The discussion on how to determine whether an illness is physical or psychological erupted this week after The Boston Globe ran its series on Justina Pelletier’s case at Boston Children’s Hospital.
According to the Globe story, Boston Children’s Hospital physicians and Justina’s parents strongly disagree over whether or not Justina suffers from mitochondrial disease, a rare genetic disorder that dramatically affects a person’s metabolism and energy levels. After Justina arrived at Boston Children’s Hospital, multiple clinicians determined that Justina’s physical ailments were psychosomatic; meaning her body’s physical condition was psychologically triggered.
So how can we tell if our symptoms are psychological or results of a physical condition?
For answers to this and further questions, we spoke with Dr. Alice Weaver Flaherty, an associate professor of neurology and psychiatry at Harvard Medical School, whose work specifically explores the connection between neurology and psychiatry.
How would you explain psychosomatic symptoms to someone who might be hearing the term for the first time?
Flaherty: The common way of describing psychosomatic symptoms is to say they are imaginary, which implies the person is making them up, but this isn’t the case. These symptoms are created by the autonomic nervous system, the part of your brain that’s involved in responses to fear, anger, anxiety, and also, relaxation. This is often called the fight or flight system, but it can be active even when you’re not doing anything. Physical responses are triggered by the brain’s reactions, and a psychosomatic symptom is when the effects of the brain’s response display in other systems or parts of the body.
What is the difference between a psychosomatic symptom and a real symptom? How can I tell?
Flaherty: You can have both. You can still have a heart rate that’s gone up because of a psychosomatic reaction to emotional stress, but it can also be racing because you’re legitimately about to have a heart attack.
How can you tell? First of all, you probably need a physician’s assistance. But one of the ways to tell the difference is to look for symptoms that can’t be caused by the brain. If you’re experiencing severe anemia, jaundice, or some clearly visible trauma, these are conditions that can’t be caused by the brain. But it’s not always so clear.
For instance, people think digestive or intestinal problems are not controlled by the brain. If your digestion stops, you’re not imagining it. But if emotional stress came before that reaction, it’s a sign the stress has manifested itself in these physical ways. Emotional stress that occurred months ago can still manifest itself in this way. But pay attention to acute stress. If your symptoms get better when stresses decrease, that’s evidence they are psychosomatic.
When a doctor says a patient’s physical ailments are in their head, does that mean the patient is making them up?
Flaherty: To say that a symptom in all in your head does not mean that it’s not a very real physical problem. Think about it, there’s a problem in your brain. That’s a physical part of your body. Some people call psychosomatic problems functional problems, and that’s because there’s a problem with a function of the brain that’s manifesting itself in the body.
When the doctor says the problem is all in your head, it’s still a problem. But, it’s not a problem with the organ that seems to be malfunctioning. It’s a problem in the brain’s control of that organ. There’s an unfair stigma attached to psychosomatic symptoms, and that’s based on when people accuse someone of faking an illness, but faking something is different. Faking an illness would involve a conscious deception. The research has a pretty hard time proving unconscious deception.
What’s an example of a psychosomatic or psychogenic symptom?
Flaherty: There was a kid playing hockey who fell on the ice and couldn’t move his legs, but there was no physical damage to his legs. He wasn’t trying to get out of the game, he was just terrified. The reason he couldn’t move his legs was because he thought that fall was going to paralyze him, so that extreme expectation in his brain made him unable to move. This was compounded by his uncle having been in a similar accident, so his brain thought the best thing to do in that situation was to not move. It was a deer-in-the-headlights sort of reaction. It wasn’t conscious.
If a patient doesn’t have a history with other psychological conditions, why would she have psychosomatic symptoms?
Flaherty: Psychological health and psychosomatic symptoms aren’t always correlated. You can have a panic attack without having a psychological anxiety disorder. It’s possible to have psychosomatic symptoms without being psychologically ill.
If I think that my physical ailments are psychosomatic, what can I do about it?
Flaherty: Basically anything that decreases your anxiety is going to help, so relaxation techniques are a great tool. A great tool is positive distractions. People don’t want to distract themselves when they think they are sick because they think they need to be vigilant about the problem. Here’s a hint that your condition might be psychosomatic: if you’re playing with your kids and you feel fine. When people don’t feel well, they think they need to be sitting there, watching their symptom, and of course that’s the best way to make a psychosomatic symptom worse.
Another thing that’s pretty easy to do at home is exercise. This is especially helpful because sometimes people’s pain thresholds are too low, so they feel uncomfortable when others may not notice a physical ailment. These sensitivity levels can change though. Physical exercise is a great way to relieve stress and make your body less reactive to pain. Exercise hurts slightly, but there’s a psychological thing that occurs when you’re choosing to do something that’s uncomfortable. Your brain says, “If I’m doing this, I better get used to it, and suck it up.” The brain adjusts to make the activity less painful. This explains how people can train to run long distances. Over time they can build up their brain’s stamina until they are running 25 miles without a problem.
Can I still take medicine to relieve physical symptoms that are psychosomatic?
Flaherty: Yes, absolutely. An important note to emphasize is that there’s not a hard and fast distinction between the physical and psychological ailment. Physical symptoms can respond to behavioral treatments just as mental conditions can respond to physical treatments. You can use therapy to help someone with heart disease, by helping them relieve stress, just like you can use medication to slow down the heart rate of someone with psychogenic/psychosomatic heart racing triggers.
How should parents handle a disagreement with a pediatrician about whether a child’s condition is psychosomatic or not?
Flaherty: Kids usually can’t make the distinction between what’s real and what’s psychological. Usually the parents are making that call. If a parent is saying that their child’s symptoms are psychogenic, and the doctor isn’t agreeing with that assessment, then you probably need to examine this diagnosis. If a physician is saying a child’s condition is not psychogenic, then a parent should stop and ask themselves what is motivating them to think that the condition is psychosomatic. If someone is saying their problem off the bat is psychosomatic, then they are probably stoics, in denial of what is actually wrong with them. Almost all illnesses have components of the physical and psychological, so they key to solving the problem is figuring out how much is related to the event and how much is related to the physical body itself. It’s not a hard and fast thing though. A heart racing may be psychogenic, but it’s still related to a very physical problem.
One of the most important things to remember is that psychosomatic symptoms can be really debilitating, so calling them imaginary is ridiculous. It’s not imaginary if people are really sick.