Pathologies of the Mind/Body Interface

Exploring the Curious Domain of the Psychosomatic Disorders

Richard L. Kradin

• Publisher: Routledge
• Year: 2012
• Topic: Psychology
• eBook ISBN:
  9781136193910
• Subtopic: Developmental Psychology
• Index: Psychology

Patients suffering from psychosomatic disorders represent a formidable challenge. Psychosomatic disorders are common, and account for substantial personal discomfort, unnecessary medical expenditures, socioeconomic loss, and disability. They are challenging to diagnose, treat, and are rarely completely cured. Furthermore, they often provoke strong negative reactions from family, friends, and caregivers, who are unable to fathom their inconsistencies. Currently, little is known as to how they develop or why their symptoms tend to transform over time. In Pathologies of the Mind/Body Interface, Richard Kradin, a medical internist, pulmonologist, and psychoanalyst at a large Harvard hospital, examines the historical, philosophical, cultural, psychological, and neurobiological factors that contribute to the development of psychosomatic disorders. He focuses on the role that developmental stress and attachment disorders appear to play in increasing the risk of developing psychosomatic symptoms, and advises medical practitioners and psychologists on how to diagnose and treat them. Dr. Kradin suggests areas of importance for future medical and psychological research into the causes and treatments of these debilitating disorders.

1 Basic Concepts

Nor is there any thing to be relied upon in Physick but an exact knowledge of medicinal physiology (founded on observation, not principles), semiotics, method of curing, and tried (not excogitated not commanding) medicines.

(Locke, 1823)

In a recent review, Escobar and Gureje describe the problems posed by psychosomatic disorders:

There seems to be a universal tendency to experience and communicate psychological stress in the form of physical symptoms and seek medical attention for them. In most cultures, these complaints and syndromes tend to be associated with increased medical visits, unnecessary medical tests, and the performance of procedures that may result in iatrogenic complications.

(Escobar and Gureje 2009, p. 41)

The universality of psychosomatic disorders indicates that they are an archetypal feature of the human condition, most likely reflecting the difficulties that inhere to the optimal developmental integration of mind and body, as well as to the level of stress reported in modern society. As the medical historian Borch-Jacobsen notes, illness, psychiatry, and culture are inextricably linked to one another (Borch-Jacobsen 2009). Psychosomatic disorders are contextual, which means that their symptoms depend on both personal and cultural influences, and as such, they are also historical and subject to change with time. For example, it appears by report that psychosomatic symptoms observed in the 17th century only vaguely resemble those encountered today (Porter 1995). In contrast, organic diseases are largely fixed in their appearance, and medical paleontologists have identified evidence of tuberculosis, gout, and rheumatoid arthritis, in mummified remains, indicating that these diseases have been little affected by the passage of time (Nerlich et al. 1997).

In the 19th century, the medical scientist Claude Bernard offered the dictum that has largely defined how medicine is conceived. This was that “structure determines function,” with the corollary that abnormal structure leads to deranged function (Bernard 1878). Disease is therefore defined by the presence of “morbid” or pathological anatomy, and symptoms due to disease tend to correlate with pathological changes and have been established over many years by careful clinico-pathological correlations.

On the other hand, functional somatic syndromes (FSS) have no established anatomic cause. They tend to be associated with constellations of psychological abnormalities and, for this reason, were traditionally termed psychosomatic disorders. The difficulties in defining functional disorders represent a challenge to the epistemology of medicine. Whereas the absence of evidence does not preclude that at some point in the future, specific causes for functional syndromes will be discovered, currently they cannot be located within the spectrum of organic pathology.¹

Much of our insight into the psychosomatic disorders comes from studies conducted by medical practitioners, historians, and anthropologists. What have repeatedly been highlighted by their research are the curious mercurial aspects of the psychosomatic disorders (Lee and Kleinman 2007). In a review on the changing face of neurasthenia—a common disorder at the turn of the last century characterized by fatigue and somatic symptoms—the psychiatrist and medical anthropologists Lee and Kleinman wrote:

Although it is not widely recognized, the professional classification of mental illness is subject to no less sociocultural influence than the symptoms or experience of the illness itself. This is partly because mental disorders are complex in etiology and dimensional in nature (e.g., normal sadness versus depression, existential angst versus generalized anxiety disorder. The lack of biological markers that preclude an etiological diagnosis is another recognized reason. These facts about diagnostic categories in psychiatry produce tensions with practical needs in clinical practice and professional training that focus on “making the correct diagnosis.”

(Lee and Kleinman, p. 53)

In part, for these reasons, the Diagnostic and Statistical Manual of Mental Disorders, the handbook for psychiatric disease classification, has in recent years adopted an acausal approach by referring to many of the psychosomatic disorders as somatoform disorders, which simply means that while they mimic organic pathology, they currently have no anatomical cause (American Psychiatric Association 1994). In doing so, psychiatric experts intended to leave open the possibility that these disorders might someday be rightly subsumed under the rubric of other organic diseases, in line with the present goals of biological psychiatry.

But as might be predicted, the new nomenclature presents a variety of difficulties. For one, it is not certain that somatoform disorders are distinct from other psychiatric conditions, in particular, the spectrum of anxiety and depressive disorders. The term also tends to ignore accumulated evidence that psychological and cultural factors almost certainly play in their pathogenesis. The psychosomatic disorders are victim of semantics, as emphasizing “psychological” or “cultural” factors does not exclude a role for the activities of the body, especially the nervous system. Consider the opinion of Norman Doidge, a psychoanalyst who has written on the importance of neuroplasticity (Doidge 2007). According to Doidge, “We all have what might be considered a culturally modified brain, and as cultures evolve, they continue to lead to new changes in the brain. As Mezenrich puts it, ‘Our brains are vastly different, in fine detail, from the brains of our ancestors’” (p. 288).

For this reason, I prefer to retain the term psychosomatic disorders and have done so in the present text. I am also encouraged in this regard by other recent texts that have continued to use the older term, in this regard (Levenson and Wulsin 2010).

It is critically important to recognize that the absence of a physical cause for psychosomatic symptoms has implications that go well beyond academic questions of philosophy and nosology. The fact is that it also tends to undermine patient care. A constant complaint of patients with psychosomatic disorders is that friends, family members, and physicians underestimate or dismiss their symptoms. The most compelling explanation is that although these individuals feel ill, they appear to be well. All people are endowed with the capacity to recognize disease, although they may not be able to diagnose its cause. The chronically diseased appear haggard, thin, frail, etc. Prior to effective treatments, most patients with chronic organic diseases either recovered or died. But, sickness is not only a subjective state of suffering; it is also a communication, a semiotic that informs others concerning one’s state of health.

For most of us, disease is repugnant. It gnaws at us concerning our own vulnerability and raises fears of contagion. The idea of contagion is ancient and at the root of much of ancient magico-religious thinking with respect to disease, impurity, and sin (Conrad and Wujastyk 2000). Contagion is a culturally defined stigma. In the early stages of disease, when cause and level of risk are uncertain, there is a near universal tendency to isolate the sick, until their danger to others is clarified.

The priestly texts of the Hebrew Bible (Berlin, Brettler, and Jewish Publication Society 2004) provide a detailed description concerning how individuals with the disease tzaraath, often improperly translated into English as “leprosy,”² were quarantined and afforded the status of “untouchable.” The disease presented as a sign in the skin, where it could be recognized by a trained priest and observed for evidence of progression.

In the Hebrew Bible, illness is judged to be the consequence of sin.³ The therapeutic approach to tzaraath in Leviticus 14 was to quarantine the afflicted person, in an effort at preserving the purity of the community. A priest would subsequently monitor the cutaneous signs, specifically looking for evidence of regression. If this was found, the disease-free sufferer was required to repent, bring appropriate animal sacrifices to YHWH, and to undergo ritual immersion, before being integrated back into the community. On the other hand, if the disease had progressed or was unchanged, the sufferer was expected to live out his life in isolation.⁴

In altered form, comparable healing rituals persist today. Patients with infectious diseases are often isolated within hospitals, treated with precautions, and only moved out of isolation when the disease has been adequately treated. They are often then sent to a rehabilitation facility before finally being reintegrated with family and community.

The ancient disease of tzaraath was a sign in the flesh. But how does one respond to the psychosomatic patient who claims to be ill without signs of being so? Here, there is a natural predisposition to question the legitimacy of the complaints, leaving the psychosomatic sufferer feeling abandoned by friends, family, and even physicians. Instead of compassion, the psychosomatic patient too often elicits skepticism and disdain from those who believe that illness is being feigned.

But at some level their complaints are actually accepted and responded to as potentially dangerous. This is evident by the fact that these patients report feeling isolated and stigmatized. Why might this be the case? I would argue that their isolation is punishment for having violated the health-related mores of society, rather than motivated for reasons of physical contagion. In the eyes of many in society, the psychosomatic patient “sins” by virtue of transgressing the cultural laws of disease. In claiming to be sick, they are guilty of a moral failure. In shunning them the community avoids the risk of psychological contagion, so that they will not be accepted in society until they have fully recovered. Curiously, biblical commentators have linked the disease of tzaraath with the sin of “speaking negatively of others.” Is the psychosomatic patient guilty of this? In solid measure, the answer is yes, as they tend to express pervasive negativity concerning their lot and the participation of others in their plight. But the fact is that cultural stigma continues to extend to all complaints psychiatric in nature, despite efforts in recent times to reverse this prejudice in society.⁵

It has been estimated that as many as 20 percent of physician visits are related to bodily symptoms for which no cause can be identified (Dimsdale, Sharma, and Sharpe 2011). This is the case on any given day and in any given medical subspecialty clinic. In an uncertain number of cases, patients with established organic disease will complain of increased symptomatology, or of new symptoms that cannot readily be explained by the underlying disease. In practice, these changes are most often attributed to the preexisting disorder, which is treated more aggressively but with little success.

The First Noble Truth of Buddhism proclaims that “all life is suffering,” and fine-tuned attention to the processes of the body supports this conclusion. As Oliver Wendell Holmes noted, at any given time, a large percentage of the population is symptomatic from some minor discomfort (Holmes 1860). Most attribute them to minor “glitches” in their normal physiology, but others are prompted to seek medical attention. This last point is too often overlooked or missed when considering the psychosomatic patient. Virtually all definitions of these disorders include not only symptoms required for diagnosis but the fact that the symptoms must prompt health-seeking behavior. Indeed, it is an inviolable feature of these disorders, which undoubtedly is telling us something important about what motivates them. The psychosomatic patient seeks reassurance, and as will be argued, this is exactly what was not optimally available to them during development.⁶

The “sick role” communicates a state of need and dependency on others (Twaddle 1981). It must be differentiated from “sickness behavior,” which includes a constellation of evolutionary physiological strategies that promote healing, including withdrawal from others; resting; and sleeping. Sickness behavior results from the release of inflammatory mediators with pleiotropic activities. For example, interleukin-1 (IL-1), which is released during inflammation, both elevates body temperature and induces slow-wave sleep (Akdis et al. 2011). Although the sick role can include elements of sickness behavior, it can also be observed in the absence of organic disease.

The psychosomatic patient adopts the sick role in response to perceived illness, but how the role is responded to can be complex. The sick role is part of an unspoken societal contract. All ethical societies are expected to provide care for those who are unwell; but the sick are also charged with making every possible effort to unburden society by taking appropriate actions to restore their health. Consequently, establishing sickness may require the consensus of doctors, third-party payers, and government agencies. Developing such a consensus with respect to patients suffering from psychosomatic symptoms can be difficult. As might be expected, third-party payers and governmental agencies are not inclined to reimburse chronically sick individuals with no objective evidence of disease.

Anxiety, depression, and stress can all exacerbate functional symptoms, but how they do so is unknown. Furthermore, why the psychosomatic symptom assumes different forms (for example, headache, palpitations, shortness of breath, abdominal pain, etc.) is also uncertain. Alfred Adler was a medical internist and protégé of Sigmund Freud, who broke with him due to theoretical differences during the emergence of the psychoanalytical movement. Adler suggested that individuals can suffer from “organ inferiority,” and that symptoms tend to develop in organ systems with preexisting vulnerabilities (Adler 1917). But Adler’s idea was already known in antiquity. Galen, a highly influential physician of late antiquity, noted that “what proves our words with absolute clarity is that we find that some people suffer from diseases in the weak organs of their bodies every six months or more” (Galen 1951).⁷ The idea of organ inferiority has never been critically examined, but it does represent an early effort at explaining why organ-specific symptoms might develop.

However, researchers of psychosomatic medicine have shown that the rule for psychosomatic disorders is for symptoms to show overlap, so that patients with chronic fatigue syndrome (CFS) may report suffering concomitantly from fibromyalgia, tension headache, multiple chemical sensitivity, food allergy, premenstrual syndrome, and irritable bowel syndrome (IBS). But patients with IBS also complain of hyperventilation, fibromyalgia, CFS, and tension headache (Kanaan, Lepine, and Wessley 2010). This raises the question of whether there are, in fact, distinct psychosomatic disorders or one extended polymorphic syndrome. Isolated chronic psychosomatic symptoms over the course of a lifetime are uncommon.

It has already been mentioned that psychosomatic disorders have a propensity to change over time (Shorter 1993). This may be likened metaphorically to microbes that develop resistance to previously effective antibiotics. Once symptoms have been demonstrated to be incompatible with organic disease, they tend to morph into new ones that continue to stymie efforts at understanding and treating them. Doctors, frustrated by their inability to respond effectively to implacable complaints, may find themselves grasping for any credible diagnosis. Patients, disgruntled by unremitting symptoms, will rarely miss the opportunity to complain of the failure of the medical profession to relieve their distress.

From the psychoanalytical perspective, it is important to identify the psychosomatic symptom as a symbol. It is a m...

Table of contents

• Cover
• Halftitle
• Title
• Copyright
• Dedication
• Contents
• List of Illustrations
• List of Tables
• Introduction
• 1 Basic Concepts
• 2 Hysteria: The Psychosomatic Disorder Par Excellence
• 3 Somatophobia
• 4 Mind and Its Development
• 5 Stress
• 6 The Placebo Response
• 7 The Psychosomatic Disorders
• 8 Psychosomatic Disorders: Living on the Edge
• 9 Treating the Psychosomatic Disorders
• 10 Conclusion
• Notes
• References
• Index