November 1st, 2015

Examining psychosomatic illness

Psychosomatic illness is often seen in people who have limited coping resources, said Kristie Puster, Ph.D. She is the director of psychological and behavioral interventions at the Hasbro Medical Psychiatric Program in Providence, Rhode Island.

The National Institutes of Health reported that prior to the 19th century, many in the medical field believed emotions were connected to physical illness. That way of thinking subsided in the ensuing years, but recent studies have shown psychological factors may be a factor in some physical conditions.

Kristie Puster, Ph.D., director, Psychological and Behavioral Interventions at Hasbro Medical Psychiatric Program in Providence, Rhode Island, said, “Psychosomatic illness is when a psychological state affects our physical functioning beyond what is normal and to the point that we become impaired in some way.

For example, a person can experience paralysis unrelated to any physical damage or physical disorder, but instead caused by difficulties with emotional expression or functioning. The paralysis is real and in no way intentional or being ‘faked,’ but its origins are psychological as opposed to physiological.”

Puster continued, “Psychosomatic illness is often seen in people who struggle to understand or verbally express their emotional state or have very limited coping resources. Specific challenges may include, but not be limited to, long standing stress, past or recent trauma, anxiety with a tendency toward avoidance, or a history of medical illness in themselves or family members that has been in some way reinforcing.”

When diagnosing psychosomatic illness, all other explanations for the illness must be eliminated before considering emotional or behavioral patterns and stressors, according to Puster.

“Many times, a person experiencing a psychosomatic illness may not be aware of the emotional factors leading to their physical symptoms, so collecting collateral information from family or other providers can be crucial,” she said.

Carol Ginandes, Ph.D., a private practitioner in Watertown, Mass. affiliated with Harvard Medical School and McLean Hospital, considers “psychosomatic” a larger term that “subsumes various mind/body conditions.”

She explained that the old-fashioned term “somatoform” relates to a physical complaint of unexplained mental origin, such as hypochondriasis or pseudocyesis. Other terms, including “psychosomatic,” have historically had a pejorative connotation, she added.

A more contemporary term – “mind/body medicine” – dispels the notion that the condition is “in the patient’s mind” and “mediates symptoms in both directions.”

Mind/body complaints are often difficult to diagnose and, clinically, medicine is in its infancy in this area, Ginandes explained. “Most medicine is not conducted in collaboration between a clinical physician and a psychologist,” she said, adding that caution should be exercised before attributing a condition to either a medical or psychological root cause.

“You should make sure to recommend every screening test for an organic condition. Never take anything for granted. Many things don’t get properly diagnosed.”

Stress can play a role in many mind/body conditions, according to Ginandes. “We think of stress as an internal response to an agent causing a condition. People who are aware of external stressors are less aware of internal stressors. The challenge is to sort out what is going on with this system and this patient in a unique expression,” she said.

When treating a patient with a mind/body complaint, Ginandes begins with an extensive assessment and a detailed history. She incorporates clinical hypnosis, which her research has shown may accelerate healing, with several other intervention tools.

“It’s critical to use your diagnostic and relational skills to have input into the mind/body interface,” she said. “There are proactive tools to use beyond listening. Psychologists with training in behavioral medicine and clinical hypnosis have a skill set we can bring to mind/body medicine.”

Ginandes said, “Scientifically, we are coming into a time when we can test and see the mind and body as an interactive feedback loop. Anything in the mind has some physiological impact in the body. Now science looks at PET scans, genetics and hormones to see things on a functional and cellular level.”

Treatment options should involve multiple interventions, said Puster.

For instance, behavioral treatments focus on withdrawal of attention and reinforcement for physical symptoms and positive reinforcement of healthier behaviors; cognitive therapy addresses distortions about health and abilities; and psychological interventions concentrate on underlying psychiatric diagnoses.

“Interventions with this diagnosis should be multidisciplinary and include support from physicians, physical or occupational therapy or other disciplines to provide many types of support and a consistent message in increasing functioning,” she added.

If left untreated, symptoms may worsen, exposing the person to unnecessary medical intervention and procedures as well as financial burdens on the individual and the medical system, said Puster.

“These illnesses are a great strain on our economic system in general, as they lead to a need for accommodations in schooling/work, work and school absenteeism, poor work efficiency and draining the resources and time of caregivers in these arenas as well.”

Jonathan M. Borkum, Ph.D., a private practitioner at Health Psych Maine in Waterville and Bangor, specializes in treating patients with chronic pain and indicated that psychosomatic illness often requires a functional diagnosis of the central nervous system, which “participates in a wide swath of physiological changes in the body,” he said, explaining that there could be a “large field of potential precipitants.”

He said, “You need to figure out which are relevant and how many have a lack of correlation. Environmental, physiological, emotional and behavioral [factors] are on equal footing. When you figure out [the cause], you can solve the problem before you.”

For instance, migraines could be precipitated by bright lights, low blood sugar, mental overwork, stress or guilt at not completing a task.

Borkum’s treatment plan aims for disease remission in intensity and chronicity.

“The duration of symptoms influences how good the prognosis is,” he said, pointing out that in some cases, patients have to learn to accept and live with the residual symptoms.

“The goal is to reduce the impact of symptoms on life, reduce the amount of mental energy going to the symptoms and identify ways to improve functioning and develop a good quality of life.”

Self-involvement is key as most interventions are voluntary and structured on observation of patterns and symptoms patient self-reports, according to Borkum.

“If someone outside does the observing, it’s not as useful.” When the patient begins to “back away” from treatment recommendations, he indicated that the direction might not make sense to the patient or does not match the way he sees his diagnosis.

“The direction could be threatening to the patient so the therapist has to understand why,” he said. “There might be things going on in life other than their symptoms.”

By Phyllis Hanlon

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