we need to take it out”
Connie is 21. She studied medical science at a UK university, graduating six months
before we met. She described herself as in an “in-between phase” of life. She was happy
to talk about voluntary vomiting, or, as it is known in this student vernacular, “tactical
chundering” or “TCing.”

______________________________________

Chris: What is tactical about tactical chundering?

Connie: Well, it is when alcohol is involved. It is usually when I am quite drunk and
I come home. If I have a dizzy feeling or I think I am going to be sick at some point,
or if I can’t sleep properly, then I will make myself be sick because I know it will
happen anyway and I will feel horrible if I don’t. I guess it has become a bit of a habit.
Whenever I get a slight dizzy feeling after I have been drinking, I will make myself
sick because I know it will make me feel better. I have known people do it while
they are on a night out. So if they feel ill during the evening, they will leave and be
sick, then come back and carry on. Mine is more when I get home and I want to go
to sleep.

Chris: Is it only when drinking? Or do you vomit at other times?

Connie: I would hate to vomit when I wasn’t drunk. That is horrible. I hate the feeling of
being nauseous and sick. But I haven’t been ill for a very long time. It is not about food.
I am happy with what I eat and with food. It is only about alcohol. I don’t make myself
sick at any other time.
Chris: Tell me about drinking too much then. What is normal?

Connie: It is the culture of universities. Going out a lot. People drink a lot before they go
out because they do not have money. So the idea is to power through early and have a
cheaper evening in the long run.
Chris: Do you eat before drinking?

Connie: No. Most people get food on their way home. People drink a lot, then go out, then
eat, and are then sick. We are putting more alcohol in so we need to take it out. I think
that is what is happening.
Chris: Would it be easier to put less in?

Connie: Having less would be easier. But I think when you drink you don’t process what
is going to happen in the future. Alcohol is just very, very available.

Chris: So is it a commonsense strategy?

(Continued)

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 e x pu l sion

Box 11.2. Continued

Connie: That is what it feels like to me. It is not abnormal to me. I see it as a barrier to
remove. I have drunk too much, put myself into this state, and it can make me feel better,
then I can sleep it off. Alcohol makes me quite sick anyway, so if I don’t do it I will wake
up an hour or two later and be sick naturally. So I get in early.
Chris: Is it taboo? Do you talk about vomiting openly?
Connie: I don’t think anyone responds in a bad way to it. Not really. I guess it is almost a
joke with the friends in my university house. It is not a serious issue or anything. Maybe
they see it as unusual because they don’t do it, but not unusual in that they wouldn’t
think of me in a different way or see it as a problem. People can get the wrong idea. They
might think that I drink too much and that is a bad thing. I would never talk about it
unless somebody asked me about it, but if they asked, I would be happy to talk. I am not
embarrassed by it. It is normal.

______________________________________

There are specific settings in which expulsion behaviors take on different meanings: fart-
ing as an expression of masculinity was discussed as one, and here vomiting has become
a way to manage alcohol poisoning. In Connie’s case, the unpleasantness of vomiting
and any social disapproval is inhibited, perhaps by the effects of alcohol, replaced by
a positive feeling of purge and the promise of sleep and no hangover. How secondary
prevention of poisoning through vomiting becomes preferred to primary prevention
through avoidance is an important research question. Also needed is research on how
expulsion behavior that is specific to one setting can generalize to others. Is voluntary
vomiting a student habit or a generational feature—an inevitable consequence of living
in an alcohol-plenty environment?

Reproductive removal

The final two physical removal senses are not gustatory but reproductive. The cycli-
cal removal of blood, mucus, and endometrial tissue vaginally is often preceded or
accompanied by discomfort and pain caused by muscular contraction of the uterus.
Although not only blood, discharging menstrual fluid is often thought of as an act
of bleeding. The psychology of blood is itself an important and relatively unexplored
field. We have an ambivalent relationship with blood: thought of often as clean even
when outside of the body (in comparison with other bodily tissue), it can be lauded
and totemized, become the object of fascination and comfort in self-harm (Glenn and
Klonsky, 2010), and be symbolic in religious thought and practice (Lucchetti Binge-
mer, 2014).

242
 r e produc t i v e r e mova l

For many women, however, the experience of menstruating is anything but fasci-
nating or comforting. For example, Trine Karlsson and her colleagues in Stockholm
surveyed over 1,500 Swedish women, 32 percent of whom reported heavy bleeding.
They used the Short Form-36, a popular measure of quality of life, and found that
menstrual bleeding was for most women associated with widespread negative impact
on aspects of life. But, as Figure 11.2 shows, in all domains of quality of life, those with
heavy menstrual bleeding reported a greater impact than those with normal blood
loss (Karlsson et al., 2014).
Menstrual bleeding is without a dominant primary sense. Its physical impact
is borne from its secondary associations with pain, temperature, and pressure
sense changes, and, importantly, from the social demands of managing the
crossing of blood from body to society. Menstrual blood as public, arguably
much more than other respiratory or gastroenterological removal, is highly
stigmatized and subject to very restrictive social norms (Johnston-Robledo and
Chrisler, 2013).

HMB Normal
56
54
52
50
48
46
44
in
g

Bo ical

lth
h

ty

em ng

CS
na
Ro onin

PC
alt
en y pa

l f itali

ea
i

M
io
ys

Ro tion
he

lh
ot
ph
ti

V
di

al
nc

ta
c
un
le

er

en
fu

le

M
al

cia
ic
ys

So
Ph

Fig. 11.2. Domains of Quality of Life judged by women with normal menstrual bleeding and
heavy menstrual bleeding (HMB).
“Norm-based mean scores for all eight SF-36 domains and physical component score [PCS]
and mental component score [MCS]. The scores for heavy menstrual bleeding (HMB)/normal
menstrual blood loss (MBL) are shown. The general population norm is 50. Statistical analysis,
Student’s t-test. The difference between HMB and normal MBL is significant (p < 0.001) for all
dimensions.”
Reproduced from Heavy menstrual bleeding significantly affects quality of life, Trine S. Karlsson,
Lena B. Marions, and Måns G. Edlund, Acta Obstetricia et Gynecologica Scandinavica, 93(1), pp. 52–7,
Figure 1, doi:10.1111/aogs.12292 Copyright (c) 2013, John Wiley and Sons.

243
 e x pu l sion

Ejaculation

The final reproductive removal sense is the experience of ejaculation. Both men and
women can ejaculate on orgasm. For men the discharge and propulsion of semen
is considered the norm and its absence can be troublesome. For women, the pro-
duction, discharge, propulsion, and exact composition of ejaculate are all hotly con-
tested. There are likely two forms of female ejaculate, one that is experienced as a
gushing and one that has lower motility and volume and is closer to seminal fluid
in its biochemistry (Rubio-Casillas and Jannini, 2011). In an interesting study of the
medical history of female ejaculation in The Journal of Sexual Medicine, Joanna Korda
and her colleagues review historical descriptions and observations as well as modern
studies. They conclude:

The phenomenon of female ejaculation has been discovered, described and forgotten in
eastern and western culture repeatedly over the last 2,000 years. Today the phenomenon
of the female prostate producing female ejaculate is beyond debate, however, future stud-
ies are needed to further our knowledge of female ejaculation. (Korda et al., 2010, p. 1974)

Although it is contested it may also be common. In an online survey of 340 women,

163 reported ejaculating, here defined simply as “an emission of fluid during orgasm,”
at least once a day or “a few times during a week” (Wimpissinger et al., 2013). The
lack of precision in their methods means that this survey is likely to overrepresent.
However, it is interesting that for women who experience ejaculation, the experience
was largely positive:

For 252 women (78.8%) their ability to ejaculate was an “enrichment of their sexual
lives”; 33 women (10.3%) were indifferent; 23 women (7.2%) “sometimes wished they
would rather not ejaculate”; 10 women (3.1%) primarily “wished they would not ejacu-
late,” and two participants considered female ejaculation as a “pathological” phenom-
enon. (Wimpissinger et al., 2013, p. 182)

In some cultures female ejaculation is highly valued and seen as a core part of sex-
ual practice (Larsen, 2010). Considering the importance of menstruation in women’s
embodiment and physical experience, it was interesting that I could find no discus-
sion of the fate of female ejaculation postmenopausally. Given the common concern
with vaginal atrophy, symptoms of dryness, and the prominent place for some of
ejaculation in experiencing sexual pleasure, it would be surprising if postmenopau-
sal changes in ejaculation were not part of some women’s experience. It has not yet,
however, emerged in general research, so may need to be explicitly asked about (Utian
and Maamari, 2014).

244
 t e l l no one

Male ejaculation occupies a large number of pages in the medical press, although
most of these pages are concerned with sexual dysfunction; in particular, with pre-
mature ejaculation. But as with many concepts in sexual health, there is a disagree-
ment over measurement making even the capturing of prevalence difficult (Serefoglu
and Saitz, 2012). In an interesting review, Alain Giami discusses the problems of what
constitutes “premature,” whether there is any sense of an objective standard, which he
proposes in the heterosexual case as one minute of “intravaginal ejaculation latency
time” (Giami, 2013, p. 32). Giami’s goals are scientific. How can we measure a phe-
nomenon without agreement or any consensus over its key features? He recognizes,
however, that the distress associated with ejaculation, whether premature or delayed,
is always personal and always contextual.

Tell no one

The context of reproductive removal is one dominated by social constraint. The

public display of both ejaculate and menstrual blood is largely taboo, and discussion
is tightly constrained to specific settings and relationships. Two social and psycho-
logical determinants largely define the experience of these removal senses. We have
seen both before. The first is the public-private dynamic, which makes most removal
sensations invisible. The second is the subject-object dynamic, which governs how
what is separate from the body stays separate, typically by inducing disgust.
Most people have no sense of what might be considered normal when it comes to
male ejaculation. Observation studies place normal ejaculation latencies at an aver-
age of about six minutes (Kempeneers and Desseilles, 2014) and the volume of semen
produced at about 4 ml (Jørgensen et al., 2012)—but when it comes to measured force
of projection there are no data of any quality. However, ignorance of these norms
remains common. For example, beliefs about inadequacy dominate the concerns of
those seeking sexual therapy, and social comparison nearly always exaggerates oth-
ers’ sexual behavior, allowing individuals to consider their own behavior as abnormal
(Scholly et al., 2005).
It is strange that we know so little and that our perceptions are so often wrong.
After all, ejaculation is not a new human phenomenon. It seems that when it comes
to sexual performance, our propensity to “tell no one” about sexual expectations,
desires, or practices means that no one believes themselves average. Sexual behav-
ior is normally distributed, statistically speaking, but perceptions of sexual behavior
may actually have an inverted or U-shaped distribution, with the majority of people
believing themselves living closer to the extremes. To date, the psychology of ejacula-
tion is largely concerned with perceived problems of timing as the source of personal
or relational distress. There is no serious study of the specific beliefs about ejacula-
tion. Psychology appears to be following the cultural norm by staying quiet.

245
 e x pu l sion

Of course, what keeps us silent about the ejection of reproductive tissue is not a
predilection for personal secrecy, but a set of closely observed social practices. One
of these is a variant of what we see in defecation, urination, and vomiting. Ensuring
distance from ejaculate is a function of hygiene beliefs. Just as menstrual blood is
often culturally constructed as disgusting, so semen and vaginal discharges are con-
sidered substances to avoid. Once escaped from the body, they enter the world of
hygiene management. Disgust can and often does play a role in the experiences of
shame and embarrassment in those who avoid sexual contact. These emotions are
also behind the stubborn resistance to changing the practice and mistaken belief of
there being any benefit to vaginal douching (Ekpenyong et al., 2014). Feminist schol-
ars have convincingly explored the role of hygiene beliefs in subjugating female sexu-
ality, objectifying female sexual practice, and maintaining a disempowering silence
around female genital practice, including removal (Fahs, 2014).
Psychology may have a role to play in better understanding how hygiene beliefs
operate in both menstruation and ejaculation. In particular, sorely needed is an
exploration of how the perception of “normal” has departed so radically from reality,
and how any social correction of our misperceptions is culturally resisted.

Summary

Being embodied is an ever-changing reality. We ingest, digest, and divest matter.

Operating across all ten expulsion senses is a fascinating, automatic redefinition of
subject to object: as matter leaves the body, it becomes other to self. Matter needs
to be not only removed but also expelled, and disgust is often the method of ensur-
ing that separation. The way we manage discorporation is socially defined. Some
senses, like farting and vomiting, can take on other meanings in particular settings,
but typically expulsion is meant to be private, hidden, and silent. Psychology has not
really contributed to the embodied senses of expulsion, and there are major oppor-
tunities for the development of a “continence psychology.” For some people, chronic
­expulsion—whether in coughing, hiccupping, defecating, or vomiting—is a major
source of distress. Needed are effective interventions to reduce the distress and dis-
ability caused by the physiological failure of control. Equally important will be to
research how and why the expulsion senses are private, sometimes secret. When we
“tell no one,” unusual beliefs and behaviors are allowed to flourish.

Notes

1. Reproduced from Margaret Vernon, Nancy Kline Leidy, Alise Nacson, and Linda Nelsen,
Measuring cough severity: Perspectives from the literature and from patients with chronic
cough, Cough, 5 (5), p. 6, doi: 10.1186/1745-9974-5-5 © 2009 Vernon et al; licensee BioMed

246
 su m m a ry

Central Ltd. Quotation used under the terms of the Creative Commons Attribution License
(http://creativecommons.org/licenses/by/2.0).
2. Reproduced from Martin S. Weinberg and Colin J. Williams, Fecal matters: habitus, embod-
iments, and deviance, Social Problems, 52 (3), p. 320, http://www.jstor.org/stable/10.1525/
sp.2005.52.3.315 © 2005, Society for the Study of Social Problems, Inc.
3. Reproduced from Martin S. Weinberg and Colin J. Williams, Fecal matters: habitus, embod-
iments, and deviance, Social Problems, 52 (3), p. 328, http://www.jstor.org/stable/10.1525/
sp.2005.52.3.315 © 2005, Society for the Study of Social Problems, Inc.
4. Reproduced from Daniela Hayder and Wilfried Schnepp, Experiencing and Managing Uri-
nary Incontinence: A Qualitative Study, Western Journal of Nursing Research, 32 (4), pp. 486–
487, doi: 10.1177/0193945909354903 Copyright © 2010, SAGE Publications. Reprinted by
Permission of SAGE Publications.
5. Reproduced from A loss of social eating: the experience of individuals living with gastropa-
resis, Jose Bennell and Claire Taylor, Journal of Clinical Nursing, 22 (19–20), p. 2817, doi:10.1111/
jocn.12196 Copyright (c) 2013, John Wiley and Sons.

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 CHAPTER 12

EMBODIED AND EMBEDDED

W e exist as bodies operating in context: we are embodied and embedded. It

is this tension—of a body that is both experiencing and experienced—that
makes physical life so interesting. A psychology of the senses needs to account not
only for the individual sensory experiences but also for how they operate together,
how they allow action upon the world, and how the world makes action possible
(Haugeland, 1998).
In each chapter, I wanted to avoid being distracted by the big five senses of seeing,
hearing, smelling, tasting, and touching. I wanted also to treat each of the physical
senses separately from each other. Bodies have been carelessly neglected in psych-
ology. For a brief period, I wanted the physical sensations, the experiences that are
so important in our everyday lives, to have our undivided attention. Of course, my
corralling each sense into its own isolated chapter was artifice, a narrative device.
Critics will argue that the senses share many features, and they will be right. There are
themes that occur across my exploration of the individual physical senses, themes
that emerge to be at the heart of a psychology of the body.
In this final chapter, I dwell on the most prominent of the crosscutting themes. First
is attending. Always under negotiation in perceptual psychology are the questions of
how, when, and under what conditions sensations are made available to conscious
awareness: when do we attend and what are the consequences of that attending? Sec-
ond is what it feels like to be motivated to alter the sensation attended to, the urge to
change experience. And third is the ability of senses when operating at their limits
to challenge the very constructions of physical reality that are essential to embodied
cognition and behavior. At the extremes of physical sensation come derealization phe-
nomena. In the end—at the extremes, when we are running out of choices—we slip
out of our bodies.
My method of reporting the personal experiences of each sense by interview was
also a contrivance. People rarely, if ever, experience physical sensations without other
sensations. Sometimes one dominates over another, but they often occur together.
Take Marni, for example, who lives with lupus and appeared in Chapter 4 to talk
about the experience of heaviness; she would have been equally eloquent talking
about fatigue, tumescence, imbalance, or temperature. Kerry was superb at discuss-
ing fatigue and did so engagingly in Chapter 6, but she could have talked about her
experiences of pain at mile 70 of her ultra run. This form of multisensory experience

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is worth closer consideration and is increasingly important in the context of aging,

where it is discussed with a clinical language of “comorbidity.”

Transitive and intransitive

Five of our senses operate outside of awareness. Balance, movement, breathing,

being at body temperature, and being under normal pressure all operate automati-
cally, without attending. It is only when forced to their limits that the nonconscious
emerge as conscious; they become falling, being propelled, not being able to breathe,
feeling swollen, or being too hot or cold. The other five of our senses—pain, itch,
fatigue, hunger, thirst, and expulsion—exist only on attending; when absent they
are typically characterized by relief. The first five are largely proprioceptive (with the
exception of temperature) and the last five are largely interoceptive (with the excep-
tion of expulsion). I like David Armstrong’s original distinction between “transitive”
and “intransitive” physical sensations as it captures both the phenomenology and the
functionality of physical senses (Armstrong, 1962). My treatment of the ten neglected
senses does not map perfectly onto his original scheme, but it comes close. A modern
version of this distinction relies more on the role of attending.

Attending

Why attend to one sense rather than another? At any one time aspects of all ten senses
are more or less available to be selected into awareness. Run a thought experiment and
test it yourself. Am I balanced? (check); moving? (check); itching? (check); etc. At times
you might want to do exactly this checking; for example, in deciding whether you should
put on a coat, or in being aware of your joint pressure when practicing a yoga exercise.
This aspect of choice in attending to bodily sensation is not only a source of pleasure
and fascination, but a dominant interest to a psychology of the body; it holds the key
to understanding how behavior is altered, how the body limits or enables possibilities.
The limits of possible actions are determined by attention toward or away from
physical sensation. But attention is a slippery concept. Traditionally, psychologists
have studied attention by reference to its restrictions using metaphors of (limited)
resources, (spendable) capacities, (narrowing) bottlenecks, and (straining) filters
(Wu, 2011). Perhaps what is most important about attention is not selection for the
sake of selection but what Alan Allport (2011) has called “selection-for-action.” We
attend for a reason, not simply as a response to the most demanding characteristics of
the stimulus. We are largely goal-directed creatures, selecting and deselecting infor-
mation, attending in order to maintain behavioral coherence toward a goal. In this
way, Allport argues, “attention [better still, attending] refers to a state or relationship of
the whole organism or person” (Allport, 2011, p. 25, his emphasis).

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Psychologists often ask the question: under what circumstances can I make one
attend toward or away from bodily sensations? Or: what are the consequences of
attending toward or away from bodily sensations? And: how stable are patterns of
attending over context and over time? The answers to these questions were reviewed
across the senses in each of the chapters. Attending is biased toward certain informa-
tion in our environment when it is meaningful to us. The classic example is in visual
attention to something that scares us. People scared of spiders will be more likely to
attend to spider-like information in the environment, what we call “cues” for spiders.
Attending toward bodily sensations or their cues has provoked a lot of research
interest, discussed in different chapters as attentional bias. There have been attempts
to establish attention bias effects for cues of pain, itch, fatigue, and breathlessness.
The most interesting findings are in breathlessness, perhaps because of its associ-
ation with panic. These studies are still at an early phase of development and need
methodological innovation. To date, experiments often use cues for sensation that
are symbolically coded, either verbally (e.g., the word itch) or pictorially (e.g., a facial
expression of pain). The most successful studies are those for which the researchers
have recreated the physical experience in a controlled environment, as Kim Delbaere
did in designing methods of inducing postural instability, and as Omer Van den Bergh
did with inducing breathlessness.
Advances will come not only in studying responses to artificially delivered signals
of impending sensation, but also in understanding what we preferentially respond to
in the natural environment. Again, methodological innovation will help. For example,
modern technologies of deliberate falling (the roller coaster, the bungee rope) make
movement through space possible to study. And digital recording technology can
now capture previously hidden behavior such as how we manage peripersonal space,
when and how people scratch, and when changes in body temperature trigger sec-
ondary regulation behaviors such as putting on a hat.

Vigilance

Not attending is the blissful norm for most people. Consider the complicated task of
remaining upright. We have constant sensory information about our physical pos-
ition in relation to the ground and to objects around us. However, thankfully, we are
unaware of signals of balance in what is largely the noise of constant information. It
is only when a change of sufficient magnitude, velocity, or character triggers a shift in
attending that we are made aware of an impending trip, slip, or fall. Imagine, though,
if every surface in the world was made unstable so that even the most familiar of
tasks, like walking down your street, became fraught with danger. Imagine, in other
words, that you are trying to walk during an earthquake, or you have had a stroke
and are learning to walk again. It would pay to become vigilant for cues of impending
instability.

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Chronic vigilance is studied under different names, borne from different scien-
tific traditions: chronic preferential attending, hypervigilance, somatic awareness.
They differ in specific features but share a presumption of a stable selection of one
of the bodily senses over competing demands. Most theorizing about vigilance uses
the pathological case as the starting point. If I visit the doctor to complain about
being cold, or tired, or itchy, or in pain, both she and I will collude in the idea that
my physical complaints are symptoms of an underlying disorder and might indicate
an identifiable pathology. If my physical sensation is irrelevant to any pathology,
then she might reasonably ask a new question, about why I am attending to that
sensation. Throughout I deliberately avoided and will continue to avoid discussion
about pathological vigilance. It is well covered in the psychiatric and clinical psycho-
logical literature. And, to be fair, the pathological case interests me much less than
the nonpathological. Normal vigilance is more common, less investigated, less well
understood, and more fascinating. We are only beginning to understand how stable
patterns of vigilance emerge and are maintained for specific goals, whether it is in
staying continent long enough to reach a public toilet, blocking out high temperature
to complete a forging process, or working with an exciting new spider at the zoo.
Delia Cioffi proposed a general model of what matters in awareness that is a good start-
ing point for a normal psychology of bodily sensation (Cioffi, 1991). For Cioffi, preferential
selection as a fact of attending is interesting, but is only the beginning of an explanation
of behavior. What happens after attending is the labeling of sensations. When I become
aware of appetite, am I “peckish,” “hungry,” or “starving”? When I feel pain, is it a “curious
sensation,” an “annoyance,” or a “frightening return of disease”? What governs the labe-
ling, and the variability between people, and within people over time and context, is often
what we are studying with the individual senses. The pain example gives a hint of what
is often being determined. Interruption by physical sensation, awareness of one’s body,
and vigilance for that sensation in the future, are affective-motivational phenomena.
In other words, when we label something, it is not simply a dry functional cataloging:
the labeling is always about feelings and action. When pain or heat or imbalance inte-
rrupt me, a specific behavior is not only made possible—it is often urged. I am interested
in the phenomenology of the physical senses: what it feels like to be tired, cold, or hungry.
But I am just as interested in the behavior that is being promoted: what it feels like to be
urged to rest, to seek warmth, or to consume.

Urge

There are at least three related meanings of urge that are relevant to the physical
senses. First, an urge is a qualia (a unique conscious event) of feeling drawn to act
in a specific way, sometimes inexplicably, sometimes overwhelmingly. This urge
can easily be seen as either a desire or a craving. This is the common use of urge in
literatures about addiction. Second, urge is an action done to you. Other people,

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or other situations, may urge you on, urge you to react, urge you to change. This is
the meaning of urge I borrow from ecological psychology in which environments
afford behavior. These two senses preserve the dualistic idea of self and other; one
is an internal force, the other external. Common to both is the third meaning of
urge, which is better understood in its related adjectival form as urgent. The behavior
being urged has a quality of immediacy, of needing to happen quickly. If it can wait,
it is not urgent.
Each of the physical senses is intimately tied to a specific urge function that defines
the flow of behavior that follows attending and labeling. One way of understanding
the studies reviewed in each chapter is to see them as attempts to explore what it is
like to be urged, or to live a life defined by a chronic physical urge. There are studies of
the consequences of urge on quality of life, and how we might intervene to treat those
who find the urge unpleasant or pernicious. And there are studies of how to promote
safety in those who ignore sensations, either naturally or in trying to improve a skill,
task, or role. Sometimes researchers have no such practical motivation. They just
want to understand. They ask: how is it possible that we manage to achieve coherent
and consistent behavior with attention switching repeatedly between multiple phys-
ical urges?
Table 12.1 summarizes the specific functions of urge. Each of the physical senses is
tied to a functional class of behaviors. Some are specific, like breathing and scratch-
ing, and some are more general, like avoiding harm.

Table 12.1: The functions of physical senses

Sense Function

Imbalance balance
Movement control
Pressure stop
apnea breathe
Fatigue switch

Pain avoid harm

Itch scratch
temperature thermoregulate
appetite consume
expulsion remove

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The transitive senses of balance, movement, pressure, breathing, and temperature

all urge when there is a threat to the equilibrium of the whole person, or what Bud
Craig has called homeostasis (Craig, 2002). Imbalance urges balance by promoting
adjustments in body position in relation to gravity. Moving too fast, too slow, without
temporal or spatial fluidity, or without control all urge attempts at direct motor con-
trol, either by changing speed, musculoskeletal micro-adjustments, or in close con-
centration on an otherwise automatic movement. Pressure senses operate in much
the same way as movement, but the urge is to stop: they act as a brake on the danger
of overextension. Breathing is possibly the purest and simplest form of urge. Halting
breathing urges breathing. Finally, temperature urges secondary thermoregulatory
behavior. When you are hot you are urged to lose heat, and when you are cold you are
urged to seek warmth.
The intransitive senses of pain, itch, fatigue, hunger, thirst, and expulsion come into
existence as urge. Like breathing, itch is functionally specific: it promotes scratch. But
pain is related to a broad class of avoidance behavior. Pain functions to promote avoid-
ance of perceived harm, so needs to rely on a wide range of perceptual and motor
behaviors. In the right context, almost any behavior can be recruited to avoid pain.
Fatigue urges switch of attending: to disengage from something old and to engage
with something new. Appetite drives the whole organism toward a single goal of con-
sumption. And expulsion urges both symbolic and physical disembodiment. To expel
is not only to separate and remove matter from the body, but preferably to project it
away from the body, and to keep it away by immediately redefining it as foreign.
Thus the function of physical sensations is to urge change in behavior. In each
chapter I discussed the psychology of what happens when we fail to register the need
for change, when we try to find ways to master and control the urge for change, or
when the context no longer affords change—through illness, decline, or restraint.
Coping with being embodied is a matter of everyday cognition and behavior: it is how
we live. Embracing corporeality could radically enrich the psychology of cognition,
motivation, and emotion. Psychology is the study of embodied behavior.

Corporeal derealization

Part of my exploration of the physical senses was an examination of extremes, which

at times I called “limit” experiences. What happens when one is at the very edge of
apnea? In inescapable pain or itch? So hungry that the category of possible food has
expanded to almost everything? So tired, cold, or swollen that taking action becomes
unthinkable?
Reading across the physical senses, there are hints of an answer. It was made expli-
cit in Chapter 2 when considering disorders of imbalance and height intolerance. At
the extremes of physical experience comes separation from self, a change in the per-
ception of a body as owned. This effect seems to operate across the physical senses

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but appears as different forms of dissociative experience, all of which have in com-
mon a separation from reality. Derealization effects include vague and fleeting feel-
ings of awareness of another’s presence and a sense of being watched. Also included
are agency alterations ranging from a complete loss in paralysis to autoscopy in
which one can elevate out of one’s body and observe it from a distance. The ultimate
combination is in being out of one’s own body watching it watching you (Lopez et al.,
2008) (see Chapter 2, Table 2.1).
In clinical neurology and psychiatry, these experiences are narrated as abnormal,
brought about largely by the failure of sensory integration through injury, disease, or
poisoning. In clinical psychology, dissociative effects are well studied at the extremes
of emotion, most extensively in the study of panic and grief. In the clinical literatures,
the dissociative experiences of derealization are often called “illusions.” But in the
normal case, I prefer to think of them simply as limit experiences. Missing is a study
of the normal psychology of breakdown in agency and ownership that occurs often
at the edges of physical experience. Phenomena of corporeal derealization come in
three forms: marionette, immersion, and unkörperliche experiences.
Marionette phenomena, or marionettes for short, are vivid experiences of disequilib-
rium in which one’s relationship with space alters. These were described by Debbie
in Chapter 2, discussing her changed relationship with the properties of the environ-
ment, when the rooms seemed near then far away (telescoping); and described as con-
cerning by Luke in Chapter 3 when flying through the air he experiences knowing he is
in the wrong position in relation to the world. There are changes of agency described
by Jeremy in Chapter 3 when he tries to initiate an action but does not complete it, and
by Emma in Chapter 4 who has a sense of being moved by gravitational force. Being
out of one’s space and losing agency come together in the idea of “height intolerance
autoscopy,” in which one’s perception changes radically. Agency is not just lost in
paralysis but more accurately surrendered as one is urged to the edge—literally, not
metaphorically. Like a marionette, one can feel either totally or partially controlled,
as space, time, and will are altered.
Immersive phenomena, immersions for short, can usefully be thought of as moments
of extreme attending. Immersions are not straightforwardly good or bad: context
defines their value. In Chapter 5 Ian described being immersed in the desire for breath
at the height of an attack of apnea; in Chapter 6 Sarah talked about not fighting fatigue
at the start of a day; and in Chapter 4 Marni talked about an awareness of heaviness
that most people will struggle to understand. I am sure that all would happily be free
of these immersions, which are unbidden, unwelcome, and often unpleasant.
However, as with Philippe Petit recounting the story of his wire-walk between
the twin towers, Luna in Chapter 2 described an immersion in achieving that elu-
sive perfect moment of balance. In Chapter 6 Kerry found an immersion when the
whole world seemed to fall away from her when running alone in the jungle. And
Jean Christophe (Chapter 10) is easily lost in the complexity of his expert appetite

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for outstandingly good wine. Finally, some immersions are relational: neither good
nor bad, and normally narrated as edifying. Examples are in Chapter 9 when Alex
discussed working with iron in his forge as both an escape and a lesson on just how
much one can cope with in life, and by Rupert in Chapter 7, who describes pain as
having changed his view on how his life can be spent profitably.
There is a third, although rare, form of corporeal derealization, which is neither
a pure marionette nor a pure immersion. I call it das unkörperliche, “the unbodily.”
In an essay of 1919, Freud described a class of experiences as das unheimliche, “the
uncanny,” whose root means “unhomely” but translates as “eerie” or “uncanny”
(Freud, 1919/2003). For Freud, das unheimliche is an expression of repression, like the
breaking-through of a faintly recognizable stranger. The original example was the
eerie feeling of uncomfortable recognition you have on seeing a lifelike doll or a full-
size waxwork figure. The idea has taken on a new life in robotics and computing with
the increased use of avatars (Cadeaux, 2013). Unexplored, however, are specific experi-
ences of departures from the bodily senses.
Perhaps the clearest example of das unkörperliche was discussed in Chapter 8 with
formication. Formication is a paresthesia that is intimately tied to the idea of a per-
ceived cause: in this case, itch feels like insects crawling under the skin. These ripples
in the body sensorium, many of which can be artificially created in the laboratory
as illusions, may be more than just curious. Unkörperliche experiences are derealiza-
tion as a form of physical departure, experienced at the extremes of sensation. Criti-
cally, the sensation becomes inseparable from its cause, and the cause is attributed
externally, as arising from outside the body: the itch is due to insects. When pain can
no longer be unyoked from the idea of harm, apnea from suffocation, fatigue from
oppression, or incontinence from shame, these may be the very situations in which
unkörperliche derealization will be observed.
In summary, I propose three forms of corporeal derealization that all operate to
distance one from sensation: a marionette is a disturbance of embedded agency, an
immersion is a disturbance of attending, and das unkörperliche are disturbances of attri-
bution. Naming them may make it more possible to study them.

Aging

Some people have lives dominated by a particular sensation: by pain, fatigue, or hun-
ger. As examples, I sought out Sam, who is an expert on holding her breath; Kerry,
who can persist through fatigue; and Alex, who works with high temperatures. But
many people have lives dominated by not one but multiple sensory experiences. For
example, people with chronic pain experience fatigue, and people with chronic fatigue
experience pain. There are specific conditions in which multiple senses are involved:
for example, patients with rheumatologic conditions can discuss unpleasant changes
in balance, movement, pressure, pain, fatigue, and temperature. Injury or disease, and

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often their treatment, can also bring multiple sensations. In fact, given how long we
are now forecast to live, the incidence of multimorbidity is set to increase. “Multi-
morbidity affects more than half of the elderly population with increasing prevalence
in very old persons, women and people from lower social classes” (Marengoni et al.,
2011, p. 438). And, for many of us, the last weeks and days of life will be a harsh les-
son in embodiment. Many of the examples of specific sensory experiences across the
sense chapters came from palliative care; in particular, end-of-life care.
Aging will challenge our assumptions about how far changes in physical sensation
can be managed. Psychology does not have a lot to offer yet. There is much unchar-
tered territory. For example, the jury is still out on how best psychology can respond
to dizziness and falling in older age: strength building or confidence building? Can we
develop an effective treatment for Raynaud’s phenomenon? We seem to have given
up. And how can the urge to scratch be diminished? In many cases the first questions
are still being asked. How on earth did sweating, for example, come to be seen as
abnormal and unladylike? And what can we do to change it? Given the taboo over
reproductive expulsion, what are the norms for expulsion as we age into our 70s,
80s, and 90s? There is a pressing need for a psychology of the aging body, a need to
incorporate embodiment into mainstream psychology.

Hands up

In closing, I am mindful of the unexpected benefits of taking a broad view across ter-
rain normally surveyed tightly within its borders; of exploring the psychology of all
of the physical senses together, instead of investigating each within its biomedical
context. I will give you one example. How often do adults put their hands above their
heads? Infrequently is the answer: perhaps to dust a high shelf or change a light bulb.
It emerges that there are many reasons why adults should raise their arms above their
heads. In Chapter 3 we saw that children reach for objects often—it is how cognition
is enabled, through exploration. And there may be significant benefits to confidence
by adopting expansive poses, in literally filling your peripersonal space. In Chap-
ter 4 the consequences of inflexibility and tumescence persuaded me of the benefits
of attempting yoga, stretching, exercising. Combine this with the thermoregulatory
advantages of moving heat around the body, as discussed in Chapter 9. Add the gen-
eral cardiovascular benefits of exercise and it is clear: expansive poses that involve
raising your hands above your head are highly likely to bring multiple benefits to
physical and psychological well-being.
There are other themes, “narrative worms” that travel across the different chapters.
For a further example, I was struck by a belief in unitary illness that appeared in a
number of interviews. Debbie, for example, in Chapter 2 remarked: “I suppose I look
at it that there are people far worse off than me, so it is something you put up with. It
is better than having a lot of other things wrong with you.” Euphemia said something

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similar in Chapter 9: “We are all going to get something and if this is it, then that is
fine.” It was a surprisingly common response to a question about coping. Given the
growing challenge of comorbidity, this particular way of isolating and minimizing
experience, and the reasoning of having received one’s share of illness, will be inter-
esting to explore. It is not clear whether this minimizing strategy will fail when other
sensations impinge, or whether it will prove robust and continue to be protective.
There will be other worms I have not spotted that work through all of our senses.

A psychology of the body

Psychology has always been too mental, relatively uninterested in the body, treating
it sometimes as just the means of transporting the mind from one place to another.
The opposite is true. Being embodied makes it possible to experience the world. It is
only by acting in and on the world that we are able to construct reality. It is because
we are embodied that the limits of our conscious experience are constantly at stake,
being defined, challenged, redrawn, exceeded, or surrendered to. You have here a nor-
mal psychology of the body that promotes a functional view of physical sensation
extended with an appreciation of phenomenological experience. In the end, psychol-
ogy is better for trying to understand individuals’ experiences. If we embrace the cor-
poreal turn in psychological science, we might be able to teach the next generation
that there are more than five senses. Being embodied is how we experience, what we
experience, and whom we experience.

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 I NDE X

Notes: vs. indicates a comparison.

A urge, 256
accidental falling, 14–15 see also obesity
acting, occupational dieting, 218 Arai, Tsuru, 108
active engagement of self, vitality, 113 Armstrong, David, 5–6, 252
activity avoidance, 37 Ashcroft, Howard, 182
fear of falling, 12–13 assessment tools, itch, 169–70
Adams, Glen, 71 attending, 251, 252–3
adolescents attentional redirection, relearning of breathing, 91
food preferences, 207 attention-control strategies, 114
heaviness–lightness continuum, 67 attention to threat, pain, 132
movement, 36 Aunger, Robert, 166
advertising autoscopic hallucinations, 27–8t
food choice, 210–11, 211f autoscopy, 27–8t
hedonic appetite, 208–9 avoidance of activity see activity avoidance
aerophagia, 231 Ayers, Beverley, 189
affective touch, 159
aging, 258–9 B
agoraphobia, panic, 92 balance, 6, 8–32
alcohol consumption, voluntary vomiting, 240 achieving of (equilibrium), 15–16
Allport, Alan, 252 biological mechanisms, 9
Altenmüller, Eckart, 49 loosing of see dizziness
analgesic culture, 140–1 natural awareness, 16–19
Andersson, Gerhard, 21 personal stories, 17–19
animalism, farting (flatulence), 233 urge, 256
annoyance, itch, 164 see also falling
anorexia, 205 ballet, equilibrium, 15
anosognia, 47 ball-throwing, 36–7
anxiety Bardy, Benoît, 35
farting (flatulence), 232 Bargh, John, 179, 180
pain, responses to, 140 baroreceptors, 81
appetite, 6, 201–24 Bastian, Brock, 135
craving, 217–20 Bath, Anja, 164–5
dietary restriction, 215–16 Baumeister, Roy, 109
food choice, 209–11 behavior
hungry behavior, 216–17 climate-driven, 181–2
overeating, 202 extinction, 163
personal responsibility, 214–15 hunger, 216–17
personal stories, 212–14, 220–1 thermoregulation, 178
pleasures of desire, 205–6 Beliefs About Yoga Scale, 58
see also hedonic appetite Berthoud, Hans-Rudolf, 202
pleasure vs. preference, 205–6 biological energy reserves, 202
power relationship, 203–4 Blackman, Lisa, 3
priority setting, 204–5 Blackmore, Natalie, 240
public understanding, 215 Blake, Anthony, 210
regulation, 201–3 blood
unappetizing food, 206–8 flow in Raynaud’s phenomenon, 193

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blood (continued) C
thermoregulation, 178 cachexia, 66–7
viscosity study, overtraining, 65 California, clothing and temperature, 183
Blumenthal, Heston, 210 cancers, persistent fatigue, 118
The Body in Pain (Scarry), 132–3 cardiorespiratory inflexibility response, 90
body ownership, height intolerance, 26 cardiovascular injury, heaviness, 65
body practices, sociology, 4 Carstens, Earl, 153
body temperature CBT see cognitive behavioral therapy (CBT)
character judgement, 178, 179 cerebellum, balance, 9
see also thermoregulation cerebral palsy, fine motor control, 48
body weight changes, 65–6 Cervero, Fernando, 130–1
van den Bos, Ruud, 215 CFS see chronic fatigue syndrome (CFS)
brain injury, anosognia, 47 Chambers, Lucy, 210
brainstem, nociception, 131 character judgement, body temperature,
brain-training, fatigue, 113–15 178, 179
Brandt, Thomas, 25–6 children
breast cancer, swollen feelings, 68 behaviour with senses, 3
breathing, 6, 79–100, 256 dietary studies in development, 207–8
to achieve, 82–4 hand raising, 258
control of, 81–2 pain, 129
definition, 79 self-exploration, 40
diving, 84–5 see also infants
dyspnea see dyspnea China, dietary differences, 206
endurance sports, 83 chronic cough, 227
expiration, 82 chronic dizziness, 20
fear conditioning, 89–90 chronic fatigue syndrome (CFS), 118–22
functionalist account, 100–1 attentional bias, 120–1
high and low altitude, 84–7, 85f cognition therapy, 120
lack of see dyspnea maintenance, 119–20
panic see panic social context, 121
personal stories, 86–7 symptoms, 120
physical mechanisms, 80 chronic hiccup, 229–30
physiological monitoring of patterns, 95 chronic itch, 161–2
proprioception, 81 chronic obstructive pulmonary disorder (COPD),
relearning of, 91–2 96, 97–9t, 100
respiratory awareness, 88–9 chronic vigilance, 254
respiratory variability, 89–90 Cingi, Cemal, 227
terror management, 100–2 Cioffi, Delia
urge, 256 value in pain, 139
see also respiration vigilance, 254
breathlessness, psychological treatment, Clark, Andy, 5
100 classical explanation, fatigue, 108
Breivik, Gunner, 40 climate-driven behavior, 181–2
Bridget Jones effect, 180–1 climbing, 84–5
Brosschot, Joss, 90 closed social practices, reproductive removal, 246
Brownell, Kelly, 214 Closs, José, 133
Brown, Judith, 134 clothing, temperature, 182–3
Brown, Kathleen, 192–3 clumsiness, 33, 36–7
Brown, Steve, 4 Cochrane reviews, 147
bruising, 134 cognition, embodied, 35–6
Brymer, Eric, 10 cognition therapy, chronic fatigue syndrome, 120
built environment, weakness, 63 cognitive behavioral model, 119–20
Buma, Lori, 83 cognitive behavioral therapy (CBT), 122–4
burping (eructation), 225, 230–2 fatigue beliefs, 122
embarrassment, 231 cognitive enhancement, stimulants, 113–14
gastric self-management, 231 Cognitive Intervention Scale, 140
gastrointestinal disturbances, 231 cognitive intrusion, pain, 140
humor, 231 cognitive tasks
Byrne, Susan, 66 short-term performance, 114

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studies of, 114 diaphragm, 80
tests, temperature effects, 183–4 diet
cold, 184 differences, 206
exposure to, 184 insects in, 206
extreme, 190–1 restriction see dietary restriction
mortality, 190, 191f dietary restriction, 215–16
Raynaud’s phenomenon, 192–3 hungry behavior, 216–17
cold-blooded loneliness, 180–1 see also occupational dieting
cold-hearted character, 179 dieting, occupational see occupational dieting
cold-shoulder of rejection, 181 disease transmission
conditioned behaviors, 163 face scratching, 158
confusion, dizziness, 20 sneezing/coughing, 226, 227
consequences, fear of falling, 12 disequilibrium, 19–29
constipation, swelling, 69 dizziness, 19–20
constricted postures, 44 threats of, 20–1
continuous pain, 141 vertigo see vertigo
control development, movement, 34–5 disgust
control of breathing, 81–2 itch, 165–8
COPD (chronic obstructive pulmonary disorder), sweating, 188
96, 97–9t, 100 vomiting (emesis), 239
coping with pain, 141–2 distance swimming, breathing, 83
core body regulation, 178 distraction, pain coping, 142–3
corporeal derealization, 256–8 dizziness, 19–22
cortex, nociception, 131 chronic, 20
Costa, Marco, 43 orthostatic, 19
cough (tussis), 80–1, 225, 226–7 treatment, 22
chronic, 227 Dolan, Eimer, 218, 220
disease transmission, 227 Domains of Quality of Life, menstruation, 243, 243f
personal distress/social threat, 229 doors, weakness, 63
severity measures, 227–8 Dros, Jacqueli, 19–20
‘Coughs and Sneezes Spread Diseases,’ 227, 228f Duckworth, Angela, 115
courage, 115 dyspnea, 95–100
courageous engagement, pain, 144 personal stories, 101–2
Couture, Roger, 83 dystonia, 48
Coward, Noel, 182 Dzokoto, Vivian, 71
Craig, Bud, 256
craving, appetite, 217–20 E
cultural ambiguity, taste, 3 Eccles, Jacqueline, 36–7
Curtis, Val, 166 Edwards, Nicholas, 67
ego depletion model, 109
D ego repletion, 109
damage, pain response, 142 ejaculation, 225, 244–5
dancing female, 244
equilibrium, 15 male, 245
flexibility, 58 elderly, accidental falling, 14–15
Das unkörperliche, 258 elite sports, equilibrium, 15–16
defecation, 225 embarrassment, burping, 231
continence, 236 embodied cognition, movement, 35–6
incontinence, 237 emesis see vomiting (emesis)
toilet training, 236–7 Emmelkamp, Paul, 187
deficient hypothesis of overeating, 202 emotions
deglutition (swallowing), 238–9 dysregulation during incontinence, 238
deliberate falling, 10–11 heaviness–lightness continuum, 67–8
deliberate practice, 38–9 incontinence, 238
delusional parasitosis, 168 respiration vs., 89
Demain, Jeffrey, 154 endurance sports
depression, persistent fatigue, 118 breathing, 83
derealization phenomena, 251 pain, 135–6
design, strength–weakness continuum, 64 energy, 112–13

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energy reserves, biological, 202 medical studies, 108
equestrian sports, equilibrium, 15–16 motivational model, 112
equilibrium, 15–16 motivation to change, 110–11
Ericsson, Anders, 38, 39 occupational studies, 107–8
eructation see burping (eructation) performance measures, 108
Ervin, Claire, 69 persistent, 118–19
eudemonia, 113 personal stories, 116–18, 123–4
Europe popular explanation, 108
dietary differences, 206 prevalence, 107
historical pandemics, 227 resource depletion, 109–10
obesity prevalence, 204 stop emotion, 111
pain prevalence, 141 urge, 256
event-sampling procedure, respiratory urge to sleep, 112
­monitoring, 93–4 see also chronic fatigue syndrome (CFS)
Evers, Andrea Faulkner, Michael, 95, 101
itch, 163, 169 fear
scratching, 162–3 avoidance model, 144
exercise avoidance, 36 conditioning in breathing, 89–90
expansive postures, 44 falling see fear of falling
expertise, value judgement, 39 incontinence, 238
expulsion, 6, 225–50 pain from injury/illness, 140
definitions, 225 visual attention, 253
releasing gases, 230 fear of falling, 11–13, 13f
urge, 256 dizziness, 20
see also burping (eructation); defecation; feeling-of-a-presence, 27–8t
ejaculation; farting (flatulence); sneeze felt experience, 114
(sternutation); sweating; urination female ejaculation, 244
(micturition); vomiting (emesis) feminist theory, 4
extended functionalism, 5 Feneran, Ashley, 157
external inhibitions, scratching, 163 Filevitch, Elisa, 163
extinction, anosognia, 47 fine motor control, movement disorders, 48–9
extreme cold, 190–1 firefighters, 183–4
extreme sports, deliberate falling, 10 flatulence see farting (flatulence)
flexibility
F pressure, 56
face, grooming, 154 see also flexibility–stiffness continuum
fairground rides, deliberate falling, 11 flexibility–stiffness continuum, 57–61
falling dancing, 58
accidental, 14–15 personal stories, 60–1
deliberate, 10–11 food
fear of see fear of falling avoidance, 205
psychology of, 9–10 choice, 209–11
see also balance liking vs. wanting, 217
Farell, Emma, 85 poverty, 201
farting (flatulence), 225, 232–5 regurgitation, 230
animalism, 233 of withholding, 203–4
anxiety, 232 formication, 168–9
humor, 234–5 fruit avoidance, 207
hygiene association, 232 Fukuda, Keiji, 118
personal stories, 234–5 Fu, Mei, 68–9
prevalence, 232 funambulism (high-wire-walking), 16
public display, 232 functionalism, extended, 5
social unease, 232–3 functionalist approach, 5
fatigue, 6, 107–28 functions of physical senses, 255, 255t
brain training, 113–15
classical explanation, 108 G
disengagement in, 111 gait patterns, 46
indefatigable, 115–18 Galtrey, Clare, 95–6

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Gasser, Michael, 35–6 Helsinki, clothing and temperature, 183
gastric self-management, burping, 231 hiccup (singultus), 225, 229–30
gastrointestinal disturbances, burping, 231 high altitude, breathing, 84
gastroparesis, 239 high-wire-walking (funambulism), 16
gender, sweating, 189 Hill, Andrew, 217–18
general distress, pain, 140 Hinckle, Nancy, 168
genital shrinking epidemic, 71 historical pandemics, Europe, 227
geography of sweating, 188 Hockey, Bob, 111
Germany, incontinence management, 237 Hollins, Mark, 6
Gibson, Stephen, 141 Hormes, Julia, 218
Gillies, Val, 188 Hot Flush Beliefs Scale, 189
Gladwell, Malcolm, 38–9 hot flushes, 189
Gleaves, David, 240 hot-headed character, 179
Glover-Graf, Noreen, 133 humanist tradition, vitality, 112
glucose hypothesis, 109 humor
gluttony, 202 burping, 231
goals farting (flatulence), 234–5
control of breathing, 81 hungry behavior, 216–17
pain, 135–9, 136t Hunter, Myra, 189
personal stories, 137–9 Huta, V, 113
Graves, Sue, 188 Hutt, Kimberley, 15
Green, Sheryl, 238 hygiene
Greeves, Andrew, 40 farting (flatulence), 232
grooming, 154–5 grooming, 157–8
hygiene paradox, 157–8 reproductive removal, 246
gustation (taste), 2, 3 hypercapnia, 81, 88
hyperhidrosis, 187
H hyperventilation, 88–9
Hadjistavropolous, Thomas, 12–13, 13f panic, 94
Haggard, Patrick, 163 hypocapnia, 88
hallucinations, autoscopic, 27–8t hypoventilation, 90
Hambrick, David, 38–9 respiratory awareness, 88
Hammarström, Anne, 216–17 hypoxia, 81, 84, 96
hand raising, 258 dyspnea, 95
hardiness, 115
Harré, Rom, 1 I
Harrold, Jo, 204–5 illness, chronic fatigue syndrome, 121
Hatano, Taku, 48 immersive phenomena, 257
head, sensory apparatus, 3 incontinence, 237
health problems, burping, 231 emotions, 238
health-promotion, relearning to breathe, 91 indefatigable, 115–18
heart rate, perception of, 89 infants
heat loss, sweating, 186–7 accidental falling, 14
heaviness movement, 33, 34–5
heaviness–lightness continuum, 67–8 see also children
pressure, 64–6 infections, upper respiratory tract, 228
see also lightness inflammation, 131
heaviness–lightness continuum, 67–8 inflammatory pain, 131
hedonic appetite, 202, 205–6 insects in diet, 206
advertising, 208–9 inspiration rate, panic, 93
food choice, 210 The Integrative Action of the Nervous System
height intolerance, 25–9 (Sherrington), 34
autoscopy, 26, 27–8t intemperate character, 179
body ownership, 26 intercostal muscles, 80
experience discussion, 25–26 intermediate goals, control of breathing, 81
paralysis, 26 internal inhibition, scratching, 163
physical arrest, 26 International Association for the Study of Pain
height loss studies, 69 (IASP), 130

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International Scientific Forum on Home Hygiene, 157–8 Leonardelli, Geoffrey, 180
interpersonal space, 43 Levitt, Michael, 232
interruption, motivated, 131–2 Lewis, CS, 132
intransitive sensations, 6, 252, 256 Lewis, Glyn, 119
intrinsic cost, tasks, 110 Lewthwaite, Rebecca, 40
involuntary hyperventilation, 88–9 Life at the Extremes (Ashcroft), 182
irritable bowel syndrome (IBS), 238 lightness, 66–7
iStopFalls program, 13 heaviness–lightness continuum, 67–8
itch, 6, 152–75 see also heaviness
chronic, 161–2 linguistic coding, social aspects of
definitions, 153 temperature, 181
disgust, 165–8 Linton, Steven, 144
formication, 168–9 Lloyd, Donna, 155
functions, 153–4 location, pain mechanisms, 130
mechanisms, 152 long-term goals, control of breathing, 81
personal stories, 159–61, 170–2 Lumeng, Julie, 207–8
pleasure of, 158–9 Lussier, David, 141
psychodermatology, 169–70 lymphedema, 68–9
psychological perception, 163
shame, 165–8 M
social contagion, 155–7 Mad Dogs and Englishmen (Coward), 181–2
social emotions, 164–5 Magin, Parker, 166
urge, 256 male ejaculation, 245
see also grooming; scratching Man on a Wire (Petit), 16
marionette phenomena, 257
J Massey, Anna, 217–18
Jensen, Mark, 146 mastectomy, total, 68
jockeys, occupational dieting, 218–19 McGill Pain Questionnaire, 162
Johnston, Chloe, 16 McNicholas, Fiona, 204
joints, range of motion, 56 meanings, deliberate falling, 11
Jütte, Robert, 5 mechano-receptors, 34
medical studies, fatigue, 108
K Mela, David, 205–6
Karlsson, Trine, 243 memory, balance, 9
Keays, Glenn, 14 Ménière’s disease, 20, 21
Kelly, Daniel, 2–3 menstruation, 225, 242–3, 243f
Kindermans, Hanne, 144 mental fatigue, 108
kinesthesia, disorders of, 46 methods of inquiry, 4–5
King, Sara, 129 Meuret, Alicia, 94–5
Kirby, Amanda, 37 micturition see urination (micturition)
Kirby, Sarah, 20 mindfulness
Klein, Christine, 46 personal theory of movement, 39–40
Klein, Donald, 94 relearning to breathe, 91
Knoop, Hans, 119–20 mindless, personal theory of movement, 40
Krampe, Ralf, 38 mirror neurons, scratching, 157
Krishna, Aradhna, 208 Morinis, Alan, 134
Kurzban, Robert, 110–11 Morrison, Alan, 14–15
Kvangarsnes, Marit, 100 mortality, cold, 190, 191f
Moss-Morris, Rona, 120–1
L motivated interruption, pain, 131–2
labeling of sensations, 254 motivational model of fatigue, 112
Lacquaniti, Francesco, 34–5 motivation to change, fatigue, 110–11
Lang, Peter, 94 motor control, lack of awareness, 40
language differences, hiccup (singultus), 229 motor performance improvement, 37–9
Larson, Jeffrey, 209 motor problems, clumsiness, 37
LeGear, Mark, 36 movement, 6, 33–54
Legrain, Valery, 131 adolescents, 36
Legrans, Dorothée, 43 clumsiness, 33, 36–7

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control development, 34–5 Orbai, Ana-Marie, 57
developmental models, 40 orgasms, sneeze (sternutation), 226–7
disorders see movement disorders Orloff, Natalia, 218
embodied cognition, 35–6 orthostatic dizziness, 19
infants, 33 Outliers (Gladwell), 38–9
lack of, 36 out-of-body experience, 27–8t
motor performance improvement see motor overeating, 202
performance improvement overexposure, food advertising, 209
personal space, 43 overtraining, blood viscosity study, 65
personal stories, 40–2 Owen, Adrian, 114
personal theory see personal theory of
movement P
posing, 44–6 pain, 6, 129–51
space exploring, 35–6 analgesic culture, 140–1
strutting, 44–6 anxiety as response, 140
urge, 256 continuous, 141
see also proprioception coping with, 141–2, 144, 146–7
movement disorders, 46–50 courageous engagement, 144
anosognia, 47 damage response, 142
fine motor control, 48–9 definition, 129–30
personal stories, 49–50 fear of from injury/illness, 140
start and stop, 48 goal pursuit, 135–9, 136t
tremor, 47–8 incidence, 129
Mshana, Gerry, 47–8 mechanisms of, 130–1
Muller, Matthew, 184 motivated interruption, 131–2
muscle disorders, weakness, 63 neuroimaging, 131
musician’s cramp, 49 nociceptive, 131
myasthenia gravis, dyspnea, 95 paying attention to, 139–40
personal stories, 137–9, 145–6
N psychological interventions, 147
nasal cavity, 80 religious aspects, 132–3
Navon, David rites of passage, 134
disengagement in fatigue, 111 self-injury, 134–5
resource depletion, 109 urge, 256
nerve damage, 131 value in, 139–40
neuroimaging vigilance, 142–3
pain, 131 worry, 143
temperature, 177–8 Pain Catastrophizing Scale, 140
neurological diseases Palese, Alvisa, 229–30
heaviness, 65 panic, 92–5
weakness, 63 hyperventilation, 94
neurophysiological studies, thermoregulation, 177 panic attacks, 92
nociceptive pain, 131 Papoiu, Alexandru, 155–6, 157
nociceptors, peripheral, 131 papular urticaria, 154
paralysis, height intolerance, 26
O parasites, grooming cuing, 155
obesity, 36, 204–5 parasitosis, delusional, 168
personal responsibility in appetite, 214 parents
prevalence, 204 anxiety in urination/defecation,
see also appetite 236–7
O’Brien, Sandra, 56 pressure in urination/defecation, 236–7
occupational dieting, 218–19, 219f, 220 Parkinson’s disease, 47–8
personal stories, 220–1 Park, Lora, 44, 45f, 46
occupations Patterson, Mark, 6
fatigue studies, 107–8 paying attention to pain, 139–40
settings in accidental falling, 14 perception of temperature, 176
olfaction (smell), 2–3 peripersonal space, 43
opportunity cost, 110 peripheral nociceptors, 131

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peripheral sensory mechanisms, appetite reduction, 69–71
regulation, 202 stiffness, 56–7
perseverance, 112–13 strength, 62
persistent fatigue, 118–19 strength–weakness continuum, 63–4
personal distress, coughs/sneezes, 229 swollen, 68–9
personal responsibility, appetite, 214–15 swollen–reduced continuum, 71–4
personal space, movement, 43 urge, 256
personal stories, 5 weakness, 62–3
appetite, 212–14, 220–1 presumed mechanism, pain, 130–1
balance, 17–19 primary Raynaud’s phenomenon, 192
breathing, 86–7 priority setting, appetite, 204–5
dyspnea, 101–2 The Problem of Pain (Lewis), 132
farting (flatulence), 234–5 Prokop, Pavol, 155
fatigue, 116–18, 123–4 proprioception, 6, 34
flexibility–stiffness continuum, 60–1 balance, 9
itch, 159–61, 170–2 breathing, 81
movement, 40–2 disorders of, 46
movement disorders, 49–50 training of, 38
occupational dieting, 220–1 see also movement
pain, 137–9, 145–6 psoriasis, 165–6
pressure, 72–4 psychodermatology, itch, 169–70
Raynaud’s phenomenon, 194–6 psychological interventions
stroke, 49–50 breathlessness, 100
swollen–reduced continuum, 72–4 chronic hiccup (singultus), 230
temperature, 184–6, 194–6 itch, 169
vertigo, 23–5 pain, 146, 147
vomiting (emesis), 241–2 Raynaud’s phenomenon, 193
personal theory of movement, 39–42 psychology
developmental models, 40 ambiguity in temperature, 189–90
mindful, 39–40 itch perception, 163
mindless, 40 toilet behavior, 237
Petit, Philippe, 16–17 The Psychology of Fatigue (Hockey), 111
physical arrest, height intolerance, 26 public display
physical effects, menstruation, 243 farting (flatulence), 232
physical experience, respiratory awareness, 88 thermoregulation, 190
physical senses, functions of, 255, 255t public-private dynamic, reproductive removal,
physiological monitoring, breathing patterns, 95 245
pleasure public understanding, appetite, 215
of desire appetite, 205–6 pulmonary embolism, dyspnea, 95
of itch, 158–9
preference vs. in appetite, 205–6 Q
Pope, Janet, 191–2 qualia of feeling, urge, 254
popular explanation, fatigue, 108 quality of life, chronic itch, 162
posing, movement, 44–6
postures R
constricted, 44 Rabie, Tamer, 166
control of, 34 Rakhshaee, Zahra, 58
power, appetite relationship, 203–4 range of motion of joints, 56
power poses, 44, 45f Raynaud, Maurice, 191
Pratt, Travis, 233 Raynaud’s phenomenon, 191–4
preference, pleasure vs. in appetite, 205–6 attack causes, 192–3
pre-performance fear, balance, 16 blood flow, 193
pressure, 6, 55–78, 256 personal stories, 194–6
flexibility, 56 primary, 192
heaviness, 64–6 psychological interventions, 193
heaviness–lightness continuum, 67–8 temperature biofeedback therapy, 193–4
lightness, 66–7 recreational swimmers, breathing, 83
personal stories, 72–4 Redding, Emma, 15

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reduction, 69–71 sensations, labeling of, 254
swollen–reduced continuum, 71–4 senses, adult vs. child behaviour, 3
rehabilitation, pain management, 146 sensorimotor adjustments, fear of falling, 13
Reid, Joanna, 66–7 sensory apparatus, head, 3
Reid, Maria, 205 sensory integration, failure of, 257
Reisig, Michael, 233 sensory neurons, thermoregulation, 177
rejection, cold-shoulder of, 181 severe morning stiffness, 57
relaxation protocols, relearning to breathe, 91 Shalev, Idit, 180
relearning to breathe, 91–2 shame, itch, 165–8
religion, pain aspects, 132–3 Sherrington, Charles, 34
reproductive removal, ‘normality,’ 245 shock, fear of falling, 12
resilience, 115 short-term cognitive performance, 114
resource depletion, fatigue, 109–10 shrinking waist illusion, 71
respiration Simmons, Roger, 15
awareness, 88–9 singing, breathing control, 82–3
emotions vs., 89 singultus (hiccup), 225, 229–30
monitoring, 93, 93f skin, thermoregulation, 177
variability, 89–90 skin disorders
see also breathing chronic itch, 165–8
restless legs syndrome, 65 scratching, 157
rheumatologic conditions, diagnosis, 56 skin lesions, disgust tests, 166, 167t, 168
de Ridder, Denise, 215–16 Skinner, Robin, 14
dietary restriction, 215–16 skin weals, 154
Rigoli, Daniela, 37 Skull, Collen, 82–3
rites of passage, pain, 134 sleep
Roach, Mary, 206 disturbance in chronic itch, 162
Rodiek, Susan, 63 onset, 112
room tilt illusion, 27–8t Small, Kate, 56
Rosedale, Mary, 68–9 smell (olfaction), 2–3
rumination, 90 Smith, Linda, 35–6
running, breathing, 83–4 sneeze (sternutation), 80–1, 225, 226–7
Russia, cold mortality, 190 disease transmission, 227
orgasms, 226–7
S personal distress/social threat, 229
Sang, Yen Pik, 26 sniffing, 80
Scarry, Elaine, 132–3 social behavior
Scholing, Agnes, 187 chronic fatigue syndrome, 121
Schutzer, Karen, 188 coughs/sneezes, 229
Schweitzer, Robert, 10 dominance in postures, 44, 45f, 46
scratching, 154, 162–3 farting (flatulence), 232–3
mirror neurons, 157 itch, 155–7, 164–5
prevention of, 163–4 public display of thermoregulation,
social contagion, 155–7, 156f 190
see also itch rejection in vomiting (emesis), 239
secondary Raynaud’s phenomenon, 192 reproductive removal, 245–6
secondary thermoregulation, 181–4 restriction in urination/defecation,
secrecy, reproductive removal, 245 236
Selby, Edward, 135 scratch, 155–7
self, active engagement of, 113 scratching, 156f
self-contained underwater breathing apparatus temperature, 176
(SCUBA), 85 sociology
self-cutting, 134 body practices, 4
self-exploration, children, 40 temperature, 179–81
self-grooming, 157 Songu, Murat, 227
self-induced vomiting, 239 space exploring, movement, 35–6
self-injury, pain, 134–5 spatial impermanence, vertigo, 22
self-starvation, as power control, 204 speech, breathing control, 82
semicircular canals, 9 Spiegel, James, 234

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spinal systems, nociception, 131 clothing, 182–3
sports, breathing control, 82 cognitive task tests, 183–4
start and stop, movement disorders, 48 extremes, 183–4
Stephens, Andrew, 240 mistakes/accidents, 183
sternutation see sneeze (sternutation) perception of, 176
stiffness personal stories, 184–6, 194–6
pressure, 56–7 psychological ambiguity, 189–90
see also flexibility–stiffness continuum social behavior, 176
stimulants, cognitive enhancement, 113–14 social psychology, 179–81
Stoffregren, Thomas, 35 sweating see sweating
stop emotion, fatigue, 111 urge, 256
strangulation, 134 working memory, 184
strength, pressure, 62 see also body temperature; cold; Raynaud’s
strengthening exercises, 64 phenomenon; thermoregulation
strength–weakness continuum, 63–4 temperature biofeedback therapy, Raynaud’s
stress phenomenon, 193–4
breathing, 90 tensegral system, 55
incontinence, 238 terror management, breathing, 100–2
Raynaud’s phenomenon, 192–3 Tesch-Römer, Clemens, 38
reduction programs, 91 thalamus
stretching, 56 balance, 9
stretch receptors, 81 nociception, 131
stroke Thelen, Esther, 34
anosognosia 47 thermoregulation, 177–8
persistent fatigue, 118 behavior, 178
personal stories, 49–50 core body regulation, 178
strutting, 44–6 public display of, 190
Suarez, Fabrizis, 232 secondary regulation, 181–4
subject-object dynamic, reproductive removal, 245 see also body temperature
suffocation thirst, urge, 256
challenges, 94 Thorndike, E, 108
feelings of, 96 toilet behavior, psychology, 237
Sutanto, Bernadet, 192 toilet training, 236–7
swallowing (deglutition), 238–9 tool use, peripersonal space, 43
sweating, 186–8 To Reach the Clouds (Petit), 16
disgust, 188 total cognitive disengagement, 112
gender specificity, 189 total mastectomy, 68
geography of, 188 touch, 4
heat loss, 186–7 balance, 9
Sweden, menstruation, 243, 243f trachea, 80
swimming, breathing, 83 transdisciplinary inquiries, 4–5
swollen, 68–9 transitive sensations, 5–6, 252
personal stories, 72–4 tremor, 47–8
swollen–reduced continuum, 71–4 tussis see cough (tussis)
Symptom Checklist 90, heaviness, 65
syncope, 19 U
unappetizing food, 206–8
T United Kingdom
Tai Chi, 114 cold mortality, 190, 191f
Tallis, Ray, 203 incontinence management, 237
tasks United Nations World Food Programme, 201
intrinsic cost, 110 upper respiratory tract, 80
persistence, 110 infections, 228f
taste (gustation), 2, 3 urge, 254–6
temperature, 6, 176–200, 256 to change experience, 251
body temperature in character judgement, 178, physical senses, 255
179 urination (micturition), 225
climate-driven behavior, 181–2 continence, 236

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incontinence, 237 self-induced, 239
toilet training, 236–7 social rejection, 239
USA voluntary, 240
adolescent food preferences, 207 Vriens, Joris, 177
child development, 207–8
clothing and temperature, 183 W
dietary differences, 206 Waitt, Gordon, 188
farting (flatulence), 233 Wansink, Brian, 210
obesity prevalence, 204 Waterman, AS, 113
weakness
V pressure, 62–3
value in pain, 139–40 strength–weakness continuum, 63–4
value judgement, expertise, 39 weightlessness, 66
Van Damme, Stefaan, 144 weight loss, 69, 70–1f
Van den Bergh, Omer, 88, 89–90 Weinberg, Martin, 233
Varlet-Marie, Emmanuele, 65 Wessely, Simon, 119
vegetable avoidance, 207 Williams, Colin, 233
Verhoeven, EWM, 163 Williams, Lawrence, 179
vertigo, 22–5 Williams, Sarah, 205
classification, 22 Wilson, Geoff, 84–5
definition, 22 Wilson, Margaret, 35
height intolerance, 25–6 wind instrument playing, breathing control, 82
personal stories, 23–5 withholding food, 203–4
vestibular system Wojcik, Wojtek, 120
balance, 9 women, sweating, 189
dysfunction, 21 Woodcock, Katherine, 11
vigilance, 253–4 working memory, temperature, 184
chronic, 254 worry, 89
visible skin disorders, 166 itch, 164
vision, 2 pain, 143
balance, 9 Wren, Damian, 95–6
equilibrium, 15 Wulf, Gabriele, 40
vitality, 112–13 Wundt, Wilhelm, 1
humanist tradition, 112
Vlaeyen, Johan, 144 Y
Vlemincx, Elke, 89 Yardley, Lucy, 20
voluntary hyperventilation, 88 Yen, Alan, 206
voluntary vomiting, 240 Yeoman, Martin, 210
vomiting (emesis), 225, 238–42 yoga, 58, 59f, 60
causes, 239
disgust, 239 Z
personal stories, 241–2 Zhong, Chen-Bo, 180

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