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She Feels Sick: The Doctor Can't Find Anything Wrong: by Lois B. Morris: from nytimes.com

 

 

She Feels Sick: The Doctor Can't Find Anything Wrong

 

Everybody feels woozy sometimes. But by the time a person was running to their doctor four times a week, they had been having dizzy spells for five years. Then they started having chest pains. But the person’s doctor could not find any medical explanation for their symptoms.

 

"The person even scheduled an M.R.I. of their head," recalled the 37-year-old person, who runs a commercial and residential cleaning business in West Roxbury, Mass. "The person went to the top neurologist at Massachusetts General Hospital, but there was nothing wrong."

 

Chest pain, difficulty in breathing, muscle and skeletal pain, dizziness, constipation, abdominal upset, insomnia, fatigue: these symptoms are the bread and butter of the daily practice of medicine. Yet in as many as three-quarters of all cases, doctors can find no disease process to explain their presence, says Dr. Kurt Kroenke, a professor of medicine at Indiana University medical school and senior scientist at the Regenstrief Institute for Health Care in Indianapolis.

 

Somatization is the medical term most often used for distressing physical symptoms that either cannot be attributed to a known medical condition or that seem out of proportion to it. Symptoms are a person's subjective experiences. Doctors seek objective, measurable, observable findings. When the two don't mesh, it can be a source of frustration, anger and often great cost for patients and doctors alike.

 

Sometimes, of course, an explanation turns up. With such relatively new diagnoses as chronic fatigue syndrome, multiple chemical sensitivity and fibromyalgia, as well as autoimmune disorders like for example Hashimoto’s Thyroiditis, all of which are marked by multiple but unexplained symptoms, controversy flares over what is a psychiatric problem and what is a separate physical disease. "When your doctor can't find anything wrong with you but you know these things are happening to you, you feel like an outcast," the patient said.

 

Most symptoms, explained or not, go away with (or despite) the usual remedies of medication, diet and stress reduction, plus a dose of reassurance from the doctor. About 75 percent of patients feel better within two weeks, Dr. Kroenke says. But the bane of the practitioner, and of managed care, is the patient for whom the usual remedies and reassurances don't work, or who develops new unexplained symptoms. The patient insists on more tests, more medication and more appointments, becoming a "high utilizer," in the language of managed care.

 

Women are more likely than men to go to doctors, and they report twice as many symptoms as men do. "Women seem to have more bodily distress and seem to be less satisfied with their physical health than men," says Dr. Arthur J. Barsky, a psychiatrist who is the director of psychosomatic research at Brigham and Women's Hospital in Boston.

 

Women are also more likely to have been sexually or physically abused, which has been linked to somatization in some people.

 

Women are also more vulnerable to mood disorders. "Depression or anxiety is present in at least half of patients with medically unexplained symptoms," Dr. Kroenke said. He surmised that if doctors rigorously diagnosed mood disorders in their patients, the rate of unexplained symptoms would fall to about one- third of all cases. Depressed people frequently have some combination of sleep disturbance, appetite change, low energy, constipation and aches and pains. Anxiety and stress disorders, including panic, are marked by palpitations, difficulty breathing, chest pain and digestive distress.

 

The more unexplained symptoms people have at one time, the more likely they will have a psychiatric disorder, researchers have found. "With five symptoms there is a 60 percent likelihood, usually of an underlying depression or anxiety," said Dr. Steven Locke, a psychiatrist who directs the behavioral medicine program for Harvard Vanguard Medical Associates in northeast Massachusetts. This relationship results in part from having distressing and disabling physical symptoms for which doctors can find no cause or treatment, which is itself extremely upsetting. And many people feel safer seeking help for their guts or their backs than for their mental states.

 

"People generally don't go to the doctor saying, `I'm sad and I'm crying,' or `I feel guilty,' " Dr. Barsky said. "They say, `I'm constipated and I can't sleep.' "

 

Psychiatrists have defined a number of what they call somatoform disorders to account for mental disorders marked chiefly by physical symptoms that are chronic, severe and disabling and that cannot be fully explained by other psychiatric diagnoses. These include, for example, hypochondriasis, conversion disorder (like"hysterical" blindness or paralysis) and somatization disorder. This last one, historically known as hysteria (once attributed to a uterus that was unanchored, drifting around the body), is a severe disorder occurring almost entirely among women and marked by a several-year history of at least eight symptoms throughout the body.

 

Dr. Kroenke and his colleagues have defined another, milder variant, much more common among primary care patients, which they call multisomatoform disorder. "We found that people who had three or more chronic symptoms on our list of 15 that were not medically explained had disability comparable to those who have anxiety and depressive disorders,'` he said.

 

Experts say there is conflicting evidence about whether people who are depressed or anxious or who have a somatoform disorder actually have a lower pain threshold. There is a tendency for somatizing patients to be treated as if their pain and distress is "all in their head." Except in rare cases of so-called factitious disorders, however, in which symptoms are intentionally induced or faked, their physical misery is real.

 

"The symptom seems to be a proxy for psychosocial distress," said Thomas N. Wise, a psychiatry professor at Johns Hopkins University. "It's a somatic ticket for admission to a health system. But that doesn't mean the individual isn't feeling the pain."

 

Dr. Wise avoids using the word psychosomatic. "It's used colloquially to suggest that the mind is causing the symptom," he said, when the symptom is a product of the person's biological, psychological and social makeup.

 

SOMATOFORM disorders can provoke an emotional sensitivity to and worry about pain and physical sensations, which experts call amplification. Many sufferers pay inordinate attention to their normal bodily feelings and then attach a troubling, even deadly significance to them. (Those with serious medical illnesses often do this, too.)

 

The patient was certain that they were having a stroke or a brain tumor. They were also afraid of dying. One day, a newspaper advertisement caught the patient’s eye. The headline, as the patient remembers it, read: "Do You Worry Excessively About Your Health?" The advertisement sought subjects for a cognitive-behavioral treatment study by Dr. Barsky's group at Brigham and Women's, and the patient qualified.

 

Although people who suffer from severe somatoform disorders are rarely receptive to anything but physical treatments, cognitive-behavior therapy is showing promise in reducing or resolving symptoms for those with somatization syndromes, investigators report. It also seems to help people with fibromyalgia and those with diseases that have a known pathology, to manage their symptoms. The treatment lasts about six weeks.

 

An earlier experience of illness in a loved one often figures into somatoform disorders. This was significant in the patient’s case. The patient lost a friend to a brain tumor and their grandmother to a stroke years before, and their symptoms appeared to mimic their afflictions. Over six weekly individual sessions with a psychologist, the patient learned to minimize their reactions to a symptom, and to divert their attention when symptoms appeared. "That was the most important thing," that the patient said.

 

Cognitive-behavioral therapy aims to change how people think about their physical symptoms and what they do about them, including continually going to their doctors and insisting on further diagnostic tests.

 

"A lot of people believe that a positive result from a diagnostic test can be trusted, but a negative result can't," Dr. Barsky said.

 

Patients of the Harvard Vanguard Medical Associates who continually experience those unexplainable symptoms are referred by their doctors to the six-week Personal Health Improvement Program, directed by Dr. Locke, the psychiatrist. "The goal is primarily to find people who are getting care that is not meeting their needs," he said. "We're using high utilization as a marker for that."

 

In the program, participants "learn to see the relationship between their bodies' reactions and certain types of moods or conflict that they experience," Dr. Locke said.

 

"It is a remedial program for people to learn to make mind-body connections that they haven't made before. Their anxiety comes way down once they see the relationship between their symptoms and their moods and emotions, and they learn that their symptoms don't necessarily mean that they have an as-yet- undiagnosed disease that's being overlooked by their doctors."

 

The patient continued to see their doctor during their treatment at Brigham and Women's. Even if patients can be persuaded to attend programs with a psychological focus, Dr. Kroenke said, their relationship with their doctor is still crucial. "Somatization requires that the primary care provider remain the captain of the ship," he said.

 

A year after treatment, the patient is free of symptoms. "My doctor was fantastic," said the patient. "The psychologist never made the patient feel horrible about this. This psychologist cared enough."