How to Make Anyone Crazy

The concept of psychosomatic illness is that an illness is entirely imagined or that the mind exaggerates an organic illness and makes new symptoms or worsens existing ones.1 Where the central feature is pain, this is called somatoform disorder.2 This is different from illness-related stress where an illness causes an emotional reaction, or stress-related illness where stress has a physiological effect. Psychosomatic disorders are believed to be centered in thought processes that  cause physical symptoms or perceptions.

Though psychosomatic illness is diagnosed in cases where the process that causes an illness is not known, psychologists and psychiatrists agree that the process of psychosomatic illness is not known.3  There are many examples of illnesses whose exact causes are not known, but are, nevertheless, considered physiological illness. So it is an arbitrary subset of illnesses whose cause is not known that are considered psychiatric in nature.  Though the protocol for psychosomatic illness generally states that it includes illnesses that have no physiological symptoms, illnesses that have clear physiological symptoms, such as fibromyalgia, irritable bowel syndrome, and chronic fatigue syndrome, are still regularly included in manuals and textbooks on psychiatric illness.

There are various ways that people in the fields of psychiatry and psychotherapy get around their own definitions of psychosomatic illness.  There is a specific diagnostic criterion for psychosomatic illness found in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, or DSM-IV. 4 This has a very complex set of diagnostic criteria for psychosomatic illness. Some conditions that psychotherapists and psychiatrists want to include as psychosomatic, would not fit under this set of criterion.  So,  fibromyalgia, irritable bowel syndrome, and chronic fatigue syndrome are called “non-DSM-IV somatization disorders.”5 What this phrase means is that people with these illnesses do not fit the definition of psychosomatic illness, but they are included anyway.

Another curiosity, found in some of the recently published manuals dealing with somatoform disorder, is the recommendation that patients be treated with gabapentin, with the belief that it is treating a psychiatric problem.6 Although used for some psychiatric disorders, gabapentin has been proven to be a neuropathic pain-blocking medication.  If it does work for people diagnosed with psychosomatic pain, then that is an indication not only that their pain may be quite real, but it may be neurological.

Although psychiatrists such as Glen Gabbard claim that “Somatization disorder is among the best-validated disorders in psychiatry,”7 the list of organic illnesses that historically have been erroneously classified as psychosomatic is long and shameful. Many of the ideas and attitudes that have caused organic illnesses to be misdagnosed as psychiatric illnesses are still part of the Diagnostic and Statistical Manual of Mental Disorders and other handbooks published by  the American Psychiatric Association. For example, the same idea that transient paralysis or loss of vision is a psychiatric problem is still there, and so somone developing multiple sclerosis could be misdiagnosed based on the information in the manuals.  

I will not say that psychosomatic illness is not possible. But in this day and age, it has to be proven scientifically. The diagnostic criterion should not be so vague as to include anything that a doctor or psychotherapist wants to throw in the basket. It is not scientific to claim that any illness whose cause is not currently understood should be treated as a type of psychiatric illness whose cause is not understood. It is simply prejudice to decide that an illness is psychosomatic because it mainly occurs in women. Further, it is unscientific to claim that an illness has no physiological symptoms simply because we do not yet have a convenient lab test for these symptoms. (This is a persistent claim regarding fibromyalgia and chronic fatigue syndrome in spite of ample research showing that these illnesses have a physiologic basis.) The advocates for the existence of  psychosomatic illness have some serious issues to deal with. What follows is a discussion of some examples of these issues and how they can impact patients.

A recurring problem in what is written by psychotherapists about psychosomatic illness is that they confuse the concepts of stress-related illness, illness-related stress, and psychosomatic illness.  For example, asthma is treated by doctors as a medical illness while some psychotherapists still claim that it is psychosomatic.  Asthma is an autoimmune problem that seems to run in families, so a genetic cause is more likely than a psychiatric one. Asthma attacks can be triggered by an allergen or by rapid breathing, as in sports asthma. Once triggered, there is inflammation and constriction in the bronchial tubes. At this point the sensitized respiratory system reacts very strongly to stressors – not only emotional stress, but physical stress such as illness and exercise.  It is easy to point to someone having an asthma attack at an emotional crisis and claim that this shows that it is psychosomatic. But the people who study the biochemistry of the illness can explain what is happening in the body in physiological terms. The illness is there, it is just that stress, any type of stress,  can create chemical reactions causing the symptoms to appear. It is true that psychological counseling may help people with asthma, but that is very different from saying that asthma is psychosomatic.

The above example seems to be a frequent type of mis-reading of medical situations that leads people to draw inappropriate conclusions. Psychotherapists are not biochemists, and they tend to base their ideas on the behaviors they see, rather than investigating what may be happening in the body that creates the behavior. They often have pre-conceived ideas that they then read into the situation.  While medical researchers study the biochemistry of stress, psychotherapists have case studies and testimonials. Unless psychotherapists pay attention to the medical research, they are in danger of developing and perpetuating their own dysfunctional behaviors, based on belief rather than science. And, surprisingly enough, some practicing physicians may follow them down that path. Psychiatrists, who do have medical degrees,  have no excuse for disregarding the medical research, though many of them persist in doing so.

Part of the underlying social problem in medicine and mental health that creates this situation is the compartmentalization of medical and mental health fields.  People in mental health read and publish different journals and manuals from people in medicine. Within medicine, people in neurology may not read journals in rheumatology, where a good deal of neurological and neurochemical research on pain is being published.

The concept of exaggerated pain or other symptoms in psychosomatic illness is based on the judgment of a doctor or psychologist who decides that a patient is having more problems with their symptoms than is normal for their condition.  But not everyone reacts to an illness the same way, and there are currently no diagnostic tools to determine if a patient’s pain perception is exaggerated.  People with chronic or prolonged pain have the problem that the endorphins are not being released in response to the pain as happens with transitory pain.  So, a doctor looking at the patient may conclude that they are in more pain than normal, simply because of this organic reaction to prolonged pain.  Also, meditation, exercise, music, and other stimuli can cause pain-reducing hormones to be released, which a  psychotherapist may regard as a “psychological” phenomenon, when, in fact, it is physical. Psychological techniques can help endorphins to be released, and psychotherapists who understand this can help a patient in pain learn these techniques. But the fact that psychological techniques can help should not be taken as evidence that the pain or illness is not “real.”

Women are more likely to develop a chronic pain problem than men, are likely to experience more severe pain than men for any given condition, and may have more secondary problems related to pain.  To take a hypothetical situation, if a twin brother and sister both develop osteoarthritis to the same degree, she will be in more pain.  This is because women have a lower threshold of pain than men. The threshold of pain for any individual may vary as well.  In addition, the twin who is female will be at more risk of developing secondary fibromyalgia as a result of pain disrupting sleep and causing substance p to rise. Why? Research on this is ongoing. But one study showed a relationship between androgens, hormones that men produce in greater quantities than women, and the level of pain of women with fibromyalgia.8  So women’s initial pain reaction may differ from that of men, and her lower androgen levels put her at greater risk of developing secondary fibromyalgia due to pain-disturbed deep sleep. The disruption of deep sleep may also put her at risk of developing other illnesses, such as infection and depression.

These physiological effects of pain are established facts. Pain is an alarm system. Many studies have shown that pain can disrupt deep sleep and that disrupted deep sleep can cause widespread body pain. Eventually men as well as women will experience this kind of pain, but women will develop it sooner, and in response to less severe pain. But disrupted deep sleep causes pain, which is why it is used as a technique in torture.

Currently, it is still common practice to diagnose women with somatoform disorder, that is, psychosomatic pain, simply because she is in pain, female, and her doctor thinks her pain is exaggerated.  So, imagine that a woman patient has surgery and is dealing with prolonged pain following this event.  Women are likely to have under-treated pain.9 Perhaps her doctor tells her to take an over-the-counter pain remedy following the surgery, but this is not an adequate. She complains to the doctor, who at this point begins suspecting that she has a psychiatric problem.  She is female, so for him, this is reason enough to see her problems as psychiatric in nature.

The patient’s pain is disrupting her deep sleep. Inside her nervous system the pain neurotransmitter substance p is rising.  In a week she goes to her doctor and says that now her whole body hurts.  The doctor knows that widespread body pain is listed as a somatoform disorder, so he sends her to a psychiatrist who confirms this as the diagnosis. Yes, they know that she has pain from surgery, but they believe it to be exaggerated and think that this additional widespread pain is “not real.”   Frequently, the belief is that she is “focusing on her pain too much.” At this point, this may be how the widespread pain may be explained to the patient.

She is still not getting enough sleep, but often patients do not realize that their sleep is poor. People may sleep through the night but still have disrupted deep sleep. This means that she may not be able to report to the doctor or psychotherapist that she is not sleeping well, only that she is tired all the time. Sleep deprivation can make people look and behave as if they have a psychiatric disorder. Her widespread body pain, fatigue, and distress are quite real, but doctor,  psychotherapist, and even the patient  may all agree that it is not.

As time goes on, the patient’s pain from the surgery gets better, but she still has widespread body pain caused by high substance p.  At this point the doctor and the psychotherapist believe this confirms that they have made the right diagnosis of somatoform disorder.  Since the source of the initial pain has healed, they believe that the rest must be a psychiatric problem. Unfortunately, the high level of substance p in the cerebrospinal fluid can itself cause disruption in the slow brain waves of deep sleep. The original pain condition may be better, but this patient is in real pain, and also at risk for other problems related to pain-related stress and deep-sleep deprivation.  This self-perpetuating situation may go on for months. If she is lucky, as time goes on, her condition does improve as substance p levels gradually go down.  The psychotherapist congratulates herself for doing such a good job working with this patient. She congratulates the patient as well, and the patient may believe that the pain was not real, but psychological, because this is what she has been told and the psychotherapy appeared to her to be effective. 

This phenomenon, where a worsening of the pain and widespread pain occurs after an initial pain problem, and persists after the initial pain problem has healed, is a classic “textbook example” of somatoform disorder. But, as we have seen, it is also a classic description of transitory secondary fibromyalgia caused by deep sleep deprivation.

Of course, there are many problems with this situation. To begin with, the doctor caused the woman’s widespread body pain by under-treating her initial pain problem. The widespread body pain could have been much better treated with medication to prolong deep sleep.  With appropriate medical treatment she could have gotten better in weeks rather than months, and avoided risks of additional illness related to the stress the pain was causing. In addition, the doctor and psychotherapist taught the patient to blame herself for her pain, rather than providing her with an appropriate scientific explanation. 

The psychotherapist may have helped the patient deal with the stress of being in pain, but did her no good by insisting that the widespread body pain was all in her mind. An informed psychotherapist might have acted as an advocate, and helped the patient get to a doctor who could treat her pain appropriately.  The doctor and the psychotherapist believe that they have done a good job, but in fact they contributed to and prolonged the patient’s pain.

It is commonly believed by psychotherapists and psychiatrists that multiple chronic illnesses, or chronic pain conditions, are indicative of a psychiatric condition.  But the above situation shows how one pain condition can disrupt sleep and cause another pain condition. In addition to widespread body pain, sleep deprivation and pain can cause confusion and depression. Although this situation has a medical explanation, it can be mistaken to be a wholly psychiatric condition. 

It is not hard to imagine that a person may have rheumatoid arthritis, osteoarthritis, and widespread body pain, or secondary fibromyalgia, caused by pain disrupting deep sleep.  As people live longer lives, there is an increased likelihood for some of us to develop multiple chronic health problems.   But in the world of psychotherapy and psychiatry, these people may be misdiagnosed with psychosomatic disorders.

In addition, medicine is beginning to show how some chronic illnesses and chronic pain may be interrelated. Recent research indicates that there are neurochemical similarities between fibromyalgia and migraine headaches, which may explain why some people have both.10 The biochemical processes that cause people with fibromyalgia to develop the secondary pain problems including mayofascial pain, restless legs syndrome, and TMJ can be explained by current science. With dopamine very low, muscular cramping to the point of causing localized neuropathic pain is behind these several conditions.11 Some psychologists and psychiatrists advocating a psychiatric explanation for fibromyalgia point to its cluster of chronic pain problems and claim that this is proof.  But the biochemical data strongly suggests a medical explanation, rather than a psychiatric one.

The theory of psychosomatic illness is full of issues like these, where the symptoms of organic illness can be misinterpreted as psychiatric illness.  Today, it is possible to do experimental research to test the psychosomatic theory by, for example, testing the cerebrospinal fluid of people diagnosed with somatoform disorder to check to see how many of them have high levels of substance p, indicating that they have neuropathic pain.  A few preliminary comparisons of people diagnosed with somatoform disorder with people with fibromyalgia have been done, but, as far as I can determine, not a comparison of their cerebrospinal fluid.

In addition to scientific experimentation, there are diagnostic procedures that could be implemented to help avoid misdiagnosis. Anyone with widespread body pain should see a rheumatologist first, before being sent to a psychologist or psychiatrist. Tests for organic illness should be done. X-rays should be taken to see if there is an arthritic condition. A sedimentation rate and antibody test can determine if there is inflammation that might suggest the onset of an auto-immune disorder. Anyone with symptoms of depression should have a thyroid test. If these tests are not done by the general practitioner, and the patient is sent to a psychiatrist instead, the psychiatrist should recommend the tests before prescribing psychiatric medication. These are not common practices at this time.

Patients need to know more about these issues so that they can ask the right questions and insist on the appropriate tests. If their physician does not cooperate, they should seek another opinion. There are doctors and medical researchers working to change the practice of medicine for the better, to make the treatment of chronic pain and chronic illness more scientific. But this is a slow process. Change will happen faster when patients, who, after all, pay the bills, insist upon it.

Return to the Table of Contents for "Of Pain and Science"

Notes

1. See, for example,  "Psychosomatic Medicine," Wikipedia.

2. See, for example, Robert M. McCarron. Somatization in the Primary Care Setting, Psychiatric Times, May 2006.
   
3. See, for example, David Servan-Schreiber, et al.  “Somatizing Patients: Part I. Practical Diagnosis.” American Family Physician, February 2000. “No one fully understands the pathophysiology of somatization.”

4. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th Edition. American Psychiatric Publishing, 2000.

5. Glen O. Gabbard. Gabbard's Treatments of Psychiatric Disorders. American Psychiatric Publishing, 2007, p. 590.
 
6. Glen O. Gabbard. Gabbard's Treatments of Psychiatric Disorders. American Psychiatric Publishing, 2007,  p. 588.

7. Glen O. Gabbard. Gabbard's Treatments of Psychiatric Disorders. American Psychiatric Publishing, 2007,  p. 585.

8. Dessein PH, Shipton EA, Joffe BI, Hadebe DP, Stanwix AE, Van der Merwe BA. “Hyposecretion of adrenal androgens and the relation of serum adrenal steroids, serotonin and insulin-like growth factor-1 to clinical features in women with fibromyalgia.”  Pain. 1999 November;83(2):313-9.

9. Joint Commission Resources. “Overview,”  Approaches to Pain Management: An Essential Guide for Clincial Leaders,  p. 4.
 See also: Marni Jackson. “The undertreatment of women in pain.” A Friend Indeed. March, 2003.

10. Sarchielli P, Alberti A, Candeliere A, Floridi A, Capocchi G, Calabresi P. “Glial cell line-derived neurotrophic factor and somatostatin levels in cerebrospinal fluid of patients affected by chronic migraine and fibromyalgia.” Cephalalgia. 2006 April;26(4):409-15.

11. Wood PB, Holman AJ.  “An elephant among us: the role of dopamine in the pathophysiology of fibromyalgia.” Journal of  Rheumatology. 2009 Febrary;36(2):221-4.