Psychological Illness in Disguise

Western medicine has been slow in shifting its focus away from the biological focus – the medical model remaining predominantly a biological model. This situation has been reinforced by specialisation in medicine and parallel advances in technology, the primary concern of the ‘organ specialist’ being ‘to exclude’ organic pathology.

by Dr. Siri Galhenage

( June 23, 2016, Colombo, Sri Lanka Guardian) Patients vary in the way they perceive and evaluate their ill-health, seek medical help and present their ailments to the doctor – a process known as ‘illness behavior’. Doctors, in turn, differ in the way they evaluate the health status of their patient, arrive at a diagnostic formulation, [using laboratory and other special investigations, if necessary], discuss their findings with the patient and adopt a treatment plan – the ‘treatment behaviour’ of the doctor. During the doctor-patient interaction symptoms relating to the body and the mind may be addressed to a varying degree.

The interrelatedness of the body and the mind is well demonstrated in ill-health, as symptoms relating to both the body and the mind may be present in psychological as well as physical illness. However, clinical surveys suggest that a significant proportion of consultations in both outpatient and inpatient settings are for physical complaints which cannot be adequately accounted for by any organic pathology, and the patient showing resistance to any suggestion that a physical basis to his/her ailment is unlikely. Or, in some instances, the intensity and persistence of the complaints is not in keeping with the degree of pathology as assessed by an experienced clinician. The phenomenon has come to be known as somatisation which brings into focus the dynamics of the illness behaviour of the patient and the treatment behaviour of the doctor.

As a consequence of only a cursory reference to somatisation in medical literature, both physicians and psychiatrists have developed limited skill in the evaluation and management of patients presenting with this relatively common phenomenon. The purpose of this review is to address this issue which has wider implications for medical education and the delivery of health care.

SOMATISATION

Somatisation is best described by Lipowski as ‘a tendency to experience and communicate somatic symptoms which are unaccounted for by pathological findings, to attribute these to physical illness, and to seek medical help for them’. It is not a diagnostic entity but a process that runs through a range of clinical conditions.

Why do some people express their psycho-social distress in a somatic idiom? Somatisation is a complex intra-psychic process through which individuals come to ascribe ‘meaning’ to their inner experience in physical terms – a meaning determined by their personality make-up, past experience, current threat and the feeling state they experience and the cultural milieu they live in.

A body of research suggests that somatisation is due to ‘personality [constitutional] vulnerability’. Some individuals have a heightened perception of bodily function, are more sensitive to internal bodily cues, overestimate sensation [eg. have low pain threshold] and may even have a distorted perception of bodily sensations.

There are others who have a diminished capacity to verbalise their emotional distress. Referred to as ‘alexithymic’ they tend to lack the words for feelings. The concept is poorly understood but some studies point to past experience of adverse life events by these individuals. Suppression of emotions in relation to childhood trauma is considered to be a contributory factor.

Some research suggests that the phenomenon is a ‘learned behaviour’ – adult somatisation being developed from a family environment unduly preoccupied with health and illness. Further, a child may learn that complaining of physical symptoms may result in ‘psychological gain’ such as receiving parental attention or evading undesirable obligations which may become an enduring pattern of behaviour. In adults a somatic focus may serve to lessen the responsibility of their life predicament and avoid the need for personal change. Adoption of a ‘sick role’ enables one to receive sympathy from others, obtain relief from obligations and use it as a powerful tool in controlling relationships. Physical symptoms are taken more seriously by family members, whereas complaints of anxiety and sadness are regarded as trivial or signs of weakness not worthy of medical attention.

Clinical evidence suggests that somatic complaints are commonly a part of depressive and anxiety syndromes. In major depressive disorder, negative perception of the self and the body is part of the ‘negative cognitive set’ which may also include a bleak view of the surroundings and the future. In certain cases of psychotic depression the feeling state of sadness may be masked [or may even be denied] with prominent somatic delusions such as ‘the body is decaying’. Individuals who are prone to morbid states of anxiety with associated symptoms of tremor [shakes], sweating, palpitations, hyper-ventilation etc. due to hyper-arousal of the autonomic nervous system have a greater tendency to somatise. They tend to develop an increased sensitivity to bodily function resulting in more intense emotion which can further increase bodily symptoms.

Cultural variations in the way emotions are expressed are well known. Studies of traditional Arab cultures, where endurance of pain without the expression of emotion is highly valued, show that there is a greater tendency for emotional distress to be conveyed in physical terms. Similarly among the Hunan Chinese where emotional complaints are taboo as they imply mental disability, somatic presentation of emotional distress is usual. In some primary cultures in Africa there is a restricted vocabulary for emotions which are expressed in physical terminology. Leff put forward a rather controversial hypothesis that ‘the tendency of ‘non-western’ societies to use somatic rather than emotional representations of distress may reflect an evolutionary pattern in the development of words for unpleasant emotions. Waziri quite rightly argued that indigenous mental health professionals have no difficulty understanding the ‘language’, and the problem arises when the patient is confronted with a ‘western-trained’ doctor!

In somatisation the patient may or may not have a conscious awareness of their behaviour. It should be distinguished from malingering where physical symptoms are produced intentionally. Clinicians come across such individuals in cases of workers’ compensation or insurance claims where physical symptoms or pain may be amplified for pecuniary gain.

NOMENCLATURE

During early and mid 20th century the phenomenon of somatisation was enshrined within the concept of neurosis. Later as international nomenclatures [Diagnostic and Statistical Manual of Mental Disorders [DSM]of the American Psychiatric Association and the International Classification of Diseases [ICD] of the WHO] were developed, the concept of neurosis which was believed to have ‘unproven causative assumptions’ was abandoned, and was redefined and reclassified to embody somatisation within the new diagnostic category of Somatoform Disorders. Conditions classified as Somatoform Disorders include dysmorphic disorder, conversion disorder, hypochondriasis, somatisation disorder, somatoform pain disorder etc. The new descriptive classifications are not without fault as there is considerable overlap between diagnostic categories. I shall not be bogged down by issues of nomenclature, but prefer to remain on the central theme of somatisation and its implications on medical practice and medical education.

The mind and body dualism was conceptualised in the days of Plato. This idea that was perpetuated for religious reasons was brought into the scientific domain by Rene Descartes [1596 – 1650], the French philosopher and mathematician, who postulated that the body is a mechanical outfit. This notion that took root in the field of western medicine did influence important research into the anatomical and physiological aspects of the body, nevertheless posing a barrier to the advancement of thought regarding the interrelatedness of the mind and the body, despite the advent of modern psychology.

This preoccupation to exclude organic pathology remains prevalent in medical practice, regrettably even among the generalists. Medical practitioners are accustomed to assessing the patient system by system, and arriving at a diagnosis assisted by biochemical, haematological and radiological investigations, if necessary. Most practitioners are cognisant of the psychosocial context in which a physical condition may present but are either oblivious to or uninterested in the possible psychological content of the presenting problem once the organic pathology has been excluded. The exclusion of organic pathology for many practitioners signals the end of the diagnostic process, and the condition is often labeled ‘functional’ – a word that has negative connotations such as ‘it’s all in the mind’; ‘it will resolve itself’ etc. It has perpetuated the dichotomy of the body and the mind – a human artifact.

ABNORMAL ILLNESS BEHAVIOUR

This situation is brought to an extreme by the somatising patient whose presenting symptoms serve unconsciously to control anxiety, yet driven by the need to pursue answers to their somatic complaints, sometimes with a tendency to seek unwarranted tests, while remaining ‘guarded’ about their inner psychological conflicts – a process which has come to be known as ‘abnormal illness behaviour’ coined by Issy Pilowsky. He defines abnormal illness behaviour as ‘a maladaptive mode of experiencing, perceiving, evaluating and responding to one’s own health status, despite the doctor has provided a lucid and accurate appraisal of the situation and management to be followed’.

ABNORMAL TREATMENT BEHAVIOUR

When confronted with a somatiser, a biologically oriented doctor is drawn into a ‘wild goose chase’ in searching for a physical pathology. During the pursuit, a spurious abnormality may sometimes be found and may entice the doctor to perform more tests that may further raise the anxiety of the patient. It is known that expensive investigations such as scans are sometimes used, not in an attempt to establish a diagnosis but as a means of reassuring the patient that no serious pathology is present! The process is more commonly seen in the case of chronic somatisers who are, with time, endowed with a thick medical file! Bruce Singh described the above mentioned practice of the doctor as ‘abnormal treatment behaviour’!

In addition to the biological mind-set, the reason for this situation is manifold: a] limited interaction with the patient; b] inadequate skill on the part of the doctor in asking the right questions and eliciting verbal and non-verbal cues pointing to psychopathology; c] even if detected, the doctor may not have the necessary expertise in making a positive psychological diagnosis, and may not have the skill or confidence in addressing the psychosocial issues with the patient in a sympathetic manner, and taking adequate steps for treatment or referral; d] fear of ‘missing’ an organic pathology which may have a potential adverse effect on the doctor’s reputation, and concerns about litigation.

The so called ‘abnormal treatment behavior’ of a doctor may potentially lead to a wastage of resources in the health service delivery. Repeated invasive investigations, even if they prove to be negative, may raise the conviction of the anxious patient of an affliction that has a physical basis and may pave the way for a chronic course. Invasive tests are not without harmful effects.

It is not being argued that no initial screening tests be performed. The contention is about continuing inappropriate investigations, spurious diagnoses and unhelpful treatments without maintaining a heightened awareness of any underlying psychological dysfunction.

It is outside the scope of this brief review to enter into a detailed discussion on the management of Somatoform Disorders. Suffice to say, the therapeutic approach should be: to engage the patient; to identify the personal, interpersonal and environmental factors that initiate and maintain the pattern of abnormal illness behaviour; guiding the patient to accept the causal relationship between the emotional distress and the somatic symptoms while making the patient feel understood; once the source of discomfort is identified, to adopt appropriate therapeutic strategies such as psychotherapeutic or behavioural techniques or the judicious short–term use of anxiolytic/antidepressant medication, if necessary. The clinician has to expect some degree of resistance on the part of the patient regarding psychological explanations, which requires an empathic yet skilled approach. Both acute and sub-acute forms of Somatoform Disorder commonly seen in primary care have a good prognosis with appropriate treatment, and the general practitioner, in my view, should be better equipped to manage them.

The same could not be said about the patient with the chronic form of somatisation, who may be quite resistant to treatment, and who may require a physician working in liaison with a psychiatrist/psychologist.

CONCLUSION

Competent medical practice requires an exploration of the interrelatedness of the body and the mind in order to make a correct assessment of the patient’s condition and to devise an appropriate treatment plan. Despite the best efforts of modern medicine and psychiatry, the dualistic notion has persisted in medical education, and hence in the practice of medicine resulting in a lag in acquiring necessary skills by clinicians.

Community attitude towards mental illness is slow in changing even with educational programmes. It is unrealistic to expect a change in ‘psychological-mindedness’ of the general community. Bringing about systemic change in the deeply entrenched pattern of health service delivery in Sri Lanka is a bridge too far. But changing the focus of the medical profession from a purely biological to a bio-psycho-social model is a realistic goal if given impetus at the undergraduate level. Thankfully this is happening in most reputable medical schools around the globe. Needless to say a sound knowledge of the biological aspects of the human condition is of importance [even for psychiatrists!]. The emphasis that I wish to make is that an understanding of intra-psychic, interpersonal and social aspects of being and their dynamic interaction in producing psychopathology is as important and should be a measure of competence of a medical practitioner, especially of a general practitioner, who should ideally be the ‘hub’ of an integrated health service.

One cannot expect a medical graduand to be fully conversant with all the nuances of the above model; after all, we gain most of our medical knowledge after graduation! Continuing education, both at a formal and an informal level, and peer review, should keep both the doctor and his patient healthy and foster the Art of practice of medicine which is gradually being eroded.