| 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 |
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
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©
Pharma Verlag Frankfurt/Germany, 1991
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