Abstract
Since antiquity it has been postulated that emotions can produce or interact with physical illnesses. That statement in its broadest sense describes the field of psychosomatic medicine, which concerns itself with the multitude of ways that psychological and physical factors intersect – for example depression and myocardial infarction. The subject of this chapter is somewhat narrower – the issue of medically unexplained symptoms (MUS), defined below. A detailed account of the broader field of psychosomatics is given by Schoenberg [1].
Introduction
Sorrow which finds no vent in tears may make other organs weep
Since antiquity it has been postulated that emotions can produce or interact with physical illnesses. That statement in its broadest sense describes the field of psychosomatic medicine, which concerns itself with the multitude of ways that psychological and physical factors intersect – for example depression and myocardial infarction. The subject of this chapter is somewhat narrower – the issue of medically unexplained symptoms (MUS), defined below. A detailed account of the broader field of psychosomatics is given by Schoenberg [1].
In a sense psychotherapy as a formal discipline began with MUS; it was during his clinical practice as a neurologist that Freud observed patients with neurological symptoms which could not be explained by structural lesions or other disease processes of the nervous system. His interest in what might be causing these symptoms led him towards an exploration of psychological factors, and culminated ultimately in the development of psychoanalysis. However, in the century since then psychotherapeutic interest has not reflected the key role that MUS played in the origins of the discipline. This chapter will give a brief overview of MUS as a clinical topic and then focus on contemporary psychotherapeutic theory and practice.
Terminology
The phrase ‘medically unexplained symptoms’ (MUS) refers to physical symptoms which after medical investigation cannot be accounted for by organic disease or physiological disturbance. This implies in a general (and unhelpful) sense that there is no medical explanation for the patient’s symptoms, but perhaps it would be more accurate to think of the implication being that there is no biomedical explanation. MUS is not a diagnosis but an umbrella term, loosely defined, which gives shelter to processes such as conversion, somatisation and dissociation. It encompasses somatoform disorders and functional somatic syndromes, and is sometimes extended to include hypochondriasis (health anxiety) and body dysmorphic disorder. The latter two conditions, however, are characterised by concern about the body rather than symptoms in the body. A medical psychotherapist is most likely to encounter patients who have been diagnosed with one or more functional somatic syndromes.
Functional Somatic Syndromes
Functional somatic syndromes are collections of symptoms described primarily according to a specific bodily system, for example the gastrointestinal system. See Table 17.1 for a list of common functional syndromes. The degree to which these syndromes truly represent discrete conditions is questionable – they frequently co-occur but the organisation of secondary acute care into specialties promotes ‘salami-slicing’ of patients’ problems. MUS then become defined more by which specialists the patient is assessed by than presence of separate illnesses [2]. For example, a patient with abdominal, chest and jaw pain may be assessed by a gastroenterologist, a cardiologist and then an ENT surgeon, and end up diagnosed with IBS, non-cardiac chest pain and temporomandibular joint dysfunction. This unfortunate iatrogenic process leaves the patient treated as if they have three separate diseases in three separate body parts. At this point the opportunity for intervening in a way which considers the patient as a whole is remote, unless efforts are made to integrate the various medical perspectives.
Table 17.1 Functional somatic syndromes
As Table 17.1 illustrates, such syndromes are likely to have been diagnosed by GPs or acute care specialists. Discrete diagnostic labels for different forms of MUS are rarely generated by psychiatrists, probably because these diagnoses relate to physical symptoms, are often unattractive to patients and do not usefully indicate to the psychiatrist what treatment(s) to recommend. The most obvious exception to this is non-epileptic attack disorder (NEAD), which may be first diagnosed by a neuropsychiatrist. In acute hospital settings the input of a liaison psychiatrist may be essential for management of complex MUS. This will include careful assessment and casenote review in order to rule out malingering and factitious disorder. MUS are not exaggerated or fabricated symptoms – neuroimaging studies have demonstrated that patients with MUS show heightened activation in cortical regions associated with pain when a painful physical stimulus is applied [3, 4]. In other words, pain (the most common type of MUS) is a demonstrable physical experience.
In addition to the complexities outlined above, there is a long tradition of terminology in this area of medical practice being repeatedly abandoned and replaced. Terms such as hysteria would now be seen as pejorative, but despite multiple attempts it has not yet proved possible to find a diagnostic label that is both accurate and culturally acceptable. This search may perhaps mirror the deeper issue of how we struggle to conceptualise problems that defy the division between physical and mental symptoms created by Cartesian dualism. Currently the preferred term in the UK is MUS, but newer diagnostic entities such as ‘bodily distress syndrome’ and ‘somatic symptom disorder’ may supersede it for a time in the near future.
A further consideration for psychiatrists is co-morbidity with personality disorder, particularly more severe forms of MUS co-occurring with histrionic and borderline personality disorders [5]. It has been argued that modern diagnostic systems have split up the syndrome of hysteria arbitrarily into personality disorder, somatisation, conversion and dissociation subsyndromes [6, 7]. These are interesting and important debates in their own right. The main task of an assessing psychotherapist, however, is to ensure that all physical symptoms are discussed in the assessment, regardless of diagnoses made elsewhere in the health system.
MUS in Primary and Secondary Acute Care
Although not often referred to psychotherapy services, MUS are extremely common, with a wide spectrum of severity [8], and patients are found in all areas of the healthcare system. Around a fifth of new symptoms presented to GPs are MUS [9], although over half of these resolve spontaneously within 12 months [10]. In secondary care MUS tends to be more persistent and severe, accounting for 35–50 per cent of new outpatients at specialist medical clinics [11, 12] and 20–25 per cent of all frequent attenders at medical clinics [13, 14]. Furthermore, frequent attenders with MUS get investigated more than other frequent attenders at acute hospitals [15].
It is clear from the data that MUS is costly in healthcare terms. The magnitude of the cost is staggering – annual NHS costs of MUS in England have been estimated to be around 10 per cent of total NHS expenditure in adults of working age [16]. This is roughly comparable to the cost of caring for diabetes, yet service provision for MUS is scanty in the NHS [17], and MUS remains a neglected topic in medical education.
Perhaps unsurprisingly, MUS are experienced as difficult to manage by many doctors. Studies of GPs and acute hospital doctors report finding MUS stressful [18–20] and hard to help [21], and feeling psychologically deskilled in this area [22]. There is a common medical view that MUS patients pressurise doctors to perform tests, but research findings suggest the opposite – GPs frequently suggest physical investigations for MUS even when patients are not demanding them, possibly in attempts to end psychologically difficult consultations [23]. The advanced consultation skills needed are not taught to acute care specialists at any stage of medical education [24]. There is an overwhelming case for medical schools and royal colleges to revise their curricula to make teaching about MUS a priority, for the sake of both patients and doctors.
Predictably, perhaps more than with any other group of patients seen by psychotherapists, the input of medical colleagues in other parts of the healthcare system has a huge impact on the success or otherwise of psychotherapeutic treatment. The struggle to manage MUS medically should always be borne in mind sympathetically; support for colleagues is a central activity for specialist liaison psychotherapy services in GP practices and acute hospitals. Some of the key medical tasks which need to precede psychotherapy assessment are described later in this chapter.
The Origins of Psychotherapy for MUS
As we noted at the start of this chapter, psychotherapy in Western medicine began with Freud’s clinical work with unexplained neurological symptoms. At the time in Europe there was interest in understanding and treating hysteria, a condition characterised by histrionic behaviour and MUS in women. The name derived from the Greek word for uterus and had been thought to be due to abnormal movements of that organ. Freud and others however attempted to understand the psychological causes of hysteria. Taking inspiration from the famous French neurologist Charcot, Freud initially tried using hypnosis but found its effects to be short-lived. He then began to explore new methods for treating this group of patients, which ultimately culminated in the discipline of psychoanalysis.
Freud theorised that hysterical patients’ symptoms were the consequence of painful repressed memories linked to childhood abuse. He believed that unconscious sexual conflicts (e.g. between guilt and excitement aroused by incestuous behaviour) were unbearable and so were rendered unconscious and converted into physical symptoms which symbolised the conflict in a disguised form. The concept of conversion comes from this source. From this perspective, the mind and the body are seen as related but separate entities; problems arising in the mind are passed down, as it were, to a physical body which receives them and expresses them.
At around the same time, Pierre Janet developed a different psychological theory of physical symptoms. He postulated that rather than acquiring symbolic meaning, traumatic experiences can cause a kind of ‘disintegration’ of the mind, with one possible consequence being disturbances of bodily functions in ways which are dissociated from higher cortical functions. From this perspective, mental trauma can affect the body without being processed by thought.
These two views can be regarded as complementary or conflicting; symptoms are symbolic representations of psychic conflicts and/or symptoms are pre-symbolic sequelae of traumatic experiences. For most of the twentieth century the Freudian view came to dominate psychotherapeutic approaches to MUS; however, in recent decades there has been a resurgence of interest in the Janetian perspective. Freud and Janet are key figures whose ideas substantially inform psychotherapy in this field today, and some consequences of their differing theoretical views will be explored in a later section when we consider the defence and dissociation models of MUS in use currently. Prior to discussing psychotherapy, we turn our attention to considering how MUS arise.
Developmental Theory
Modern theories of MUS are informed by developments in psychoanalysis, neurology and neuroscience, as well as a convergence of psychodynamic and cognitive-behavioural concepts. There is less emphasis nowadays on the separateness of body and mind. One key theoretical advance has been the elucidation of the view of the self as a mind–body entity, as suggested by Winnicott [25] and subsequently many other psychotherapists. This is a very large topic indeed and beyond the scope of this chapter. A very brief summary statement with regards to MUS would be to say that thinking psychoanalytically about what constitutes selfhood paved the way for appreciating that humans are not born with fully integrated minds and bodies. From this perspective, we can view the integration of mind and body in adulthood as a developmental achievement, made up of a series of milestones en route to a healthy sense of self in adulthood.
This is a complex area conceptually, but worth grappling with in the effort to understand MUS. If not present from birth, how does our sense of self arise? And what is it made up of? It may help to imagine a small baby when considering these questions. That baby probably does not have a sense of self as we would understand it in adult terms, but certainly does have a level of self-awareness. For example, the baby can have non-conscious awareness of its own hunger or thirst, without a cognitive process occurring which says ‘I am hungry/thirsty’. We might think of this as an embryonic mind–body connection, an example of the biological process of interoception – our conscious and non-conscious sense of the internal state of the body – which can in turn be viewed as the fundamental basis of selfhood [26].
Possessing interoception, the baby can then eventually begin to discern not just basic biological experiences (e.g. hunger) but also the sensorimotor phenomena that form the basis of its emotions. These phenomena, the physical components of emotions, do not need to be imagined by us – we all experience emotions as powerfully physical. But our hypothetical baby at this stage does not recognise those phenomena for what they are. He experiences them bodily but cannot think about them. It is only later that the baby gradually achieves the milestone of recognising certain sensorimotor experiences as ‘belonging’ to, being part of, certain emotions.
The ideas summarised above (and the empirical and observational studies of humans and other mammals that support them) inform the psychodynamic idea that affect development follows a sequence from body to emotion to thought, with all three elements present and intricately intertwined in healthy adult functioning. Research now supports this idea – the modern discipline of affective neuroscience has shown that emotions are embodied phenomena which form a foundational level of the mind both preceding and underpinning cognition [27].
As we noted above, the human starting point – the normal state of the infant – is theorised as one of undifferentiated sensations, in which emotions are primarily experienced as bodily, as sensorimotor phenomenon. In other words, it can be argued that humans begin emotional life in a state of somatisation. Affect development is from this perspective a process of desomatisation [28]. We have to learn how not to somatise our feelings. How do we achieve this milestone? Not on our own. From a psychodynamic perspective, in early life we require considerable nurture in order to recognise, differentiate and begin to verbalise our feelings. Protective caring relationships with adults are essential. Knowing what we feel (physically and mentally) and being able to say what we feel are not innate characteristics. Adverse childhood experiences such as misattunement, neglect or abuse can damage this process, leaving the person vulnerable to ongoing somatisation as a major aspect of a damaged sense of self [29]. Early childhood adversity is a known risk factor for adulthood MUS [30]. There are some important similarities here to developmental theories of affect dysregulation in personality disorders, and the theoretical overlap between MUS and personality disorder has been noted by some psychiatrists and psychotherapists [7, 31, Mace, personal communication, 2008].
In both types of disturbance it is often necessary psychotherapeutically to help the patient learn to recognise what they feel as well as express it verbally, before exploring why they feel what they feel. This kind of therapeutic effort (a demanding and painstaking one for both patient and therapist) may need to start by aiming to rebuild or repair the very foundations of the sense of self.
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