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Linus Geisler: Doctor and patient - a partnership through dialogue   © Pharma Verlag Frankfurt
Discussion with the patient with psychosomatic symptoms
The patient with psychosomatic disease
The diagnostic approach
The diagnostic-therapeutic discussion
Some people have a great fire in their
soul; nobody ever comes to warm
himself by it, and passers-by only
notice a wisp of smoke coming from the
chimney - and go on their way.
Vincent van Gogh
Discussion with the patient with psychosomatic symptoms
Psychosomatic symptoms arise from a disturbed relationship between the body and mind. This results from the interchange that takes place between the body and mind. Whatever the mind finds meaningful or irrelevant is expressed one way or another by the body (Luban-Plozza). Broadly speaking, understanding psychosomatic factors means understanding both health and sickness which arise from the interaction of somatic, mental and social factors (Lipowski, 1984).

The term psychosomatic disturbance can be understood in both a broad and in a narrow sense. In the narrow sense, these are those illnesses with evidence of organic damage, for which psychological or psychosocial factors are thought to play a role in the etiology (e. g. ulcerative colitis). In the case of functional disorders (e. g. tachycardia), no organic disease can be found. Patients with these disorders are very frequently seen in clinical practice but often disliked, as "no abnormalities are detected".

Of course psychosocial factors play a role in every illness: "It is not possible for the patient not to react psychosocially."

The main characteristic of psychosomatic disorders is that emotions lie at their roots.

The discovery that psychotherapy can positively influence certain diseases is not new. Antiphon of Athens (480-411 BC) is acknowledged to have discovered the "Art of consolation". Paul Watzlawick describes how Antiphon let the patients speak about their sufferings, and used these utterances both in shape and in content in such a rhetorical (and modern) way that the patients were brought to a new interpretation of what they had previously accepted as "real" or "true". This means that there is a change in the picture of the world in which they suffer. Antiphon later had a house near the Agora in Corinth, with the words: "I can heal illness with words" written above the door.

The term "psychotherapy" first appeared in 1872 in the book "Illustrations of the influence of the mind upon the body" by the Englishman, Daniel Hack Tuke. Sigmund Freud laid the basis for psychosomatic theory. It was Victor von Weizsäcker who introduced the term of social illness in 1930, and brought the subject into medicine. Thure von Uexküll with his colleagues were the major pathfinders in the field of psychosomatic medicine; however he continually warned that a "medicine for minds without bodies" might develop in parallel with a "medicine for bodies without minds".

Psychosomatic disorders require a great deal from the doctor. The understanding discussion between the doctor and the patient is the basis for the discovery and the treatment of psychosomatic illnesses. Almost 50% of patients in general practice (also) have psychosomatic disorders (K. Hoehle, 1988). Psychosomatic disturbances are more frequent than usually thought in inpatients. Peter Hahn (1988) found evidence from the University Medical Clinic in Hannover that 49% of patients in general medical wards, 38% on surgical wards and 35% on orthopedic wards suffered from psychosomatic disorder. Up to 30% showed severe social anxieties.
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The patient with psychosomatic disease
Psychosomatic disease is something that arises from the relationship between the emotions and the body. A characteristic feature of the psychosomatic patient is his inability to express his emotions ("emotional illiterate"). This inability to adequately perceive emotions and to be able to describe them, led to the introduction of the term "alexithymia" (inability to speak about feelings) by the American, Sifneos and his colleagues. This limitation of awareness of feelings, coupled with the inability to describe them, are often taken fatalistically by the psychosomatic patient. The "somatic response" which develops from the conflict is used as the introductory symptom ("entrance ticket") for care from the doctor. Mechanical and concrete thought processes with limitation of imagination means that the vast proportion of symptoms in these patients present as physical complaints or discomfort although it is the emotions that are disturbed. These patients are not able to take part in discussions with psychodynamic goals. They occasionally seem wooden, like a "puppet on a string", leading to the term "Pinocchio syndrome" based on the puppet in the tale of Carlo Lorenzini.

As the psychosomatic patient usually describes physical symptoms and neither allows nor finds ways of discussing hidden emotions or his reality, it is inevitable that "somatic function" will be investigated to the limit, but lead only to "normal findings". This assessment of normality will release shame and anxiety on the part of the patient. The result is a worsening of the doctor-patient relationship which can lead to the patient changing his doctor, even up to as many as 10 times. Typically the patient always says at the close of the discussion:

"Nobody can help me." This immediately releases feelings of helplessness in the doctor with the desire to relinquish the patient into the "psycho-"area (or - in Germany - at least to send him on a cure) to be relieved of this patient for a bit.
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The diagnostic approach
The psychosomatic patient does not speak about problems or conflicts. On the contrary (especially if these are mentioned too early) strong defense reactions develop. The (premature) psychosomatic diagnosis will be seen as a "challenge", which rapidly leads to problems within the doctor-patient relationship and probably to a change of doctor. The patient often has a pat theory about the cause of this disease. The descriptions of physical symptoms can be very vague: "everything hurts..." or "the whole of my left side is wrong...". A typical characteristic of lack of complaints: "It's only the diarrhea; if it wasn't for that I wouldn't have any problems..." The doctor has to be especially attentive when anxiety is mentioned (usually indirectly). Anxiety is often a diagnostic clue in psychosomatic illness ("follow anxiety when it appears"). However the doctor himself often has anxiety about leaving the somatic level when dealing with anxious patients.

Psychosomatic patients are likely to react more intensely than healthy people to physical changes and stimuli that affect their body. For example, they are aware of every heart beat. Panic attacks with a racing heart are typical. However concurrent ECG tracings reveal that the heart rate is in fact only 10 to 15 beats faster than usual. The typical description usually includes only the physical discomfort ("racing heart"). The patient refers to this again and again. This description fails to mention that the physical symptoms have triggered thoughts of danger followed by massive anxiety (anxiety about life itself). This anxiety must be mentioned cautiously: "What happened at the onset of the attack? Did your heart race? Did you then notice - it would be understandable - feelings of anxiety?"

Particularly in the case of psychosomatic diseases, the most useful diagnostic tool is active listening during which implications of intonation and every possible shade of meaning are picked up. Mirroring (reflection) as a technique for the verbalization of emotional content should be used at first with extreme caution (floating question technique). It is far more important that the discussion reveals what is wrong with the patient and what upsets him that what he "has". The sort of questions that are useful are those such as: "What is it like at weekends or on holiday?", "What had just happened?" If the description is unclear, the technique of the good detective should be used to patiently go through the story once again (Luban-Plozza). Exploration of the psychosomatic patient needs patience. The doctor should bear in mind the Indian who rode in a car for the first time, and begged the driver to stop after the first mile. "Why?" asked the driver. "Because my soul hasn't caught up yet!" answered the Indian. Intense sensitivity, good observation, listening with "four ears" and patience are vital due to the "emotional illiteracy" of these patients.
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The diagnostic-therapeutic discussion
There are hardly any other patients with whom in understanding discussion both diagnosis and therapy are so closely intertwined. A diagnosis of psychosomatic disease should be positive and should not be reached by exclusion of other diagnoses. This means that it should rest on psychological findings which make the development of the physical complaints understandable as the expression of unresolved conflict (Michael von Rad, 1988). This is only possible when the personality of the patient, his life story and the present influences on his life are taken into account. The life story of the patient is particularly important, even more than the history of disease. Luban-Plozza described these patients as injured folk from whom the plaster must be removed very, very carefully, as there is so much anxiety about the anticipated pain.

As both discovery and comprehension concern what is happening between the emotions and the body, the emotions must (with great care) be introduced into the conversation very gradually. The timing as well as the dose is important here, so as not to release a marked defense reaction (K. Bosse, 1988). Every comment of the patient must be taken seriously and interpreted correctly. If the symptom is referred to an organ, it is important to remember that each organ has a symbolic meaning (so called "psychological, fantasized anatomy") as well as its anatomical characteristics and physiological effects.

As many patients with psychosomatic symptoms have extreme dependence on key figures in their life, looking at these people is also important, or as Hohle says: "The heart now dislikes what the mother disapproved of." These sorts of likely connections must be worked at with patience.

Attention also must be paid to the usually ineffective attempts of the patients to protect themselves emotionally. For example, one third of these patients take tranquilizers, a quarter take laxatives and a fifth take sleeping tablets (Luban-Plozza). Careful questioning may reveal that the patient has attempted to get help from other sources (homeopaths, naturalists, herbalists, etc).

As the patient with psychosomatic symptoms is usually employing the physical symptom as an "introduction" to his doctor, the somatic approach is most likely to be effective initially. A thorough physical examination (even though this has usually been done several times before) is a prerequisite for the step-wise sounding out of the emotional disturbance at the root of the disorder. The physician as a therapist should behave in the way enshrined in the meaning of the original Greek word: "servant, guide and companion."

To be a physician means to understand and make possible. The doctor does not need to take on the role of leader, interpreter, sage or magician (Victor von Weizsäcker) but rather that of the "one who makes it possible; not the one that takes the decision, but he who stands with the patient as he decides". He should be a "motherly father-figure". The patient does not need advice thrown at him. He needs to be accepted and have light shone on his path, rather than interpretation and symbolism. This "supportive psychotherapy" is the domain of the family doctor. It requires a prolonged and reliable availability which in fact only the family doctor can provide. The doctor has to act as a translator: he has to attempt to convert the "silent physical complaint" into a language which helps the patient to escape from his fixation on physical symptoms.

The objective of the discussion is therefore not to give definite recommendations. The patient must come to recognize for himself what is going on inside himself. The doctor cannot solve problems, but he can help the patient to recognize his own conflicts and to endure them. Only when all this has started to happen over the course of several discussions should the doctor check whether or not his patient is ready for an "attempt at explanation" (Luban-Plozza).

Finally as a result of empathetic behaviour, emotional warmth, active listening and careful verbalization of feelings (Carl Rogers) on the part of the doctor during these diagnostic-therapeutic discussions, a person will appear from the largely dumb psychosomatic patient. This person, who by the language of his own body learns to cope with his disturbed emotionality, will finally become his own doctor.

When should the general practitioner refer this patient on for more specialized help? G. Rudolf (1988) gives simple advice: "When he is no longer able to answer his patient's questions." 

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Linus Geisler: Doctor and patient - a partnership through dialogue
© Pharma Verlag Frankfurt/Germany, 1991
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