Psychosomaticism and the cloud of unknowing

Some months back (in a post I didn’t see at the time), Dr Crippen wrote about a patient of his whose problems he believed to be psychological in origin.  In response to a follow-up post that he wrote on the issue, I queried this conclusion.   Dr Crippen responded by issuing a challenge:

Within the limits of the facts as given (and I appreciate that IS a bit
limiting) please come up with a better diagnosis than
family/social/psychological problems.

This is precisely the attitude that concerns me, and it’s precisely because so many doctors hold this attitude that I queried this particular case.

Now, the rest of this post is not aimed at Dr Crippen’s handling of this patient, because I do not have enough details on that to comment any further than raising the question.  Dr Crippen, quite rightly, changes the details in any patient account he puts on line to preserve anonymity, so even if he has specific reasons for thinking that "Joan’s" problems are psychological in origin, he’s not going to be able to tell me what they are.  From what he says in the follow-up comment that I linked to, it sounds as though he does have such reasons, despite not being able to discuss them.  And in that case, fair enough.

(A quick addendum: Since writing this post, I’ve also followed up a link of Dr Crippen’s and found that he makes much the same points as me in a further post.  So, I repeat that the rest of his post is not aimed at him.  But his challenge was a handy jumping-off point for a post I’ve been wanting to make for a good while now.)

But the point I wanted to make is that we should not be assuming that a patient’s problems are psychosomatic without having specific reasons.  And "I can’t come up with a better diagnosis" is not such a reason. 

There is far too much of a tendency among doctors to believe that ‘psychosomatic’ means ‘we can’t find a physical diagnosis’.  Spot the flaw in that logic?  If we can’t find a physical diagnosis, that definition is saying, then there can’t be one.  We couldn’t possibly have missed something.  There couldn’t possibly be anything about the human body that we just plain don’t know.  Why, we doctors know absolutely everything, and never miss a trick!

It’s a form of arrogance.  And it’s a way of putting the onus back on the patient.  We can’t admit that there might be things we don’t know, so, if we can’t make a diagnosis, then there must not be one to make.  Must be all in your mind… right?

We’ve been doing it for centuries.  Over a hundred years ago, Freud made his name by coming up with psychological diagnoses for a number of patients with complex, bizarre, otherwise inexplicable symptoms – in other words, symptoms that were clearly psychosomatic in origin.  Right?  Well, except that on reading the case descriptions in light of modern knowledge, it actually looks as though a lot of them had classic symptoms of temporal lobe epilepsy. 

These days, of course, we know all about temporal lobe epilepsy and the weird symptoms it causes.  So, these days, we wouldn’t make that mistake, would we?  Well, hopefully not – although it isn’t so many decades since Karen Armstrong spent years seeing a succession of psychiatrists about her distressing visual hallucinations without it ever apparently occuring to any of them that sending her to a neurologist for an EEG might be a smart idea.  (After all, she clearly did have all sorts of psychological problems – lots of difficulties adjusting to the world after seven years in a convent, culminating in anorexia nervosa – so of course any problems she had had to be secondary to those!  How could someone with psychological problems possibly have a physical illness as well?)  But how many similar mistakes might we be making without knowing it?  How many possible ways are there for the human body to malfunction that we simply don’t as yet have a clue about?

Doctors don’t know everything.  Far from it.  And individual doctors are even further from knowing everything than doctors collectively, because the sum total of what we do know so far exceeds what any individual doctor could ever hold in memory.  So, maybe your problem happens to be one that is documented in some article or textbook somewhere – but if it’s one that your particular doctor hasn’t heard of, then you might just be out of luck.  (Ever heard of interstitial cystitis?  Krissy saw lots of doctors who hadn’t, before she finally got her diagnosis.  Guess what they all told her her symptoms were due to?)

Of course, hopefully your doctor will refer you for further investigations if things get really baffling.  Maybe the doctor you’re referred to will know what your problem happens to be… and maybe not.  Usually you’ll get a fair number of investigations before people throw their hands in the air and give up, but, at the end of the day, your problem may exclude diagnosis.

There isn’t really a way round that, because, no matter how much everybody expects us to be omniscient and omnipotent, we’re not.  Deal with it.  We’re not doing it to annoy you, believe me.  But that cuts both ways.  We should have the guts to come out and say "Sorry, but I’m afraid we really don’t have a clue what’s causing your symptoms."  And we shouldn’t stick a label of ‘psycholological’ or ‘psychosomatic’ on a patient just to give us something behind which we can hide our own ignorance.

None of this is meant to say that psychological causes of illness do not exist.  Of course they do.  But be honest with yourself about why you want to make that a diagnosis for any given patient.  If the only reason you have for diagnosing your patient with a psychosomatic disorder is that you can’t find a physical one, then forget it, because that isn’t a good enough reason.



Filed under The doctor is OUT. To lunch.

2 responses to “Psychosomaticism and the cloud of unknowing

  1. If you were not a doctor and not in danger of contracting cooties and passing them on to ill patients I would kiss you full on the lips for this post.
    For what it’s worth, I have never been angry or agitated with a doctor when they told me, “I don’t know”. Ever. I might be agitated or angry that there isn’t an obvious cause for my problem, but that’s very different.
    I respect the hell out of any professional in any job who can say, “You know, no idea. Let me go look that up/talk to someone/try and refer you to someone who knows.
    My IC magic docman is nearly impossible to get in to see because he spends a HUGE portion of his year going to seminars and presentations on the latest IC treatments and findings. Because he spends his time doing his research and updating his information, I got top-shelf treatment. For that shit I will wait for six months to get in to see him. Easily.
    IC doctoring is horrible. It’s like stage four cancer doctoring. There is so little to be done, it’s like having a job throwing popcorn packing at a moving frieght train and hoping that it stops.
    But if you do it, even if you don’t stop the train, in my book you’re a hero.
    I begrudge the medical profession nothing. The field is learning as much as it can as fast as it can and nobody can know it all. I begrudge them the “it’s your fuckedupness, not my mistake” attitude, but every time I post about a doc with that attitude I talk to someone who has their story of the one doc that got it. The one doc that looked into it, who believed them, who found someone else that really helped them.
    Those docs are worth their weight times a thousand in gold.
    Thanks for this post. It’s marvelous.

  2. Belatedly – a very thoughtful post. I liked a post about caring for people with MUS that was on a similar theme and discussed the issue of some people effectively being denied permission to be ill.

    MUS is a collection of legal, social, medical, psychological and cultural attitudes. Sontag described how the metaphors and myths surrounding certain illnesses add to patients’ suffering. Sontag further commented that whenever the cause of an illness is mysterious, then it is assumed to be an expression of psychological problems or a moral weakness. Sontag wryly notes that the assumption disappears when science uncovers a plausible medical mechanism for the illness. Before Multiple Sclerosis was ‘rehabilitated’, it was described as a creeping paralysis and linked to female hysteria.

    The post, like yours, argues for the need for ethics in caring for people who have no diagnosis.
    Regards – Shinga

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