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Psychosomatic explanations for disease

Sigmund Freud and Jean-Martin Charcot were born 150 years ago, but their ideas about the effect of the subconscious on disease continue to resonate in the scientific community.1 Freud and colleagues argued that unconscious mental processes such as sublimated rage could manifest as physical symptoms. However, with the advent of superior technology, one by one, many diseases once supposed to be caused by psychological stress have since been attributed to other factors including infections.

According to the Marshall Pathogenesis, chronic fatigue syndrome, multiple chemical sensitivity and other chronic inflammatory diseases are likely caused by pathogens, yet many physicians consider these diseases to be “medically unexplained.” Medically unexplained diseases are widely prevalent2 but at the same time have few discernible markers or objectively measurable symptoms. While a lot of Freudian ideas have fallen out of favor, one legacy remains: difficult-to-explain diseases are still routinely attributed to psychological causes. The process by which patients supposedly manifest psychological problems as a disease has been named and renamed, classified and reclassified: hysteria, psychosomatic disorder, somatoform disorder, conversion disorder, functional disorder, etc. In each of these diagnoses, however, the stated origin of disease is unchanged: symptoms that cannot be explained are ultimately “all in a patient's head.”

While there is no denying the existence of some sort of “mind-body connection,” there is minimal compelling evidence that as the 19th century Swiss physician Georg W. Groddeck claimed: “Illness has a purpose; it has to resolve the conflict, to repress it, or to prevent what is already repressed from entering consciousness.”3 Despite the stark absence of evidence supporting these views, it is not unusual to read papers describing how patients with long-term so-called psychological illnesses may be subconsciously manifesting them, because it would allow them to have more “care, attention, disengagement, or even financial benefits.”4 Nor, is it uncommon for new theories to spring up along these lines. In one example, a 2008 continuing medical education publication taught physicians that when a celebrity becomes ill, healthy people are suggestible enough to develop long-term illnesses consistent with the celebrity's descriptions of their conditions. Such claims are recklessly speculative, harming patients and stalling needed research.

Treating patients who complain of so-called medically unexplained symptoms with cognitive behavioral therapy or, in the case of chronic fatigue syndrome, graded exercise therapy, may do more harm than good.5 The emergence of metagenomic technologies offers a more sophisticated set of tools for detecting and characterizing microbes in these disease states. Perhaps it is only the use of this technology that will finally relegate the notion of patient as attention-seeking victim to historical relic.

Many patients' complaints are "medically unexplained"

Numerous studies have demonstrated that many of the physical complaints presented to physicians are unexplained from a medical perspective.6 7 Depending on the setting, between 30 and 66% of patients who seek medical care have unexplained symptoms.8 9 10 According to a 1996 estimate, the eight most common physical complaints (fatigue, backache, headache, dizziness, chest pain, dyspnea, abdominal pain, anxiety) account for more than 80 million physician visits annually in the United States, and only 25% of these symptoms have a demonstrable organic (of the body) cause.11 According to the Marshall Pathogenesis and as described elsewhere in the Knowledge Base, many of these “unexplained” symptoms are likely due to microbes.

Historical examples of psychologizing problems with organic causes

Lupus, multiple sclerosis, AIDS, and Lyme disease suffered similar fates before “tissue evidence” was available. Patients were belittled by armchair speculators masquerading as scientists. Who among us believes this was helpful? A simple “I don't know” would have been better than specious speculation.

The authors confuse absence of evidence with evidence of absence. They are not the same. Absence of evidence may reflect insufficient research, inadequate technology, poor methods, flawed paradigms, closed minds, or lack of clinical experience; for example, in 1980, there was no clear evidence that AIDS was viral—blood products were considered “safe.”….

The chronic fatigue syndrome and fibromyalgia (probably the same disorder) are characterized by considerable suffering and disability. We must not add to that suffering by trivializing patients with “functional” labels. Marginal care inevitably ensues.

Thomas L. English, M.D.12

Medicine has a long and ignominious history of erroneously psychologizing problems with organic causes. Several classic examples of how psychological stress supposedly affects disease have been debunked.

Disease Early and erroneous claims More valid explanations
cardiac disease Type A behavior – in which people are impatient, time-conscious and controlling – was first described as a substantial risk factor in coronary disease by the cardiologists Meyer Friedman and R. H. Rosenman.13 Research since then has found that Type A behavior is not a good predictor of coronary heart disease.14 On the basis of this and other criticisms, Type A theory has been termed obsolete by many researchers in contemporary health psychology and personality psychology.
camptocormia - forced posture with a forward-bent trunk supposedly seen in soldiers during World Wars I and II; claimed it could be cured quickly and durably by a “persuasive” electrotherapy15 muscle weakness; an organic comorbidity of Parkinson's and ALS
schizophrenia claimed to be caused by cold, distant mothers16 17 no widely accepted cause, however, communities of microbes have been increasingly implicated
stomach ulcers claimed to be cause by stress Helicobacter pylori
tuberculosis in the developed world, claimed to be caused by tubercular personality18 – romantic, unfulfilled, cosmopolitan people that need change and excitement Mycobacterium tuberculosis
ulcerative colitis in children, according to one author's claims, caused by interdependent on relationship between patients, parents, and grandparents19 no widely accepted cause, however, communities of microbes have been increasingly implicated

Eminent journals in the field of psychology from only several decades ago are full of preposterous descriptions of how factors including patients' subconscious urges, ineffectual fathers, and repressed rage can cause diseases like asthma, hyperthyroidism or rheumatoid arthritis. It is possible to unearth hundreds of such statements in the medical literature.

Bloody diarrhea of the child [who has ulcerative colitis] is interdependent with the behavior of his parents and grandparents and with the behavior of his siblings; hence, it is necessary to know about the developmental course of the two parents, the parents' images of the respective sets of grandparents, the parents' roles as husband and wife and the parents' roles as parents of the patient and the siblings of the patient.

P. Adams, in a 1968 Psychosomatics paper20

Evolution of an empirically unsupported idea

Ancient Greece – origin of hysteria

The notion of hysteria can be traced to ancient times. In the gynecological treatises of the Hippocratic corpus (5th and 4th centuries BCE), the father of medicine describes an illness in which the uterus dries up and wanders the body in search of moisture. They called this hysteria. Symptoms would then be caused by the uterus pressing on other organs. If it had wandered as far as the cranium, for example, the symptom would be headaches.21 Plato's dialogue Timaeus tells of the uterus wandering throughout a woman’s body, strangling the victim as it reaches the chest and causing disease. This theory is the source of the name, which stems from the Greek cognate of uterus, hystera. Galen, a prominent physician from the second century, wrote that hysteria was a disease caused by sexual deprivation in particularly passionate women. In the 17th century, Sydenham said, “hysteria could simulate any medical disease.”22

19th century – psychological stress manifests as physical illness

Freud and his contemporaries such as Charcot agreed that hysteria occurred among women, hypothesizing that instead of being a disorder of the womb or anything biological, hysteria was a product of emotional distress, anxiety or some other psychological cause. Extreme psychological stress, they argued, manifested itself in the body as illness, a view which Dr. Henry Maudsley summarized thusly, “Sorrows which find no vent in tears may soon make other organs weep.” 23 Uncovering the root psychological trauma, Freud said, would cure illness. This theory that became the basis for his practice of psychoanalysis.

During the latter half of the nineteenth century, doctors matter-of-factly considered hysteria the most common of the functional nervous disorders among females. One Victorian physician cataloged 75 pages of possible symptoms of hysteria and called the list incomplete.24

1980 – hysteria renamed conversion disorder

In 1980, hysteria was officially renamed “conversion disorder,” based on the hypothesis that patients convert their subconscious anxieties into physical symptoms. Conversion disorders belong to the broader designation of illnesses known as “somatoform disorders,” which includes hypochondria. Conversion disorder is currently defined by the American Psychiatric Association as symptoms that cannot be fully explained by a general medical condition (among other criteria).

Criticism of hysteria

The theory of hysteria has been heavily criticized almost since its reformulation by Freud, Charcot and other 19th century neurologists.

  • 1908: Steyerthal – Armin Steyerthal predicted that, “Within a few years the concept of hysteria will belong to history … there is no such disease and there never has been. What Charcot called hysteria is a tissue woven of a thousand threads, a cohort of the most varied diseases, with nothing in common but the so-called stigmata, which in fact may accompany any disease.”25
  • 1961: Slater – In his Maudsley lecture and later writings, Eliot Slater, M.D. questioned the concept of hysteria as a valid diagnosis, showing that serious physical illness subsequently emerged in many patients initially labelled hysterical and that the physical illness could often account for their allegedly psychological symptoms. Slater later wrote: “The malady of the wandering womb began as a myth, and as a myth it yet survives. But, like all unwarranted beliefs which still attract credence, it is dangerous. The diagnosis of 'hysteria' is a disguise for ignorance and a fertile source of clinical error. It is, in fact, not only a delusion but also a snare.”26 Ultimately, Slater wrote in 1982, “the diagnosis of 'hysteria' applies to a disorder of the doctor–patient relationship.”27
  • 1963: Popper – The preeminent scientific philosopher Sir Karl Popper pointed out that Freud's theories of the psyche were ultimately unscientific, because the null hypothesis had never been disproven: “As for Freud's epic of the Ego, the Super-ego, and the Id, no substantially stronger claim to scientific status can be made for it than for Homer's collected stories from Olympus. These theories describe some facts, but in the manner of myths. They contain most interesting psychological suggestions, but not in a testable form.”28

Feminist criticism

In her 2000 analysis,29 Briggs says that scholars of women and gender have long argued that hysteria participated in powerful narratives of cultural crisis, which goes a long way toward explaining the logical glue that held together an apparently endless catalogue of symptoms as a singular syndrome. She goes on to say hysteria was the “provenance almost exclusively of Anglo-American, native-born whites, specifically, white women of a certain class.” “The primary symptoms of hysteria in women were gynecologic and reproductive—prolapsed uterus, diseased ovaries, long and difficult childbirths—maladies that made it difficult for these hysterical (white) women to have children.”

Barbara Ehrenreich and Deirdre English, for example, have concluded hysteria is virtually a diagnostic fiction, arguing that nineteenth century physicians called upon narratives of nervous illness to denounce women’s agitation for expanded social roles. They cite the now classic example of Harvard president Edward Clarke arguing against women’s education in 1873 by claiming that the blood demanded by the brain would prevent the reproductive system from developing properly.30

Criticism of conversion disorder

The impetus for renaming Freud's notion of hysteria in 1980 was to put the theory (with its transparently sexist origin31 and pejorative overtones) on supposedly more scientific ground. Different sub-types were reassigned to other categories and several other small changes were made. For example, in the interests of diagnostic specificity, patients who are feigning (faking) illness are excluded from the diagnosis, however, feigning is “very difficult to either disprove or prove.”32

As Peter Halligan comments, however, the greatest liability is a more fundamental one: conversion still has “the doubtful distinction among psychiatric diagnoses of still invoking Freudian mechanisms.”33 According to Richard Webster's excellent analysis, “the only strict criterion is that the patient's symptoms were medically inexplicable.”

A 2010 psychiatrist-written paper on somatoform disorders could not be more aptly titled: “Understanding and managing somatoform disorders: Making sense of non-sense.”34

It is difficult not to draw the conclusion that, in formulating its criteria in this particular instance, the American Psychiatric Association did little more than take an old diagnostic error and give it a new name together with a new aura of respectability. Since the very concept of “conversion” is specifically psychoanalytic, and since it is historically indivisible from Freud’s own idiosyncratic theories of “hysteria”, it further seems that the creation of the category “conversion disorder” was a politically astute way of preserving the old concept of “hysteria” in euphemistic disguise.

Richard Webster 35

Even more than 100 years after this idea was first proposed, researchers remain at a loss to find any compelling scientific evidence for somatoform disorders. Psychology, physiology and functional brain imaging technology (e.g. EEG, fMRI, PET, or SPECT) have failed to elucidate the neurobiology of conversion disorder.36 Methodologic problems of such studies “abound.”37 Even in cases where psychological stress can be measured in patients with the diagnosis of somatoform disorders, these reactions to stress are “similar to the severity of psychological stress in non-psychosomatic neurological disorders.”38

Today conversion disorder does not connotate the full measure of diagnostic stigma that hysteria does, but that may change as patients learn what conversion disorder means. Some commentators report that the term “conversion disorder” has not been accepted by patients.39 40 Indeed, papers about conversion disorder also discuss the challenge of dealing with patients who feel insulted by implications they are engaging in “elaborate self-deception.”41

Conversion disorder is the subject of criticism even among those responsible for rewriting the Diagnostic and Statistical Manual of Mental Disorders. A 2010 letter to the editor of American journal of psychiatry criticizes the name and criteria for conversion disorder, suggesting alternatives.42 In the letter, Stone et al. eschew “conversion disorder” in favor of the term “functional neurological disorder.” The absurd criterion that the symptoms must be medically unexplained remains, which they euphemize as “diagnostic features” that “provide evidence of internal inconsistency or incongruity with recognized neurological or medical disorder.” This proposed change in terminology (and others) would do nothing to remedy this fatal flaw of any psychosomatic diagnosis.

Whatever their official designations, somatoform and conversion disorders are not substantively different than hysteria. The existence of such conditions is not supported by scientific evidence. In practice, these terms, no matter which is used, will remain a “diagnostic dustbin.”43

Contemporary examples of psychologizing illness

Even today, many physicians and researchers continue to believe that a number of medically unexplained symptoms are direct manifestations of internal psychological conflicts. Conditions widely believed to be “somatoform diseases” include:

  • chronic fatigue syndrome (myalgic encephalomyelitis)
  • Gulf War syndrome
  • multiple chemical sensitivities
  • nonepileptic seizures – Seizures in the absence of abnormal EEG-video monitoring readings are widely believed to be caused by sexual abuse.44 This is in spite of the fact that an EEG only measures electrical activity on the first few millimeters of the skull, with even skull and scalp thickness producing variations in readings.45
  • migraine as well as a variety of types of pain in the back, chest, abdomen, limbs and face
  • vulvodynia (vaginal pain)46

Epidemiology of conversion disorder

In practice, few “diseases” are diagnosed more inconsistently than conversion disorder, and that is evident in the widely variable estimates for its prevalence. This strikes at the heart of its usefulness and validity as an explanation for illness.

Prevalence

It is fairly obvious that the actual prevalence of conversion disorder probably approaches zero, but some researchers continue to debate how common it is. Estimates of “disease” prevalence have differed by several orders of magnitude. For some researchers, conversion disorder is as common as ever. Carson et al. imply that over 15% of new attendees at neurology outpatient clinics had conversion disorder.47 On the other hand, Singh and Lee surveyed primary care physicians and identified 18 patients (out of a catchment population of 37,000) with conversion symptoms.48 Akagi and House call the disorder “vanishingly rare.”49

For its part, the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) offers strikingly imprecise estimates for its prevalence: “Reported rates of Conversion Disorder have varied widely, ranging from 11/100,000 to 500/100,000 in general population samples. It has been reported in up to 3% of outpatient referrals to mental health clinics. Studies of general medical/surgical inpatients have identified conversion symptom rates ranging between 1% and 14%.”50

Patients most often diagnosed with conversion disorder

For interest, here is a list of certain groups thought to be more susceptible to psychosomatic illnesses:

  • women – There is no solid evidence of conversion disorder in women, but it is routinely assumed they are more likely to have it. According to a 2010 eMedicine article, the prevalence of conversion disorder “is higher in women than in men, with a female-to-male ratio of 2-10:1. Approximately 25% of emotionally normal postpartum and medically ill women report conversion symptoms sometime during their lives.” A study of Turkish women in the general population reports that 48.7% of participants had a lifetime history of a conversion symptom.51
  • victims of sexual abuse52 – The association between history of sexual abuse and conversion disorder is a transparent example of diagnostic bias. A diagnosis of conversion disorder cannot be made until a patient history is taken.53 If a patient history discloses sexual abuse, the person is more likely to have conversion disorder. Therefore, victims of sexual abuse are more likely to suffer from conversion disorder – or, so the logic goes.
  • rural residents and other patients who may be naive about medical and psychological issues – In one study, high rates of conversion disorder were thought to be seen in Appalachian males. In another study, this 2003 one is from Turkey, lower education level and socioeconomic and sociocultural problems were supposed to play a role in the “disease.”54
  • wealthy and overworked people – Poor people (see above) are more likely to get conversion disorder, but so are rich people. CFS was once called the “the yuppie flu.” This characterization has a 19th century equivalent, neurasthenia, which was also thought to be a disease of affluent people with “unflagging devotion to work.”55 In their 2001 paper, Van Houdenhove et al. employ the euphemism “high action-proneness” for saying CFS patients tend to be “hyperactive” prior to disease onset.56 57 This folklore is analogous to claiming patients with obstructive lung diseases contract those illnesses by excessive breathing. According to this impenetrable logic, unlike so many other diseases, patients' dissatisfaction with being sick is responsible for them remaining sick.
  • military personnel58 – Gulf War syndrome has been widely labelled an example of conversion disorder. As discussed in the section War - a crucible for disease, it's clear war contributes to higher rates of disease among veterans, but, as the higher rates of cancer, hypertension, and obesity illustrate, these illnesses are certainly not psychological. In one 2004 paper, Jones et al. claimed that servicemen and women were more likely to “somatize” a disease when it becomes more popular in the medical world.59 There is no evidence for this.
  • not physicians and not researchers – It may be worth noting that we have yet to see anyone claim that researchers or physicians are more prone to conversion disorder. Edward Jenner, the discoverer of the smallpox vaccine, complained of hysterical-type symptoms, an exquisite sensitivity to sound, in his final years alive. “Were I female,” Jenner wrote, “I would call it Hysterical – but in myself I know not what to call it….”60

Unfortunate legacy of psychosomatic explanations

  • misallocation of research funding – In 1998 it became known almost 13 million dollars for CFS research – more than half61 – had been redirected or improperly accounted for by the United States CDC. The agency stated the need to respond to other public health emergencies. The director of a U.S. national patient advocacy group charged the CDC had a bias against studying the disease.62 In cases where money is spent directly on research for medically unexplained conditions, funds are often used to study ineffective approaches such as cognitive behavioral therapy.
  • ineffective/harmful therapies – Because patients suffering from CFS/ME suffer from an organic cause, these interventions are unsettling, if not sadistic. It is tragic or humorous to think cognitive behavioral therapy (CBT) or graded exercise therapy (GET) would ever be considered a first-line therapy for illnesses such as AIDS, leprosy or other diseases for which the infectious causes of which are less disputed. In a 2009 study, F.N. Twisk et al. concluded, “We conclude that it is unethical to treat patients with ME/CFS with ineffective, non-evidence-based and potentially harmful “rehabilitation therapies”, such as CBT/GET.”63 Nevertheless, as of November 2010, the top three treatments for CFS on the Centers for Disease Control website remain, respectively: professional counseling, CBT and GET.
  • added insult to injury – On top of receiving care for which no effective first-line therapies exist, patients must contend with dubious physicians who assume that these patients are somehow responsible for their illnesses and subconsciously trying to trick themselves and their physician. As ludicrous as it may sound, some say CFS/ME patients benefit from illness:

Apart from the many disadvantages, long-lasting illness can also have more desirable consequences, such as care, attention, disengagement, or even financial benefits, which might also be considered perpetuating factors.64 65

A.J. Barsky et al.66

Misdiagnoses

One of the most damaging effects of the term “hysteria” is that it has encouraged doctors to think they have arrived at a diagnosis of symptoms which, in reality, remain mysterious. This in turn means that it is much easier for doctors to miss real but obscure organic illnesses.67 Ever since renaming hysteria, the day-to-day practice of diagnosing conversion disorder remains no less questionable due to its inherent subjectivity68 and a lack of a credible scientific basis.

The diagnosis of “hysteria” is all too often a way of avoiding a confrontation with our own ignorance. This is especially dangerous when there is an underlying organic pathology, not yet recognised. In this penumbra we find patients who know themselves to be ill but, coming up against the blank faces of doctors who refuse to believe in the reality of their illness, proceed by way of emotional lability, overstatement and demands for attention … Here is an area where catastrophic errors can be made. In fact it is often possible to recognise the presence though not the nature of the unrecognisable, to know that a man must be ill or in pain when all the tests are negative. But it is only possible to those who come to their task in a spirit of humility.

Eliot Slater, M.D., 1982 69

Overemphasis on positive thinking

Related article: Stress

If the mind has the power to cause illness, wouldn't the mind also have the power to reverse it? One of the popular implications of Freudian notions of the mind-body connection is that positive thinking both protects against disease and cures those patients who are already ill. Indeed, researchers have shown psychological stress appears to have a certain effect on immune function.70 The extreme version of the “mind over matter” theory is that illness though is a manifest failure to be positive:

There are no incurable diseases, only incurable people.

Bernie S. Siegel, M.D., 198671

Some studies suggest that positive thinking is helpful to a certain extent, but it is always a problem inferring causation from these types of observational studies. Sick people may be more likely to be pessimistic, but it could just be that people are happy because they are healthy. Positive affect (mood) may be marginally associated with lower rates of AIDS mortality,72 but what is to say that AIDS patients who are depressed aren't sicker than their more optimistic counterparts – and that this effect cannot be adequately controlled for using multivariate analysis (which attempts to control for such differences)?

Positive thinking in cancer

Psychological causes for illness are widely invoked in relatively well-defined diseases such as cardiovascular diseases, but especially cancer.

We believe that emotional and mental states play a significant role both in “susceptibility” to disease, including cancer, and in “recovery” from all disease. We believe that cancer is often an indication of problems elsewhere in an individual's life, probably aggravated or compounded by a series of stresses six to eighteen months prior to the onset of cancer.

O. Carl Simonton M.D., 1992 73

It has become conventional wisdom that a positive attitude improves a cancer patient's survival duration. According to Rittenberg et al.,74 while many studies and articles have been published claiming that various psychological parameters influence the course of cancer, their results have been contradictory and methodologically impaired.75 76 77 Other studies have supported this conclusion:

  • A 10-year follow-up study of 136 breast cancer patients looked at how patients who participated in a psychosocial program compared to those who did not. The program consisted of weekly cancer peer support and family therapy, individual counseling, and use of positive mental imagery. The study showed no positive impact on survival. Ironically, the senior author of this study (who disputed his study's methodology) was the same person who claimed there are no incurable diseases, only incurable people.
  • A 2001 New England Journal of Medicine study found that supportive-expressive group therapy does not prolong survival in women with metastatic breast cancer, but instead only improved mood and the perception of pain, particularly in women who are initially more distressed.78
  • Cunningham et al. showed in a randomized controlled trial that psychological intervention had no significant effect on patients with metastatic breast cancer.79

Positive thinking may be appropriate as one of many successful coping strategies. To attribute more to it or, worse, to insist that patients believe in its power to cure, positive thinking can be stigmatizing, adding an extra burden to an already devastated patient.80 If patients fail to become healthy, they are to blame as they are not trying hard enough to be positive. Chronic diseases are traumatizing life events. Sometimes crying, anger, or any of the other signs of negative attitude may be useful for effectively coping with the challenges of being sick. Norem et al. argue convincingly that sometimes pessimism and negative thinking are indeed positive psychology, as they lead to better performance and personal growth.81

In no way should psychological support add an extra burden to an already devastated patient.

I contend that by forcing a cancer patient to accept the concept of “positive mental attitude”, which is the rage these days in America, we as health-care professionals are not allowing patients to face reality, to set their own goals, to be allowed to grieve, or to plan appropriately for the future.

Popular literature, television, and movies are filled with the notion that we can influence physical health and illness through mental attitude. Positive feelings lead to cure and recovery, while negative feelings probably caused the disease in the first place and certainly influence its course.

Promoters of this concept typically provide anecdotes of how their interventions of positive thinking and imagery resulted in new, miraculous remissions or cures. Likewise, they frequently eschew the medical establishment and standard treatments. The fact that for many cancer patients there is no known cure allows the promoters of positive thinking to accuse the establishment of being self-serving….

Those of us in the profession know that the combination of what is seen under the microscope and the extent of disease have the greatest influence on prognosis. Would it were just so easy as prescribing “positive mental attitude”!

Cynthia N. Rittenberg 82

Lederberg et al. state that encouraging a “positive attitude” with extreme hopes and beliefs leads to equally extreme disappointments.83 They decry the fact that healers “let patients bear personal responsibility for failure, or blame it on their having sought traditional treatment. The hapless patient has no choice but to join the universal chorus in blaming himself or blaming the cancer establishment.”

Glossary

The following “psychological disorders” are diagnosed in the 2000 edition of the mental health professional's handbook, Diagnostic and statistical manual of mental disorders: DSM-IV-TR.

  • somatoform disorder – From the Greek term “soma” for body, a broad category of mental disorders characterized by physical symptoms that mimic physical disease or injury for which there is no identifiable physical cause. Also known as Briquet's syndrome or Brissaud–Marie syndrome. Currently defined by Diagnostic and Statistical Manual of Mental Disorders. Includes conversion disorder (see below), pain disorder (see below), hypochondriasis (see below), body dysmorphic disorders (overly preoccupied by body image), and neurasthenia (exhaustion of the central nervous system's energy reserves).
  • conversion disorder – A type of somatoform disorder in which there is a loss or alteration in physical functioning that suggests a physical disorder but that is actually a direct expression of a psychological conflict or need. The term “functional” sometime is used to imply the existence of a conversion disorder, e.g. “functional weakness”, “functional neurological deficit”, etc.
  • pain disorder – A type of somatoform disorder in which a patient experiences chronic pain in one or more areas. This disorder often occurs after an accident or during an illness that has caused genuine pain, and is then thought to take a “life” of its own.84 Previously referred to as “psychogenic pain disorder” and “somatoform pain disorder.”
  • hypochondriasis disorder – A type of somatoform disorder in which patients are said to have excessive preoccupation or worry about having a serious illness. Cyberchondria is a colloquial term for hypochondria in individuals who have researched medical conditions on the Internet. Contrary to popular belief, there is virtually no incentive to be a hypochondriac. Hypochondria is widely used as a disparaging term for patients with chronic disease. It seems likely that most hypochondriacs genuinely have symptoms of organic cause.

A relatively uncritical eMedicine article on somatoform disorders offers more specific criteria by which the DSM-IV-TR recommends diagnosis of these conditions.

  • functional disorder – In orthopedics, the term functional disorder has long been used to describe a structural defect such as a misshapen bone or enlarged heart. In the last several decades, however, neurologists and psychologists have increasingly taken to using the term to describe how dysfunctional signaling of the nervous system causes “medically unexplained symptoms.” For example, one will hear irritable bowel syndrome described as a “functional gastrointestinal disorder.” Like conversion disorder, functional disorder are thought to be precipitated by stress and other psychological causes. Functional disorders are often treated in the same way that conversion disorder is: cognitive behavioral therapy.

Read more

  • HystoriesHystories is torturous read authored by Elaine Showalter, a literary critic, who seems to genuinely believe that hysteria is a genuine medical condition. In her book, Showlater lumps in CFS patients with… self-described alien abductees. This comparison is at once quite consistent with the thinking of certain segments of the medical community and plainly absurd. As one Amazon.com reviewer commented, “If you want a laugh, I recommend reading Showalter's latest in Journal of Literary Criticism of Immunology.” In the preface to the revised edition, the author laments that her book elicited such outrage from upset patients.
  • Hysteria, medicine and misdiagnosis – An essay that combines a section from the opening of Chapter 5 of Why Freud Was Wrong with the Appendix (“The Diagnosis of 'Hysteria'”) which was originally written as a continuation of that section. Webster offers a truly excellent treatment of his topic.
  • In the psychiatrist’s chair: how neurologists understand conversion disorder – A 2009 paper containing selections from 22 interviews with neurologists on how they understand and diagnose conversion.
  • Charcot's bad idea – A book that looks at how the diagnosis of hysteria and conversion disorder was revitalised by a group of like-minded physicians under the terms of “functional weakness” and “functional neurological deficit” in order to “develop constructive ways of talking with patients.”

Notes and comments

While it may be true that patients with CFS/ME, for example, exhibit a “loss of adaptability,”85 fixate on a physical cause for disease86 or, to use a demeaning phrase, display “illness behavior”87 – the same could be said for anyone who suffers from any disease.

A common feature of many [anecdotes of the tendency of doctors to misdiagnose real organic conditions as psychological disorders] is the credulous and perhaps not always fully conscious acceptance by some physicians of extreme theories of psychosomatic illness for whose correctness there exists no evidence whatsoever, and which are ultimately derived from ancient medical fallacies about the non-existent disease of hysteria.

The careless use of the term “somatization”, and, indeed, the very fact that this medically tendentious word is used at all, almost certainly contributes to sustaining this climate of credulity. It also suggests that modifications of terminology alone will not solve any problems. It is the concept of “hysteria” and not merely the external label which needs to be discarded.

Richard Webster 88

One of the main problems… as the history of medicine eloquently demonstrates, soundings taken by physicians of the depths of their own ignorance are notoriously unreliable. Whenever such soundings are taken it is almost invariably claimed that the waters are already shallow and that the dry land of absolute physiological knowledge will soon be in reach. In reality, however, the ocean of medical ignorance has remained both dark and deep and has concealed numberless shoals of undiscovered pathologies and physiological mechanisms.

Richard Webster 89

  • men who have suffered an industrial accident, employees in a health profession or health insurance, and recipient of care by a “devoted spouse”90 91

Chronic diseases are not culturally transmitted

Many have argued that the tendency for conversion disorder to wax and wane in certain groups at certain times illustrates how these diseases are culturally transmitted and could not be somatic in origin. According to a frequently invoked view, the media should be blamed for hysterical outbreaks: “culture increasingly encourages patients to conceive vague and nonspecific symptoms as evidence of real disease and to seek specialist help for them,” and the “the media and the breakdown of the family encourage patients to acquire the fixed belief that they have a given illness.” He goes on, “Patients tend to adopt them on the basis of what the culture considers to be legitimate illness.”92

This explanation is suspect. Whatever label physicians have chosen to give medically unexplained symptoms, they have always existed. One commonly held misconception about the history of psychoanalysis was that Freud’s early patients came to him because they were suffering from emotional difficulties or because they displayed symptoms which clearly had a psychological origin. In reality, a large proportion of the patients whom Freud treated during his early years in private practice had initially sought medical advice because they were suffering from physical symptoms; they had enlisted the help of a physician for no other reason than that they believed themselves to be ill. Among their symptoms were headaches, muscular pain, neuralgia, gastric pain, tics, vomiting, clonic spasms, petit mal, epileptoid convulsions, and a host of other physical reactions.93

Given the frequency with which patients complain of medically unexplained symptoms, it is presumptuous, if not preposterous, to claim that hundreds of millions of people suffer from a type of psychological condition that has minimal biological evidence to support it. It is much more likely that certain disease states have not been sufficiently characterized and that conversion disorder or any of its historical predecessors are just examples of an invalid diagnosis applied subjectively. Interviews with practicing neurologist certainly suggest as much.94

In 2000, Thomas English authored this excerpt response to a review that dismissed CFS as a “self-perpetuating, self-validating cycle.”

Supposed misdiagnoses of conversion disorder In their 2005 BMJ systematic review, neurologist Jon Stone et al. conclude “due to improvements in study quality” (as opposed to improvement in diagnostic vigilance), the rate of misdiagnoses for conversion disorder has fallen to around 4%.95 If systematic reviews existed when Charcot and Freud lived, it seems likely the neurologists of their time would estimate misdiagnoses at a similarly low rate. However, if history is any guide, the actual number of misdiagnoses for “conversion disorder” approaches 100%.

Stone et al.96 and Allin et al.97 have argued that in the time since Slater (see above) the number of misdiagnoses of somatoform disorder have declined to an acceptable level: no more than several percent. The criteria used for such a conclusion is the frequency with which diagnoses are later changed. Even if these data were valid, the fact that somatoform disorder is applied more consistently does not mean that the diagnosis is any less problematic. It seems more likely that medicine has not satisfactorily described a disease state.

20th century – decline in diagnoses of hysteria

Over the course of the early 20th century, the number of diagnoses of female hysteria sharply declined. Several historians addressing the “disappearance” of hysteria have attributed the phenomenon to psychological and sociocultural factors. For example, some critics have blamed this decline on laypeople gaining a greater understanding of the psychological principles behind conversion disorders such as hysteria, explaining that with such understanding psychoanalysis no longer achieves the desired response from patients.98

  • The predominant disturbance is a loss of or alteration in physical functioning suggesting a physical disorder. It is involuntary and medically unexplainable…
  • One of the following must also be present:
    • A temporal relationship between symptom onset and some external event of psychological conflict.
    • The symptom allows the individual to avoid unpleasant activity.
    • The symptom provides opportunity for support which may not have been otherwise available.

Embracing uncertainty and microbial hypotheses

Often missing from the dialogue on medically unexplained symptoms is an honest assessment of evidence and uncertainty. Based on the pervasiveness of medically unexplained symptoms and the historical trend alone, it is pretty clear that so-called somatoform disorders occur on a much smaller scale than many psychiatrists have argued:

According to the Marshall Pathogenesis, many medically unexplained symptoms are already being connected to microbes. Until the last decade, the best technology has failed to detect and characterize any more than a fraction of microbes in the human body. With the increasing availability metagenomics, it would seem the most promising avenue for further research is in characterizing the discrepancies in microbial populations between health and disease. Bacteria on the surface of a human tongue

DSM stakes out both grounds

with rates up to 30% of

  • Hysteria/conversion disorder is as common as ever -

The total incidence of conversion disorder has been estimated to be from 2.5 to 500 per 100,000 in the general population,6,11 with most studies estimating from 5 to 10 per 100,000.6,10,11 Prevalence is estimated at approximately 40 per 100,000.6 Among hos- pital inpatients, the incidence is 20 to 120 per 100,0008; from 1% to 14% of neurology and psychiatry patients ex- perience conversion disorder.6,8,10 XXXXX

6. AkagiH,HouseA.Theepidemiologyofhystericalconversion.In: Halligan PW, Bass C, Marshall JC, eds. Contemporary Approaches to the Study of Hysteria. Oxford: Oxford University Press; 2001:73–87 7. Binzer M, Andersen PM, Kullgren G. Clinical characteristics of patients with motor disability due to conversion disorder: a prospective control group study. J Neurol Neurosurg Psychiatry 1997;63:83–88 8. Folks DG, Ford CV, Regan WM. Conversion symptoms in a general hospital. Psychosomatics 1984;25:285–295 9. Roelofs K, Naring GW, Moene FC, et al. The question of symptom lateralization in conversion disorder. J Psychosom Res 2000;49:21–25 10. Stefansson JG, Messina JA, Meyerowitz S. Hysterical neurosis, conver- sion type: clinical and epidemiological considerations. Acta Psychiatr 11.

Ms. Showalter correctly alerts us to the medicalizing of problems caused by strong emotions and psychological stresses, she overlooks an equally common diagnostic error: the psychologizing of problems with organic causes. Until the bacillus that causes tuberculosis was identified, TB was thought to be a result of having a tubercular personality. Until the bacterium that causes peptic ulcers was identified, ulcers were said to be caused by repressed anger – still a favorite psychoanalytic culprit. In California, a woman spent 12 years in therapy, her muscles getting steadily weaker until she couldn't lift her hand to brush her teeth. The psychiatrist said that her problem was her repressed rage at her parents; she turned out to have myasthenia gravis, a progressive muscular disease.

Pursued by Fashionable Furies, http://www.nytimes.com/books/97/05/04/reviews/970504.04tavrist.html?_r=2

As the preeminent scientific philosopher Karl Popper pointed out, Freud's – and, by logical extension, his heirs' – theories of the psyche are ultimately unscientific, because they are not testable.99

http://www.prohealth.com/me-cfs/blog/boardDetail.cfm?id=1389548

highly elaborated self-diagnoses

There are many different ways researchers and physicians have used for blaming the patient for their illness.

Consider a patient with chronic back pain that many clinicians would regard as predominantly psychological and social rather than organic in origin. The patient's greatest risk is that he or she will be regarded as a malingerer, with its offensive suggestion of deliberate lying. In practice most clinicians would avoid such a judgment, preferring to speak of somatization. But this term too is troubling, with its implication that the patient has deceived himself, albeit subconsciously, into a belief that the condition is physical (when its true origin is social or psychological) and is seeking to gain the collusion of the doctor in this idea. The clinician may then judge the patient as a subtle manipulator, a sort of ‘pseudo-malingerer’, thus tacitly conflating ‘psychosomatic’ with deception. Alternatively, the clinician may feel the patient is in denial or ‘stuck’, in that he or she cannot see that the pain is non-physical in origin.

The doctor then faces a moral dilemma. One option is to acknowledge that the patient has a problem but agree to differ on its cause. Thus, back pain continues to offer the patient a refuge or safe haven; but an objection is that the doctor's interpretation has negative moral overtones of unconscious deception, lack of insight, or denial. The alternative is for the doctor entirely to reject the ‘reality’ of the symptoms, but this implies doubts about either the patient's honesty or the validity of the problem—i.e., rejection of the patient. To sustain the doctor-patient relationship doctors frequently accede to the patient's model, though this may reinforce illness behaviour5-7 and legitimize ‘pseudosyndromes’ of the sort that emerge intermittently for social and cultural reasons.8

Lombardo 100

include section “descriptions”?

Medicine abhors a vacuum, and in the case of medically unexplained symptom presentations such as chronic fatigue syndrome or irritable bowel syndrome, a variety of fundamentally flawed psychological and behavioral explanations have emerged. While such explanations have since been supplanted by more credible alternatives with superior explanatory power, these explanations have had staying power. Today, many patients are routinely diagnosed with “somatoform disorder,” a mental disorder characterized by physical symptoms that mimic physical disease or injury.

While many teams are linking microbes to diseases, before such research was possible patients with medically unexplained symptoms were believed to be manifesting psychological tension.

Medicine abhors a vacuum, and in the case of medically unexplained symptom presentations such as chronic fatigue syndrome or irritable bowel syndrome, a variety of fundamentally flawed psychological and behavioral explanations have emerged. While such explanations have since been supplanted by more credible alternatives with superior explanatory power, these explanations have had staying power. Today, many patients are routinely diagnosed with “somatoform disorder,” a mental disorder characterized by physical symptoms that mimic physical disease or injury.

ridiculous to say 60% of patients (everyone who suffers from a medically unexplained condition) has conversion disorder, but that's exactly how conversion disorder is defined.

One study of health care utilization estimates that 25–72% of office visits to primary care doctors involve psychological distress that takes the form of somatic (physical) symptoms. http://www.minddisorders.com/Br-Del/Conversion-disorder.html#ixzz16RO2OxL4

But a 2002 study suggests that conversion disorder is just as prevalent as ever, with incidence rates on par with those of schizophrenia.

frequently point to the rise and fall of hysterical pandemics as evidence that these symptoms couldn't be driven by organic causes such as infection.

http://emedicine.medscape.com/article/294908-overview

http://bigthink.com/ideas/23883

http://www.wikidoc.org/index.php/Conversion_disorder

Though previously thought to have vanished from the west in the 20th century, some research has suggested it is as common as ever. Akagi, H. & House, A.O., 2001, The epidemiology of hysterical conversion. In P. Halligan, C. Bass, J. Marshall (Eds.) Hysterical Conversion: clinical and theoretical perspectives (pp. 73–87). Oxford: Oxford University Press.

famous belle epoque (beautiful age) of hysteria Micale MS On the "disappearance" of hysteria. A study in the clinical deconstruction of a diagnosis. Isis. 1993;84:496-526.

Freudian pathogenesis for chronic disease

Conversion disorder is a relatively common presentation in neurological practice, accounting for perhaps 1%–3% of diagnoses in general hospitals (3726004) and more in specialist neurological settings (7931373). Carson et al (12810775) found that 30% of new attendees at neurology outpatient clinics had “medically unexplained symptoms”, a category that includes, but is not synonymous with, conversion disorder. When followed up 8 months later, over half were still troubled by their symptoms and had not improved. No cases developed a neurological diagnosis. In primary care, conversion disorder is less common. Singh and Lee (9330242) surveyed primary care physicians and identified 18 patients (out of a catchment population of 37 000) with conversion symptoms. They found an association with female gender and a history of childhood sexual abuse.

http://www.wikidoc.org/index.php/Conversion_disorder

In a study at the University of Iowa conducted from 1984-1986, patients diagnosed with conversion disorder were in large part men, especially those with a history of military combat.[21]

One study reports that conversion disorder accounts for 1.2-11.5% of psychiatric consultations for hospitalized medical and surgical patients.

At the National Hospital in London, the diagnosis was made in 1% of inpatients. Iceland's diagnosis of conversion disorder is reported to be 0.00015% [18]. Eastern Turkey has a higher rate than the more affluent western regions where medical facilities are more sophisticated.[19]. In Eastern Libya the incidence is 8.3%. In Saudi Arabia the rate is 5.1% with a 2:1 ratio of women to men. Egypt in the 1960s had a diagnosis rate of 11.2%.[20]

Epidemiologic studies have fallen into 2 categories: those following the general population and those examin- ing hospital inpatients. The total incidence of conversion disorder has been estimated to be from 2.5 to 500 per 100,000 in the general population,6,11 with most studies estimating from 5 to 10 per 100,000.6,10,11 Prevalence is estimated at approximately 40 per 100,000.6 Among hos- pital inpatients, the incidence is 20 to 120 per 100,0008; from 1% to 14% of neurology and psychiatry patients ex- perience conversion disorder.6,8,10 Motor conversion is estimated to occur at the rate of approximately 5 per 100,0007 and thus manifests itself in a large proportion of all conversion cases. Women are affected more often than men, accounting for 60% to 80% of motor conversion cases.6,7,9 The mean age of pa- tients is 39 years.7,9,10 Compared with the control group, patients with conversion are less likely to be high school or university graduates.7

Conversion patients are signifi- cantly more likely to have an Axis I comorbidity, occur- ring in approximately one third of patients, with major depression being most common.7,9 Axis II comorbidities are more prevalent in motor conversion patients, occur- ring in approximately one half of patients.7 Mild trau- matic brain injury may also predispose patients to con- version disorder.12 Anecdotal information provides other factors associated with motor conversion, including mul- tiple somatizations, employment in a health profession or health insurance claims, and continuing care by a devoted spouse (i.e., secondary gain).13,14

–Motor Conversion Disorders Reviewed From a Neuropsychiatric Perspective

http://www.amazon.com/gp/product/0674031660/ref=s9_simh_gw_p14_d1_i2?pf_rd_m=ATVPDKIKX0DER&pf_rd_s=center-2&pf_rd_r=1BWXHNWVWVH5FJABGQN7&pf_rd_t=101&pf_rd_p=470938631&pf_rd_i=507846

http://www.amazon.com/Hystories-Elaine-Showalter/dp/0231104596

http://books.google.com/books?id=ovXV7amJgL0C&pg=PA109&lpg=PA109&dq=A.+Steyerthal,+Was+ist+Hysterie&source=bl&ots=IfJ2TmeV1P&sig=kuaI049aCu2pbfWBWWNzMNW2efc&hl=en&ei=8mbyTPnzDIT7lwen2PGzDA&sa=X&oi=book_result&ct=result&resnum=1&ved=0CBMQ6AEwAA#v=onepage&q=A.%20Steyerthal%2C%20Was%20ist%20Hysterie&f=false

http://www.ncbi.nlm.nih.gov/pubmed/8282518

http://www.wikidoc.org/index.php/Conversion_disorder#_note-16

http://www.google.com/search?sourceid=chrome&ie=UTF-8&q=tourette's+conversion+disorder#hl=en&expIds=17259,27642,27744&sugexp=ldymls&xhr=t&q=historical+examples+conversion+disorder&cp=11&qe=aGlzdG9yaWNhbCBleGFtcGxlcyBjb252ZXJzaW9uIGRpc29yZGVy&qesig=L-3yhmx74MyTPNeppDfWfQ&pkc=AFgZ2tkrf1IyFbYv-4PQv5p5JBVHoTfNDalnZhPeaiCbHZjiGNqIve_j1II-RZWZHc8HBLBjJnpzlZc_eujqRl54eu6jNNQlUg&pf=p&sclient=psy&safe=off&aq=f&aqi=&aql=&oq=&gs_rfai=&pbx=1&fp=74b11d96122089a2

http://www.jstor.org/pss/235644

http://books.google.com/books?hl=en&lr=&id=Jxfm86wOR8UC&oi=fnd&pg=PA156&dq=%22medically+unexplained+symptoms%22+OR+%22medically+unexplained+diseases%22&ots=fdW16xDT4P&sig=bis1b69GZZYrCnxbgSqEphaMtsY#v=onepage&q=%22medically%20unexplained%20symptoms%22%20OR%20%22medically%20unexplained%20diseases%22&f=false

http://apt.rcpsych.org/cgi/content/full/12/2/152

Briquet's syndrome

More studies on cancer here: http://www.amazon.com/Health-Psychology-Theory-Research-Practice/dp/1412903378

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