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It’s All in Your Head

I have never used those words to a patient or about a patient.  I have also never heard a colleague use any similar term to a patient. And yet on many occasions I have had patients ask me, “So you’re telling me it’s all in my head?”

The concept of what are now called psychogenic symptoms is a tricky one for various reasons. There is an unfortunate stigma attached to the notion that our brains can cause physical symptoms. Making the diagnosis is complex. Outcomes are variable and are hampered by the difficulty in communicating the diagnosis to patients. Psychogenic symptoms often mask underlying physiological disease. And the risks of both false positives and false negatives are high.

This complexity leads some to argue, in essence, that psychogenic symptoms do not exist at all – that the diagnosis is a cop out, a way to blame the patient for the failings of the physician. But this approach, ironically, is a cop out, because it seeks to white wash what is a real and complex disorder with an overly simplistic and moralistic approach.

What are psychogenic symptoms?

Various terms have been used over the years to refer to symptoms that are generated by psychological stress or other factors. Hysteria is an unfortunate term which was invented to refer to the uterus, as if such symptom were uniquely female. For obvious reasons the term “hysteria” is no longer used. Psychosomatic is still a proper term, meaning physical symptoms with a mental cause, but the term does have a bit of a stigma attached. The term psychogenic is most widely used today, simply meaning having a mental cause.

A related concept is embellishment or psychogenic overlay. In these cases there is an underlying physiological disease or disorder which then results in stress and anxiety which further generates psychogenic symptoms on top of the physiological symptoms. What this means is that the presence of even demonstrably psychogenic symptoms does not necessarily mean that there is no underlying disease, and a thorough workup is still indicated.

Psychogenic signs and symptoms are real – the patient really experiences them, and often they lack insight into the origin of their symptoms. Psychogenic is not a synonym for fake, they are usually not voluntary, and patients cannot just stop their symptoms. A psychogenic disorder is a real disorder  – it is just that the problem is with the brain’s software, not hardware (if you will excuse the geek metaphor).

Sometimes people have a depressive or anxiety disorder, which may be reactive or may be primary and due to a biochemical disorder in the brain. Anxiety puts a lot of stress on the body and can absolutely manifest with physical, and sometimes very dramatic, symptoms. Stress itself can also manifest with physical symptoms.

This should be no surprise to anyone familiar with neurobiology. The brain is an organ, just like any other organ in the body. It is made of tissue, and it is connected to the rest of the body through the nerves as well as the neuroendocrine system. Thoughts alone can speed up your heart by releasing adrenaline, they can cause butterflies in your stomach or nausea through increased vagal activity, or can flood penile tissue with blood causing erection. A fright can cause your blood pressure to drop resulting in fainting. Stress can chronically increase blood pressure.

So we all have psychogenic symptoms at some point in our lives, and we take them for granted. The fact that more dramatic symptoms can also result from purely psychogenic causes should not be that surprising.

How do we known when symptoms are psychogenic?

Often knee-jerk critics of the psychogenic diagnosis claim that it is purely a diagnosis of exclusion – an expression only of lack of knowledge on the part of the diagnostician. Excluding underlying physiological causes is an important part of the diagnosis – but not the only part.

In neurology (my specialty) for example, there are many situations in which positive evidence can be brought to bear to demonstrate that a patient’s symptoms cannot be neurological. There is a well-described entity known as pseudoseizures or non-epileptic seizures in which patients have involuntary seizure-like episodes.  A seizure is an abnormal electrical discharge in the brain, firing neurons in unison and causing symptoms based on where in the brain the neurons are firing. There is a limited number of patterns that seizures can have, because they are “sloppy” and just spread directly to neighboring neurons (not following complex networks of neurons). There are some patterns of convulsive movement, for example, that are simply impossible – they cannot be due to motor seizures.

Also, at times patients will have psychogenic weakness, either partial or complete paralysis of a limb. True neurological weakness has certain features which cannot be simulated (voluntarily or involuntarily) and there are techniques we use in the neurological exam to look for these features. Likewise there are features that are very suggestive of what we call effort-dependent weakness (which does not imply insight or deliberateness). Essentially, different causes of weakness have different features on neurological exam that we can distinguish, often quite easily.

Further still, without a detailed knowledge of neuroanatomy, patients with psychogenic symptoms will tend to display distributions of symptoms that do not follow anatomical pathways. Or they will display patterns of movements that do not correspond to any part of the motor system.

Another feature that is suggestive (but not proof) of a psychogenic disorder is that the hard or objective findings that normally accompany a neurological deficit are absent. These include reflexes that do not require any cooperation, voluntary effort, or subjective feedback from the patient – they come pretty close to a direct examination of a circuit in the nervous system.

To summarize, there are cases in which patients exhibit neurological symptoms which seem to defy neuroanatomy, reveal features of effort, do not correspond to known systems in the nervous system, and lack any hard or objective finding that should be present. Even in these cases, we are likely to do a full workup looking for an underlying problem (as stated above, psychogenic symptoms may simply be overlaying a physiological lesion or disease). In psychogenic cases thorough neuroanatomical scans are normal, as are physiological tests for nervous system function.

In cases where there are positive features of a psychogenic disorder, and a thorough absence of other demonstrable causes, the diagnosis of a psychogenic disorder is perfectly reasonable. It is not a negative judgment about the patient, it is simply an attempt to make an accurate diagnosis.

False positives and false negatives

Nothing in medicine is 100%, and all diagnoses have false positives and false negatives. Physicians learn to deal practically with this uncertainty. For example, even though we may have made a confident diagnosis, we will still rule out alternatives we cannot afford to miss. The diagnosis of a psychogenic disorder is no different.

The public tends to focus on the risks of the false positive – diagnosing a symptom as psychogenic when there was a missed underlying physiological disorder. While this happens, it is again no different than any form of misdiagnosis. This is, admittedly, the worst-case-scenario. But to put it in perspective, this often occurs after a thorough workup that has failed to reveal the diagnosis. So the failure to make the underlying diagnosis occurs whether or not the alternate diagnosis of psychogenic is entertained.

Putting the notion of a psychogenic cause aside, physicians often face the situation in which patients have symptoms that cannot be diagnosed. The body is complex, and we cannot always explain every symptom. Workups are designed, in fact, to look for entities which can be treated, not necessarily to explain symptoms at all costs. So when we say we don’t know what is causing a symptom what we really mean is that we have ruled out anything that we could treat. What we are left with are all the subtle biochemical or physiological causes that we either cannot rule out, or are simply not worth investigating because they will not change management.

Sometimes patients are simply uncomfortable with this situation (perhaps because it was not communicated to them well). They may seek a diagnosis until they find someone willing to make one, and then they will blame their previous doctors for “missing” the real diagnosis. Sometimes the actual diagnosis is missed, and patients were right to seek other opinions. But at other times the new diagnosis is the fake, but it is more acceptable to the patient than the stigma of  stress or anxiety induced symptoms.

It should also be pointed out that sometimes there is an underlying disorder causing psychogenic symptoms – serious anxiety or depression. These are just as much “real” disorders as anything else.

In short, we see every permutation of diagnostic misadventure because the human body is complex, our knowledge and technology are limited, and the doctor-patient relationship is increasingly complex.

There are also risks to the false negative, however – missing a psychogenic disorder when that is the proper diagnosis. Patients who have disturbing symptoms due to psychological stress or anxiety will often seek multiple opinions. They will get what we call “the million dollar workup” – sometimes over and over again. There are real risks associated with so many tests. Sometimes the tests themselves are invasive and contain risks. But even safe tests, if you get enough of them, are bound to result in false positives, which could lead to a misdiagnosis, further invasive testing, and improper treatment with risks and side effects.

I have seen this scenario play out as well. I have had a few patients who, in my opinion, had entirely psychogenic symptoms, but through their tireless seeking of medical attention ended up being on numerous medications they did not need, and being subjected to many invasive procedures which then led to complications. In the end the patients had physiological and anatomical disorders and symptoms, but all ultimately resulting from the failure to properly diagnose their original symptoms as psychogenic. They would have been much better served if they were aggressively reassured that they did not have the diseases they feared, and if they were directed toward gentle quality of life interventions, as well as psychological attention for their underlying disorder. In one case the patient had what can only be called mental illness, and needed to be aggressively redirected toward psychiatric treatment.

The point is – there are risks both ways (like in all of medicine). There are risks to prematurely making the diagnosis of a psychogenic disorder or missing an additional underlying trigger, and there are risks to missing the diagnosis of a psychogenic disorder.

Conclusion

In a perfect world the unfortunate stigma attached to the psychogenic diagnosis would disappear. It is very counterproductive. We need broader understanding that the brain is also an organ and can manifest symptoms in a variety of ways. Psychogenic causes are just another item on the differential diagnosis.

Physicians, for their part, should likewise remove any stigma attached to patients with psychogenic symptoms and need to approach the diagnosis as if it were any other – with positive and negative signs, and risks to false positives and false negatives.

Posted in: Neuroscience/Mental Health

Leave a Comment (36) ↓

36 thoughts on “It’s All in Your Head

  1. kirkmc says:

    I have to react to this.

    It is often far too easy for doctors to assume psychosomatic problems than to search for real ones. I’ve been there – I have cavernous angiomas of the brainstem, and saw doctors about dizziness, and they all assumed it was “in my head” (which, in a way, it was). I am in touch with many other people with this problem, whose symptoms were brushed off until they, like me, had brain hemorrhages.

    Frankly, I’ve come to wonder if there are any psychogenic problems; if it’s just that we know so little about the brain that we ascribe to the mind problems that, one day, we will understand better.

  2. tarran says:

    One major hindrance to the treatment of disorders of the mind is the cultural attitudes towards the mentally ill; first – people who were mentally ill were abused or mistreated (forcibly sterilized, imprisoned, had their property confiscated, lost custody of children etc), secondly – often accusations of mental illness were used to marginalize/discredit people, both by individuals (my wife is crazy and I should be put in charge of her property) or more dangerously by the state or the sovereign (the Soviet classification of dissidence as a mental illness being an extreme example).

    Moreover, the all in your head phenomenon is all too real. Contrast the symptoms of somatism (a pshychological syndrome) with those of endometriosis, for example. All too often the argument that “it’s all in his/her head” is used as a rationalization to reject a person who is frustrating to us.

    One way to get rid of the stigma is to not dance around it. Use the stigmatic terms ina non stigmatic way. To take the terms back so to speak.

  3. kirkmc – you are making what is called a hasty generalization. I am sorry for your personal story – it is, as I stated, the worst-case scenario when a real and serious problem is misdiagnosed as psychogenic.

    But you cannot extrapolate from your personal story to the conclusion that there is no such thing as psychogenic illness. Read my post again. There are cases where there is really no question but that the presentation is psychogenic.

    And to be crystal clear – this means there is something mysterious happening the brain – but it is functional, not pathological.

  4. Galadriel says:

    Your argument that doctors will only make a diagnosis of “it’s all in your head” after numerous tests is lovely and idealistic. Sadly, my experience and that of many others I know does not agree with this lovely argument. Too many doctors seem willing to jump to this conclusion without testing for anything, or doing only a few mildly probing tests before apparently deciding that diagnosis is too difficult–I’m not kidding, I had a doctor last year tell me that diagnosing severe headaches “is like shooting into the dark” and therefore we should just give up trying. (“Oh, and here, take these antidepressants.”)

    Sadly every single person I know with a stubborn illness, one that requires more than a few minutes of a doctor’s time, has had to face at least one doctor who told them it was all in their head. I and they have had to not only keep trying to find an accurate diagnosis on our own–playing roulette with random specialists, hoping one can help–but also fight with doctors who were refusing to continue investigating. A pinched nerve causing severe headaches, someone with nasty ovarian cysts, even someone in the early stages of Alzheimer’s!

    “Your [possibly nonexistent] stress/depression/anxiety is causing your [wide range of] symptoms” seems like a favorite diagnosis when a couple of blood tests can’t turn up a clear answer, rather than one reserved for cases where extensive testing has been done and the cause just can’t be found. It’s a beautiful article, but I’m just not seeing that part of the argument in practice.

    I’m distressed about the frequency of diagnosis, not arguing against psychogenic illnesses completely. I just wish doctors WOULD reserve it for such cases, rather than using it as a crutch.

  5. kirkmc says:

    “But you cannot extrapolate from your personal story to the conclusion that there is no such thing as psychogenic illness.”

    That’s not what I said. What I said is that I wonder if such things exist; not because of my problem, or the problems of another commenter, but because of the many discoveries made in neuroscience that show that many such ailments have neurological (ie, brain-related) causes. Would you agree, for example, that fibromyalgia is a real ailment? (Many don’t.) It was long considered to be psychogenic, and is now considered to be brain-related. What I think is that neuroscientist will discover many more such ailments in the coming decades.

  6. fibromyalgia is not that simple. I cannot give you a short answer – but I don’t think even fibromyalgia skeptics think it is psychogenic, rather just that it’s a vague syndrome with lots of causes.

    But you are still going on the premise that the diagnosis of psychogenic is purely a diagnosis of exclusion. It is not. There is evidence from the exam in some cases that the symptoms are coming from the conscious part of the brain – they must localize there.

    For example, in patients with psychogenic blindness it can be demonstrated by direct examination that their visual pathways are intact. In some cases you can also produce inconsistent exam findings – meaning the patient reports no vision, but they will flinch to visual threat. We can confidently conclude in some cases that the symptoms being manifested are functional – they are due to higher level processing in the conscious part of the brain – not due to deficits in the subcortical pathways.

    Call it what you will – that is how the localization is established. We then combine that with ruling out underlying pathology or metabolic or electrical abnormalities. Even if there is still some mystery thing going on – it must be compatible with the functional localization.

    We then do what we do in all cases where we have functional symptoms and pathology has been ruled out – we make our best clinical diagnosis and treat accordingly. We look for plausible factors and treat them. If the patient has chest pain and stress – treat the stress. If they have functional blindness and stress – treat the stress. (keep in mind we have already ruled out anything else that needs to be treated).

    Regarding Galadriel – it is difficult for me to respond specifically to second-hand anecdotes. I am not dismissing your story, just recognizing the reality that I need first hand details to respond specifically.

    But generically I will say – sure, there are bad or mediocre doctors out there. I never deny that. Sometimes they just are not good an communicating delicate situations. Sometimes they are too complacent and they give up too quickly. Sometimes they are overworked and take shortcuts. That’s reality.

    But none of that invalidates the reality of neurological psychogenic phenomena.

  7. Jojo says:

    Very interesting post, and I’m sure it will be very controversial as well. Since we are discussing anecdotal situations, I’ll add one from the psychogenic side. I am bipolar and come from a family with a strong history of bipolar illness. When I went off my medication to become pregnant, I discovered that I suffer from restless leg syndrome and experienced significant amounts of joint pain in my left knee and right wrist. It was so bad that I expected I would need surgery to correct the problems. However, when I was able to resume my antidepressants I was shocked when all of my pain went away within a week. I was relieved to learn that it was all in my head and that treatment was very simple.

    My sister, who suffers from poorly managed depression, also suffers from joint pain. She has been diagnosed with chronic Lyme disease and treated with antibiotics for 6 months – which resulted in a thrush infection in her mouth which lead to three abscessed teeth. She has had many cortisone injections in her knee and wrists. She also spent about 10 years making weekly visits to a chiropractor. I think it’s a decent gamble that her symptoms, like mine, are psychogenic and would be more appropriately treated the way mine are. In her case, the false negative for psychogenic illness has cost her at least 20 years of uncontrolled pain, significant financial costs, and she has undergone unnecessary and dangerous “medical” procedures.

    I think this just supports Dr. Novella’s point that both false negatives and positives do occur. It’s frustrating for any patient that receives a false diagnosis, and I’m sure there are a decent number of doctors that too easily lean one direction or another.

    To me, the most frustrating aspect of this dilemma really is the stigma associated with the “it’s all in your head” diagnosis. That stigma has kept my sister from seeking proper treatment, and it makes discussing my illness unwise in my professional circle. It’s a very isolating feeling not being able to discuss what I have been through, especially since people frequently ask me why I don’t have a second child. It seems unwise to answer with the real reason that I suffered pain, insomnia, and disturbing feelings in my legs for two years and I don’t want to go through it again. People tend to end conversations with me quickly after that and I know I’m labeled as “one of them.”

  8. kirkmc says:

    Jojo: it’s interesting that you were convinced that your pain was psyhcogenic because it went away with anti-depressants. Because a number of anti-depressants (and other medications, such as anti-convulsants) are used for chronic pain. In your case, maybe it was in your head; but maybe it was a neurological reaction to the fact that you stopped taking your bipolar medication, which was then corrected by the anti-depressant.

    My point is that many, many things can be neurological in cause (I had some astounding pain in my hand after a brain hemorrhage) and not necessarily “in the head”.

    Dr Novella: I was recently reading (perhaps in the New Yorker) about Ramachandran and the way he “cured” people of phantom limb syndrome. would you call that a psychogenic ailment?

  9. Jojo says:

    Kirkmc – I don’t think we are working from the same understanding of the term psychogenic. Clearly, with both my bipolar disorder and the pain I experience when it is not treated, something really is going on with my brain, and that at this time, the true cause of both is unknown. However, I’m going to fall back on Dr. Novella’s comment above where he states

    “And to be crystal clear – this means there is something mysterious happening the brain – but it is functional, not pathological.”

    Using that distinction, I still believe the pain and restless leg syndrome are psychogenic. I’m not a doctor, so I could be misunderstanding what the true medical meaning of psychogenic is.

  10. anjou says:

    Worst case scenerio here… After 7 months of horrible pelvic pain, 35 pound weight loss and general malaise, countless tests that showed nothing I was told that I was perfectly “fine and should go try to get pregnant as I had been trying before getting sick.” I said I didn’t think that would not be such a good idea when I had pelvic pain and could not eat. Chart suggesting I was crazy followed me… when I demanded a biopsy of an inguinal node, another doctor told me it was nothing, but allowed the biopsy after I practically stood on my head to get it. Biopsy misread as benign (later determined to be lymphoma when it was compared with a later biopsy that was read correctly). Delayed a lymphoma diagnosis by two years and putting the lymphoma at an incurable stage.

    Sometimes, it is perhaps better to say, “I don’t know what is wrong.” then to imply the patient is crazy especially when the patient is not one to frequent the doctors office, has no history of somatization and then suddenly starts banging down the doors saying something is seriously wrong.

    Seriously, the mailman at my office was spreading rumors that I had cancer because of the massive weight loss (I truly looked like an end stage cancer patient) and he was more accurate in his assessment than several internists.

  11. colli037 says:

    I’m a neurologist working in a pain clinic, and have to say I agree with the concept of psychogenic symptoms. We see them literally every day.

    This can range from patients “adding in” some weakness on the exam so we know they are “really sick” to much more elaborate symptoms. In some of the more obvious cases, the underlying psychiatric distress is so well “converted” into the physical symptoms, the patient appears “normal”, at least until more in depth evaluation of their emotional state. In many situations, the symptoms that we call psychogenic are serving a real purpose for the patient, as these symptoms are “easier” for the patient to live with than the “stress” or events that triggered them.

    I have real problems with generalist diagnosis psychogenic symptoms—Like some of the above posts, I have seen many patients diagnosed with psychogenic illness that end up have an identifiable cause for the symptoms. Because I treat pain, I have seen patients with easy to find causes for their pain, if only someone had looked. And I’ve seen symptoms called “psychogenic” that were in fact normal neurologic symptoms that fit well with known anatomy and diseases, but the referring physician just didn’t know.

    tim

  12. Great article. I have a slightly different take on one point:

    Workups are designed, in fact, to look for entities which can be treated, not necessarily to explain symptoms at all costs.

    You are absolutely right that workups are “not necessarily (designed) to explain symptoms at all costs,” (see below) but workups are designed to look for entities that we know about, whether or not they can be treated. The most important category consists of serious entities, especially life-threatening ones. We know about most of those, even if we can’t cure some of them.

    As argued here before, a major barrier to the public understanding of medicine involves the misconception–even held by some doctors–that the purpose of diagnostic workups is to explain whatever symptoms a patient may have. Frequently workups do eventually explain the symptoms, but their first purpose is to “rule out” serious diseases that the presenting symptoms might suggest (that’s why we use the term “rule out”).

    IMHO, this misconception is an important basis for the current obsession with “health.” A typical advertising slogan might say: “health is not merely the absence of disease.” Honest physicians would agree that reducing risk factors for diseases, to the extent that we understand them and they can be reduced, also figures into “health.” But that is not the same thing as feeling good.

    Thus terms such as “wellness” emerge, suggesting something more than what physicians can honestly offer.

    Enter less-than-honest pitchmen, frequently with the backing of business interests, to promise people more than we can give them. This is prevalent not only in woo-based pitches but in many mainstream ones, and most physicians seem to acquiesce.

    As a friend recently said, “the problem with health care now is that everything is for sale; and I mean EVERYTHING.”

  13. kirkmc says:

    Is “underlying psychiatric distress” not a “dis-ease”? Calling symptoms of such an ailment psychogenic seems to me a cop-out; if there is indeed a quantifiable disease – or distress – that is causing symptoms, then they’re not simply psychogenic, are they? (Unless I mis-understand the whole point here…)

    Tim seems to agree with the posts that I and others made about mis- or non-diagnoses; that in many cases, it’s just an easy way out to prescribe a tranquilizer or anti-depressant for symptoms that a doctor doesn’t understand. Thats’ what most of us lay-people understand by the concept presented in this article.

    However, Tim, if you work with pain, you certainly see that in many cases the pain is real, yet you don’t understand where it comes from or how it gets to the level it reaches. Many people have extreme pain that comes from areas that doctors don’t understand. (In my case, I have neuropathic pain caused, in part, by brainstem lesions.)

  14. kirk – I think you still misunderstand. I don’t think you are really reading what I am writing and trying to understand it, but are sticking with your baseline assumptions.

    “Disease” refers to pathology. Not all syndromes are diseases. Some are better labeled disorders. Stress is usually a risk factor, or may in fact be a cause of some disorders – that does not make them diseases. A stress induced disorder can absolutely be psychogenic.

    Psychogenic does not mean fake or made up. It means the symptoms are functional – they result from the function of some organ, rather than disease or damage of it – and they are ultimately psychological, stress induced, affective in origin. They are not the result of damage to the circuit but a misbehaving of the circuit because of higher cortical activity (i.e psychological).

    Also – there are lots of garbage pail diagnoses that lazy clinicians use instead of thorough evaluation. Psychogenic is not the only one. The fact that it is overused or abused in some cases does not mean it is not real or a useful concept.

  15. kirkmc says:

    My careful spelling of the term “dis-ease” was meant to have a clear meaning: unlike a disease (as you say, which refers to pathology) it means something that is not normal, a “lack of ease”. I clearly am not referring to diseases in the strick sense of the word. But my point was that “underlying psychiatric distress” is a “dis-ease”, or syndrome, or condition, or disorder, or whatever. Such disorders – if you prefer that term – have symptoms, which may or may not manifest themselves in ways that you could call psychogenic. But aren’t those symtoms _real_ symptoms of underlying psychiatric distress?

    And what is the difference in your user of the term “psychogenic” and “psychosomatic”? Do they mean the same for you?

    I’m sorry, I am trying to understand what you’ve written, but perhaps the fact that I’m not understand is partially my fault and partially because of the way you’ve written it… (I’m a writer by trade, and when my readers don’t understand, I don’t usually blame them, but try and find where I went wrong.)

  16. @kirkmc

    “Is “underlying psychiatric distress” not a “dis-ease”?”

    Perhaps you are not aware that the term “dis-ease” is generally considered to be a hallmark term for woo-meisters of alternatives to medicine, and generally raises red flags when it is used.

    “I’m a writer by trade, and when my readers don’t understand, I don’t usually blame them, but try and find where I went wrong.”

    Of course if the majority of your readers do understand and a small minority do not, you probably draw a different conclusion. Maybe you try and find where your reader went wrong and try to guide them to the answer. Maybe you determine your reader just isn’t listening no matter what you say.

    You don’t seem to be able to either accept or understand the distinction between pathological and functional disorders.

    “But aren’t those symtoms _real_ symptoms of underlying psychiatric distress?”

    I don’t think anyone here has argued otherwise. I don’t recall Steven having said the symptoms weren’t real, or that they weren’t the result of some genuine condition that needed to be addressed. You seem to be stuck on the concept of “a disorder is a disorder” and if something doesn’t work right, it’s “broke”.

  17. pmoran says:

    There is no real mystery as to where the unexplained symptoms come from. See—

    http://www.medicine.ox.ac.uk/bandolier/band157/b157-8.html

    With such large background levels of symptomatology in the “normal” population, it should be no surprise that quite benign symptoms assume excessive focus in susceptible individuals, or exaggerated in those under stress becoming troublesome illnesses in a few.

    When looked at this way, psychosomatic” is a sound term. It is non-judgmental as to the primary source of the symptoms. It does not change the obligation to exclude at least common causes in the first round of investigation.

    It can be explained to the patient as “there is probably a mixture of things going on”. I found that patients generally accepted this concept, while hating any hint that the doctors thought it was “all in the mind”.

    Investigation could then proceed wtihout each negative one simply adding to the patient’s anxieties.

  18. Dr Aust says:

    Hmmm. The sine qua non of this discussion of “psychogenic” presumably has to be chronic fatigue syndrome / ME. (I notice someone mentioned fibromyalgia up above). For a recent British example of the heat that can be generated when discussing CFS/ME, try here.

    The CFS activist / pressure groups seem to be loudly proclaiming at the moment that the recent “We found a retrovirus in the CFS samples” paper in Science “lays to rest” the idea that any part of CFS is psychogenic. I know Wallace Sampson has had a pretty uncompromising look at this here at SBM, but I would be genuinely curious to know what Steve thinks, partly in the light of this post, and partly since I surmise he might have CFS patients. I tried offering some scientific caution (about the XMRV study) and general “doesn’t the truth probably lie somewhere in between” views in the comments over at the British blog I linked above, but my remarks didn’t seem to sit too well with the CFS folk.

    Are there going to be any more posts coming on the CFS XMRV stuff apart from Dr Sampson’s?

  19. chat_de_pole says:

    I am one of your avid readers, and often agree whole-heartedly with your positions.

    However, in this sense, I am torn. I believe that, as mentioned here previously, extraneous testing can often bring more harm than good on a macro scale. I also believe that “the mind” can and does generate symptoms that are hard, and perhaps even impossible, for a trained and experienced physician to recognize.

    My problem with this post is that, despite the lack of a diagnosis, a patient is still unwell. Neither our contemporary level of medicine’s inability to diagnose or offer treatment, nor the non-existence of such a treatment, fix the patient’s problem.

    Having been in the presence of patients with apparent psychogenic symptoms, I can assure you that saying “there there” only exacerbates the problem, triggering well-understood reactions of anxiety and antagonism. And let’s not forget both anxiety and anger are psychogenic as well, to employ a broader definition. Anxiety and anger can also be neurological.

    Am I abdicating the use of “benzoes” or “sedatives” for treatment of all psychogenic symptoms? Absolutely not! Am I brushing aside their existence? Absolutely not!

    I am, however, uneasy with the conclusion of defaulting “toward gentle quality of life interventions, as well as psychological attention for their underlying disorder.” I think this conclusion begs the question of the disorder being psychological and not neurological in nature.

  20. chat_de_pole says:

    Boo!

    I obviously meant “advocating” instead of “abdicating.”

    :: pats self… there there ::

  21. Robin says:

    As a daughter of a chronically misdiagnosed patient, I can attest that labeling someone as psychogenic or functional can have severe consequences if the patient has an overlooked explanation for symptoms. Not only does it leave the patient without treatment but it harbors resentment, distrust, and can leave the door open to abuse from physicians who examine the patient with medical record acquired bias. I know this isn’t supposed to happen but it does. Isn’t “psychogenic” really a euphemism for somatization and should the diagnosis be left to psychiatrists?

  22. qetzal says:

    @chat_de_pole:

    How could a psychological disorder be anything BUT neurological?

    @Robin:

    I thought Dr. Novella presented a very compelling argument on how a trained neurologist can positively diagnosis a psychogenic disorder, at least under the right circumstances. Given that, why do you think that such diagnoses should be left to psychiatrists?

  23. Harriet Hall says:

    When there is positive evidence for a psychogenic disorder, as in pseudoseizures, the diagnosis is easy. Unfortunately, in most cases we have only negative evidence: a patient with vague symptoms and no objective findings. For every anecdote of a missed diagnosis there is another anecdote of a patient who was harmed by the consequences of a false positive test that probably wasn’t indicated in the first place. The real problem we face is deciding when to stop doing diagnostic tests. It isn’t reasonable to do an exploratory laparotomy or repeated CT scans on every patient with unexplained symptoms.

    There is a fine line between doing too little or too much. We must rule out life-threatening, treatable conditions. Once we have reasonably ruled those out, we can reassure the patient, concentrate on helping him cope with the symptoms so they interfere less with his life, and constantly reassess to see if new symptoms or a poor response to treatment indicates a need for further testing.

    I think there are a lot of cases we could classify as “functional” where the anatomy is normal but its functioning produces symptoms in patients who may be hyperaware, hypersensitive, or hyperreactive. There may not be a psychiatric diagnosis.

  24. Robin says:

    @qetzal Because there is a difference between ruling out and diagnosing?

    Would Dr. Novella be able to determine if his patients had a “functional” problem — a matter of sensitivity as Harriet Hall pointed out — or a somatization disorder which is a psychiatric diagnosis and has its own set of criteria. If anxiety and depression are severe enough to give rise to stress based symptoms, a mental health evaluation would be useful not only for diagnosis but also treatment.

  25. Basiorana says:

    The biggest problem with the stigma comes when you have patients with pre-existing psychiatric disorders. There are many doctors who assume anything without an immediate, obvious explanation in a patient with a history of psychiatric illness is psychogenic, without doing any tests at all. Of course, many times it is; psychiatric patients will often feel the symptoms of their illness in their body. For example, I feel anxiety as difficulty breathing, back and chest pain, muscle tightness, and headaches– never as actual anxious feelings. I know it’s anxiety based on what triggers it and what calms it. This is psychogenic pain, because there is nothing physical or neurological causing the pain, but it is still real pain, caused by involuntary reactions in my body to the emotion of anxiety.

    Of course, because I do have a history of psychogenic pain, physiological pain is ignored. I have a genetic knee disorder that was called psychogenic for years until my sibling was diagnosed with it via x-ray; the x-ray I took quickly revealed the issue.

    I think the problem is that most doctors have little or no experience with psychiatry and maybe a little more with neurology, and thus are uncomfortable with any brain-related issue that isn’t a hole in the head, particularly those that aren’t clearly defined like anxiety, depression, etc. It’s like how docs respond to pregnant women, sending them to OB even if they have something completely unrelated to the pregnancy.

  26. Tsuken says:

    Wonderful post – and excellent responses to comments.

    As a psychiatrist I feel I have to respond to some of the implications made in some of the comments: that if there is not a discernible lesion, if a condition is psychogenic, then it’s somehow not real. I know Dr Novella has also adressed this in the original post, and in the comments, but it doesn’t go away. The symptoms are real, we are not moralising, we are not advocating ignoring or shushing or saying “there there”.

    Nor should we necessarily be prescribing antidepressants, much less benzodiazepines. Antidepressants can be useful treatment agents, but not if just given to anyone with symptoms that aren’t physiologically-based. All that does is give a lot of people a lot of adverse effects with little to no benefit … kind of like over- or inappropriately investigating.

    Just as psychosomatic symptoms are not false, trivial, or irrelevant, psychiatric treatments are not trivial things to be handed out willy-nilly.

    I also want to echo Basiorana’s point about people with psychiatric illness having their physical complaints ignored – even though they are in fact at *greater* risk of medical morbidity than the general population. That doesn’t however invalidate any of Dr Novella’s excellent post.

    @qetzal and Robin: it shouldn’t be a neurologist *or* a psychiatrist; both should be involved in the diagnosisng, and potentially care, of what is often (always?) a complex case.

  27. Of course if my evaluation of a patient reveals a possible underlying psychiatric disorder I refer them to a psychiatrist for evaluation and treatment. Just as psychiatrists often refer to neurologists to evaluate for a possible underlying neurological disorder when a patient presents with psychiatric symptoms.

    There is a lot of overlap between psychiatry and neurology and many cases require the input of both specialists.

    On the other issue – as Harriet and others also pointed out – the trick is in knowing how far to take a diagnostic workup. More is not always better, and continuing to search until pathology is found is not always in the patient’s best interest.

    Think of it this way – how many tests would you have to do in order to make sure that you never missed a diagnosis? How much harm would result from all of that testing?

    In medicine, there is always a balance between false positives and false negatives, sensitivity and specificity. If you focus only on one side of the equation it will give you a distorted view of good clinical practice.

  28. keleton says:

    Harriet Hall said: “For every anecdote of a missed diagnosis there is another anecdote of a patient who was harmed by the consequences of a false positive test that probably wasn’t indicated in the first place.”

    I believe this to be true, and sometimes both of these scenarios happen to the same patient over the course of an attempt to diagnose and treat their symptoms. I have a story to share that illustrates no real severe damage but uncounted wasted dollars and time investigating incidental findings before the real cause was finally discovered. What I took away from the experience was that unless you have classic textbook symptoms your disease or disorder is likely to be missed, unless you have a truly excellent physician (harder and harder to find, as it is not very profitable and they put in long hours for their efforts). It seems that anyone can get through med school if they can memorize the biology and many healthcare providers (nurses more than doctors, but the nurse seems to have a great deal of authority especially in the hospital setting) I have encountered seem to lack critical thinking skills.

    My husband (a 36 year old male with no known health problems other than moderate to severe sleep apnea that was adequately treated with CPAP) failed to recover completely from a routine upper respiratory viral infection and for several months he was told he had “viral syndrome” and would just need to rest and recover. Relevent or not the CPAP therapy was started approximately 6 months before the rest of the saga began but he reported feeling more fatigued than before the CPAP. In search of a diagnosis the disability insurance would accept we continued to visit the PCP for regular follow ups. At one of these appointments an EKG was performed. His path led from a slightly abnormal EKG (WPW pattern) which was later determined to be a false positive – to a cardiologist for a complete workup due to several risk factors (smoking, family hx, weight) where he failed to complete the stress test because he was too weak to get his heart rate over 100. A shot of adenosine and a 24 hour monitor determined that his heart was healthy and not the problem.

    Next, as he continued to have shortness of breath he was sent to the ER by his primary care physician to rule out pulmonary embolism. This lead to a referral to a pulmonologist who also completed a full workup and ruled out any pulmonary cause, determining that his lung function was actually quite good.
    After that a poorly timed blood draw indicated low testosterone and low cortisol, apparently the doctor did not realize that cortisol is a time sensitive test. He was put on testosterone gel during which time he was apprehensive to touch our infant daughter for fear of transferring the hormones to her even after he washed his hands. It was assumed that his problem was endocrinological so he was sent to an endocrinologist for a full work-up. Again due to several risk factors, she thought it he might have type 2 diabetes and did a slew of labwork along with a pituitary MRI to see there were any abnormalities causing the low testosterone. She repeated the cortisol test appropriately (though getting lab staff to do it correctly was a bit of a struggle) as well as additional testosterone assays and all were normal. Still believing his problem might be endocrine related I asked for a personal favor from our daughter’s pediatrician who got him an appointment with one of the top endocrinologists in Seattle outside of normal office hours within a couple of days. Again all tests were normal but he did investigate the possibility of adrenal malfunction more aggressively. The doctor concluded that yes, indeed there was obviously a problem, but it was clearly not endocrine related. Goodbye and good luck.

    Then the pituitary MRI incidentally revealed a large arachnoid cyst which my husband was referred first to a neurologist (who was married to a dentist and spent most of the visits discussing dental hygiene “what kind of toothpaste do you use?”) and then to a neurosurgeon who concluded the arachnoid cyst was benign and then to another neurosurgeon for a second opinion. The second neurosurgeon was also one of the best in Seattle and difficult to get an appointment with. He quickly concluded that the arachnoid cyst was benign and was kind enough to try to help us outside of his specialty by looking at some of the other symptoms. By this point my husband had gained significant weight (approx. 80 lbs) since the original onset of illness about 4 months prior. Because it was mostly abdominal the good doctor believed it might be a large mass or tumor. He was screened for various tumor markers and a CT of his abdomen was ordered. Keep reading, more on that later.
    While all this was going on he had an appointment with a gastroenterologist to try to help with his longstanding IBS-type symptoms and she did not hesitate to schedule him for a double GI scope – upper endoscopy and colonoscopy. He was vaguely uncomfortable with her offhand manner and didn’t like her assistant so I threw a tantrum and got him scheduled for the procedure with another doctor at the practice who was actually board certified and had an excellent reputation. The new doctor had a much better bedside manner and after the test he advised me that at the follow up appointment they would perform a breath test for a condition they were investigating as a possible common cause of previously unexplained IBS cases: SIBO or small intestinal bacterial overgrowth. They said they were one of the 2 facilities on the west coast beginning to diagnose and treat this condition. When the follow up appointment was scheduled he unfortunately saw the first gastroenterologist who blew him off in about 5 minutes saying his exams were perfectly normal and healthy and to come back for a colonoscopy for screening in 13 years when he turned 50, and she did not feel it was worthwhile to pursue SIBO. This was not what had been explained to me by the doctor who performed the procedure so I demanded a follow up appointment with him who then performed the breath test for SIBO and finally! We got a positive result we thought was meaningful. During this time he was also screened for both hemochromatosis and various vitamin deficiencies. These tests were normal. By this point lymphocytes had returned to normal and ALT/AST which were previously elevated had returned to near normal. He was treated with Xifaxan to supposedly wipe out all intestinal flora then prescribed probiotics and a special 50 mg erythromycin that we had to get at a compounding pharmacy to promote continued intestinal motility to prevent the condition from recurring. His IBS symptoms improved significantly but he was still not feeling better.

    The shortness of breath and fatigue continued, sleeping up to 20 hours a day at times so the primary care doctor decided he must have narcolepsy. Provigil was prescribed and when that had undesirable side effects he was switched to Ritalin as a stimulant so he could get through a day. By this time our family was in serious financial trouble and he had to return to work somehow. The neurologist he saw for the arachnoid cyst was also a board certified sleep specialist and believed narcolepsy was an incorrect diagnosis. He again asked about toothpaste and sent him for more vitamin testing.

    At some point after getting by on Ritalin for a few months he developed an ear infection and visited his primary care physician once again for treatment. The infection did not respond to the first treatment and spread to the outer ear which was extremely painful. He was sent to the hospital for IV antibiotics but once he got there the hospitalist decided that was an inappropriate treatment and performed a different procedure which I cannot recall. He followed up with an otolaryngologist who cultured the infection and prescribed several antibiotics one after the other and the infection was still resistant so he had tubes installed in both ears. Even this measure failed to cure the chronic ear infection that had been going on for a few months at this point and every time I would show up at the pharmacy with a different prescription they were surprised to see me. When a CT was done of the temporal bones to see if the infection had spread and to try to determine any underlying pathology the results were so shockingly bad that he was sent from that ENT (who was more of an ear guy) specialist to another one who specialized more in sinus problems. An additional CT was ordered so all the sinuses could be viewed and it revealed complete opacification of all but the mastoid sinuses. The surgery was scheduled and the doctor assured him it would be very minor, quick recovery and “mild discomfort”. Having had a maxillary sinus cystectomy and turbinate reduction myself the previous year I was skeptical of these claims but he said he had developed new innovative techniques and that the majority of his patients didn’t even require pain medication. Note that at this time my husband was not suffering (nor had he ever) from sinus pain, swelling, pressure, headaches, or any expected symptoms of a sinus infection at all – it was all manifested as treatment resistant ear infections.

    The procedure was quick and outpatient but the recovery was brutal and it was very difficult to get adequate pain management. Once he did finally recover from the sinus surgery described as a “total excavation” by the surgeon he began to feel better. The shortness of breath and debilitating fatigue went away.

    Back to the abdominal CT recommended by the second neurosurgeon: Incidental findings included a horseshoe kidney and a fatty liver. These findings caused my husband a great deal of anxiety despite several doctors who assured him that they were benign conditions and he should just lose weight and have the ALT/AST monitored annually. But if he had the energy to press harder I’m sure someone would have consented to a liver biopsy or even worse, attempt to resection the kidney or even shunt the arachnoid cyst.

    Throughout the entire process I was regularly visiting the same family practice primary care physician for my own needs. Each time he would see me alone he would inquire about my husband and suggested several times that he believed the problem to be psychological or psychiatric and asked me to try to convince him to go for an evaluation.

    The responsibility for the mishandling of this case may rest partially with the patient/family (me) because I know enough to make suggestions but am not a trained physician or clinician. I felt I had to advocate for him because he was so significantly debilitated he was not communicating all of his concerns to the doctors and I knew there was something they were missing. So I pushed back hard when I felt he was being dismissed without serious consideration. This may have lead to many of the unnecessary tests though the main time I had to really push was with the GI doctor. Yet time after time we chased false leads, and eventually the problem turned out to be sinusitis. It was indescribably frustrating and stressful for us that it took all these doctors and tests to discover this – when it was finally discovered the surgeon stated that it had likely been a chronic condition for a long period of time.

    TLDR: My husband had sinusitis that took almost 2 years and nearly a dozen specialists to diagnose and treat.

  29. qetzal says:

    @keleton

    Whew! No kidding on TL! Especially for you & your husband. I hope things are fine for you both from here on out!

    @Dr. Novella

    Evaluations by both a neurologist and a psychiatrist certainly make sense, at least to this non-MD.

    Re:

    [H]ow many tests would you have to do in order to make sure that you never missed a diagnosis?

    I think the answer must be infinite. Every test result has the potential of being a false negative or positive. To be absolutely sure, each one would have to be followed up with a confirmatory test, followed by another to confirm the confirmatory result, ad infinitum. You’d never get there.

    Maybe we could call that something like “Zeno’s diagnostic work-up.”

  30. kirkmc says:

    “Think of it this way – how many tests would you have to do in order to make sure that you never missed a diagnosis?”

    This assumes that the doctor(s) ordering the tests are never wrong, that they’re never confronted with disorders they don’t know or understand. In other words, if the doctors are ordering the wrong tests (I know, there are basic tests that are always run first, like blood work-ups, etc.), maybe they’re not looking in the right direction.

    The problem is that GPs/PCPs don’t have enough knowledge of “strange” conditions to spot them all the time. If they then pass someone off to a specialist, but it’s the wrong specialist, then that second doctor can order all the tests he/she wants and not find anything.

    While you think the anecdotes posted by several people here are not worth considering, they are examples of the difficult-to-figure-out conditions, disorders and maladies. Granted, such problems make good copy – like the NYT columns – but they are indicative of a non-negligible number of patients.

  31. kirk – I never implied these cases are not worth considering. We publish such cases all the time in the medical literature for educational purposes. They usually contain very useful lessons – it’s always better to learn from other people’s mistakes than your own.

    But my point really is that they are only one slice of the whole picture. I am trying to put them in perspective.

    I agree that often the problem is insufficient experience on the part of the doctor. Rare diseases are rare – so we don’t see them much. This is where diligence comes in, and it’s easy to be lazy and complacent.

    In fact, I think this may be a worsening problem in medicine, as managed care is sapping support for academic institutions and time and effort spent on training new doctors. This is a separate much longer discussion – but I am concerned that physician training is being lost in the debate over health care costs. This will be to our long term detriment.

    Further, the CAM trend is also very counterproductive, as it actively works against critical thinking skills in clinicians.

  32. Stacey says:

    The largest problem I’ve encountered is actually specialists who run far too easily or quickly to a psychogenic diagnosis when presented with a difficult case.

    In a personal sense, some of the neurologists I’ve seen were by far the worse. I had one notice that I had a history of depression (perfectly controlled on medication) and refuse to examine me because obviously (for her) anyone with any history of depression would only have a psychogenic problem. Another neurologist gave a cursory physical examination and told me that since no neurological problem ever included hyperreflexia as a symptom I was either malingering or had a psychogenic problem. She was even noted as a specialist in ataxia and other movement disorders — for those who may not know, I mention this because at minimum, the more common spinocerebellar ataxias have hyperreflexia as a symptom. A third told me that there were just some problems medicine couldn’t help with and had I considered religion? None of them did any tests more involved than a CBC with differential and a basic suite of physical neurological exams.

    I am happy to report, however, that I found other far better neurologists who have confirmed dysautonomia. Even the neurologist I saw in the interim got to a point where he said, “I really don’t know and I’m sorry.” That was far better in a great many ways than being dismissed out of hand. Intended or not, that’s how a great many people view a diagnosis of a psychogenic disorder and that response rests largely on the head of the doctors (especially the specialists) who do use it as a means of making the hard problems go away. It’s obviously how I see it from the neurologists who tried to diagnose me with it. And as you said, it is indeed easy to be lazy and complacent.

    I would like to note that for all of the doctors I have personally encountered that attempted an easy route away from me, there were more that were kind, caring, and above all attentive physicians. I don’t want anyone to generalize from this to believe that there are a great many doctors out there that for whatever reason diagnose a psychogenic condition without testing.

    I agree that it’s tragic that there are doctors missing what is a very real problem, but I suspect diagnosing it when it isn’t the case is more common than the reverse. I did run in to one neurologist who firmly believed that my symptoms were the result of eating too many chickpeas — not only do chickpeas play an astonishingly insignificant role in my diet, but as I understand it that syndrome has not been seen in the wild so to speak since the 18th century (and on a continent I do not inhabit). That seems to me to rather be the opposite extreme and the sort of mentality that could lead to missing a psychogenic diagnosis when one would be appropriate.

    Are you aware of any studies that compare the rates of misdiagnosis relating to psychogenic illness? I would love to know whether or not my impression there is accurate.

  33. micheleinmichigan says:

    Great article! A few thoughts/questions from a patient view…

    Sorry to be the one with silly questions, but, for those of us who are not medically trained or (even have much science) The distinction between psychogenic or neurological or hormone/endocrine based is sort of confusing.

    So depression related pain that is helped by SSRI’s is considered psychogenic not hormone/endocrine based? It’s confusing when one says it’s the working of your mind, not your brain. That just makes me think “isn’t the mind IN the brain, CAUSED by the brain and all those funny wrinkles and chemicals flowing between neurons?.”

    But I do see a diagnosis that is more therapy based can be most helpful. I mean sending the patient to a psychiatrist when cognitive therapy and anti-depressant (mood stablizer’s, etc) would be most helpful, to the neurologist for seizure medication (etc).

    Of course this can go both ways. There are people with chronic injury based pain (meaning not psychogenic) that are helped by cognitive therapy techniques, say in pain management clinics to lived with pain or lower the experience of pain in order to keep the use of pain meds in check.

    Oh, I just found the Steve’s definition of functional and disease in the comments, that helps somewhat.

    Personally, I have autoimmune thyroid disease. It’s a disease that often takes a while to diagnoses as the thyroid loses function intermittently over a period of time. The symptoms can be quite vague and there are quite a few that are also associated with stress (fatigue, dizziness, depression, aches and pains, GI issues). After at time, I had quite problematic symptoms even while my TSH was still in “normal” level (and yes, the doctor told me I didn’t have symptoms of thyroid disease, so I was quite surprised when my symptoms magically disappeared with Synthroid.)

    My take away from that experience (and I think this would apply to psychogenic diagnosis as well), is that more clarity of the diagnoses process would be helpful for the patient. I think some doctors assume we patient know these things and many of us don’t.

    For instance a “next steps” portion in each doctor’s appointment. So when I’m at an annual physical and complain of dizzy spells and the doctor tells me they could be associated with stress – try relaxation techniques or getting up to get a drink of water, etc the next thing they should say is “If that doesn’t help come back in six weeks, 4 months, whatever” The same would go toward a specialist saying “your symptoms don’t seem to be neurologically based” should always be followed by “I think you should see your primary or this other specialist (or whatever).

    Call me dumb (or raised doctor adverse), but whenever the doctor gave me advise or treatment that didn’t work or ran a test that came up negative, I took it as “oh well, I guess that’s all they can do.” It took me years to figure out I was supposed to keep coming back if the symptoms was still a problem. And I have to say, alot of my friends are the same way, and some of them take CAM remedies for their issues.

    Strangely, I found pediatricians to be much better at this than my other doctors.

    Lastly, I think our current health insurance system worsens the false separation of psychiatrists (and psychiatric disorders) from other medical specialist. Sure a neurologist can recommend a psychiatrist (who hopefully who specialized in psychogenic disorders), but many health care coverage plans have completely different groups and networks dealing with “mental health issues” that will then send the patient to a social worker (who may or may not have any experience with that disorder, the patient can’t tell) who consults with a psychiatrist for prescriptions, neither of which often consult with the patient’s other doctors (or vise versa). At least this is how our insurance works (and ours’ is very large provider.)

    Thanks so much for the article, very thought provoking.

    Disclaimer: If this comment seems to be disagreeing with the orginal article, it doesn’t mean to. I’m in agreement with the article. I’m just offering (late) thoughts and questions.

  34. stewart says:

    Steven, I’d just like to add a bit to this.
    1. Psychogenic/conversion disorders are commonly seen by neurologists, with estimates of about 10% of the patients seen by neurologists having these sorts of concerns. Interestingly, although its generally neurologists who make the diagnosis, it’s generally psychiatrists who provide the treatment. As noted above, at least in the US, this can lead to some challenges due to the insurance system. I wonder if the VA does better with this?
    If you see some dramatic footage from 1918, the Wellcome Trust has posted some of the film shot at a service hospital, including scenes fo progress over time. http://catalogue.wellcome.ac.uk/record=b1667864~S8
    2. When a psychogenic disorder is diagnosed, the diagnosis is reliable, and doesn’t often change to a new diagnosis. A new paper in Brain by Stone et al. (Symptoms ‘unexplained by organic disease’ in 1144 new neurology out-patients: how often does the diagnosis change at follow-up?), found that only 4 out of 1030 patients (0.4%) had acquired an organic disease diagnosis that was unexpected at initial assessment and plausibly the cause of the patients’ original symptoms. Thank MRIs for aiding the diagnosis of MS, for example.
    3. Functional imaging does show some interesting findings in psychogenic movement disorders (easiest to do in that setting, I think), which are similar to those seen in analogous hypnotic states. Harvey et al. have a paper available online looking at some of this evidence, which can be helpful to look at.
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2671741/
    So it’s not just a diagnosis of frustration, it is common enough that neurologists see it frequently, and it is associated with alterations in function that make sense from a circuitry perspective.

  35. adiemusfree says:

    As a clinician with 20 years working in chronic pain management, my problem is not that medical people jump to the conclusion that a problem is ‘psychogenic’, it’s rather the opposite – too few stop the diagnostic treadmill from going on and on and on and on…
    Psychogenic is a difficult term for me to use – I’d prefer to use another label if at all possible, and this has been discussed over and again as to what might the replacement label be.
    I don’t like ‘psychosomatic’ because of the baggage that goes with it.
    I don’t like the psychogenic label because it does suggest that somehow the psyche has generated its own physically manifested problem instead of being properly psychological or psychiatric (tongue in cheek OK?)
    Medically unexplained is a possibility, although people don’t like this term either – it can suggest ‘well keep on looking then’
    Somatoform is a further option – I quite like this in some ways, but it’s been ‘psychiatricised’ a bit too much for me.
    I also have chronic pain (fibromyalgia) and major depressive disorder, and after working with people who have felt misunderstood and misrepresented by the health profession I think it’s a two-way problem. The first is for health professionals to listen and empathise FIRST. And the second is for people looking for help to consider acceptance as one option for learning to live with a chronic problem. Acceptance doesn’t mean giving up hope, but it does mean giving up the anger and frustration and disappointment of life not going the way we’d like it to. Ill health of any sort happens to anyone – and not all health problems are explainable nor curable. Getting angry and fed up about it doesn’t change this fact – it just makes coping with it much harder.
    Perhaps some honesty from health providers to say ‘well I don’t know what it is, but I care about you deeply and I can help you have a life despite your problem’ might help disillusioned people with unexplainable symptoms feel more helped.
    And in doing so the secondary hurt from a health system that fails people who don’t fall into neat categories might be lessened, and the attitudes that people who aren’t ‘fixed’ by the health system might soften.

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