Time for ‘new perspective’ on psychosomatic illness

It is time for a new perspective on psychosomatic illness to help doctors understand these disorders differently, “so we learn better ways to explain them to our patients,” the recent ISR Autumn Meeting was told. Dr Suzanne O’Sullivan, Consultant Neurologist at the National Hospital for Neurology and Neurosurgery in the UK, asked: “If both doctors and patients had a better appreciation for how physical symptoms arise in the absence of disease, how many fruitless searches for disease could be prevented and how could we foreshorten people’s experience of psychosomatic disability?”

Dr O’Sullivan’s presentation was titled: ‘It’s all in your head.’ “Our bodies interact with our psychological and social wellbeing in such a way that they will inevitably produce physical symptoms. But, perhaps if we reacted to them differently, and understood them differently, we could prevent the downward trajectory to disability and that’s what I feel most hopeful for.”

Asking why do so many patients reject a psychosomatic diagnosis, Dr O’Sullivan suggested it is because the medical formulations currently deployed do not address the biology. She warned that medicine relied “far too heavily on the ‘stress-induced model’”. During her talk, Dr O’Sullivan noted the enduring influence of Freud on medicine, with his attribution of all hysteria and psychosomatic symptoms to psychological trauma. Dr O’Sullivan said that “formula very rarely works for our patients”.

“First of all, many people deny the existence of stress or trauma in their lives and do not associate that formulation with their symptoms. And, secondly, even if we can clearly identify a stressor what has led to the symptoms, identifying that stressor rarely results in that type of miraculous catharsis that Freud describes.

“So our formulations are not really tallying with patients’ experiences of their own bodies and that makes it impossible for them to accept our formulations.” She said that in neurology there is a move away from this sort of stress-induced formulation for psychosomatic disorders. “I don’t fully agree with that move,” said Dr O’Sullivan, “as I think many psychosomatic disorders are clearly stress-induced and there are clearly stress pathways that induce bodily symptoms.”

“However, I also accept that a large number of patients deny any association between traumatic or major life events and their symptoms.” She said this happens because some patients do not recognise this association. But, that there are also “people that symptoms develop in the absence of psychological stresses and in the absence of any particular life events”.

“They are a very significant group that are, unfortunately, being increasingly alienated by a stress hypothesis for psychosomatic symptoms.” Looking for “alternative mechanisms”, Dr O’Sullivan said that “functional and psychosomatic disorders are very often more to do with the fallibility of brain processing than they are with a
stress reaction”.

“In other words they are the mistakes our brain makes when trying to make sense of bodily changes and the environment.” She outlined how the predictive expectations of your brain to the environment might in certain circumstances be wrong and this can occur with expectations with pain. “We need to learn to work with our patients’ experience of their disabilities rather than against them,” she said.