Illness & the Mind-Body Connection

'Even if medical tests cannot explain your pain or tiredness or disability, it does not lessen your suffering. The pain of medically unexplained illness is every bit as real as any other and, if anything, is multiplied by the lack of understanding.'

- Dr. Suzanne O’Sullivan, It's all In Your Head: Stories from the Frontline of Psychosomatic Illness

What is Psychosomatic Illness?

We typically use the word "psychosomatic" to label conditions that we believe may begin with thought and emotion, and then negatively impact the body. In our current psychology diagnostic framework, these conditions are captured under the category of Somatic Symptom and Related Disorders. All of the diagnoses in this category share a common feature: "the prominence of somatic symptoms associated with significant distress and impairment (DSM-V)."

The DSM-V reworked this category because previous versions of the DSM classification system placed too much emphasis on providing these diagnoses when medical symptoms were "unexplained." As stated by the authors, "It is not appropriate to give an individual a mental disorder diagnosis solely because a medical cause cannot be demonstrated." There are so many reasons why medical symptoms may not fit together! For example, most medical research has been done on male bodies - meaning that the bodies of women are less understood. Women, therefore, are at higher risk for medically unexplained illnesses and medical complications, and more likely to hear the dreaded opinion that a condition is "all in one's head." In addition, we all have variations in our physiology regardless of our sex, and medical science is far from being able to explain every condition. The practice of medicine is the art of taking what is known about most bodies at any given point in history, and then skillfully applying that knowledge to the unique body sitting with a doctor in an exam room - with humility.

Individuals with somatic symptom disorders as classified by the DSM-V often have multiple, current, somatic symptoms that cause distress and disruption in their day-to-day lives. Some signs of these types of disorders include:

• Persistent and even intrusive thoughts about the seriousness of medical symptoms

• Persistent high levels of anxiety about health or signs of illness in the body

• Lots of time and energy is devoted to these symptoms/concerns

For these individuals, medical illness becomes a preoccupation, and fear leads to behaviors such as repeatedly checking the body for signs of illness, or avoidance of doctors or hospitals.

Somatic Symptom Disorders vs. Medical PTSD

If any provider is considering a diagnosis with a somatic symptom disorder, they need to screen for medical PTSD. Somatic symptom disorders have significant overlap with symptoms of PTSD. Classic symptoms of PTSD include hyperarousal (high levels of anxiety), hypervigilance (wariness regarding threats), and avoidance. People with medical trauma frequently avoid medical visits as a way to cope. With medical trauma, the vigilance response is focused on the body, and the body is the source of tremendous anxiety.

Medical PTSD is associated with The Five Fs:

Fight: Anger or escalation. This may occur during medical visits or procedures.

Flight: Fear and the desire to escape. This leads to behaviors such as avoidance of care or leaving exam rooms in the midst of a visit.

Freeze: Overwhelm. This may result in shutting down, inability to speak, or difficulty making decisions.

Fawn: People-pleasing. This behavior is an attempt to protect relationships (e.g. by being the "good patient"), however may be a sign that a person does not have the bandwidth for conflict or boundary-setting due to stress and overwhelm.

Find: Vigilance. This is frequently focused on the body (e.g. repeated scanning for physical symptoms). Depending on the nature of past trauma, it may also be focused on medical environments or relationships (e.g. medical mistrust, guardedness during visits).

The Problem with Mind-Body Dualism

The term "mind-body dualism" refers to Western culture's tendency to separate the mind and the body, viewing them as two distinct things. Mind-body dualism is deeply problematic, as is the label "psychosomatic." Our brains are in our bodies. What impacts the body is very likely to impact how we think, feel, and behave. We don't always know when or how any illness "begins," but we know that stress both contributes to disease onset, and that disease onset causes stress (for an example of these relationships, see this Stress and Cancer Fact Sheet). We made up distinctions between the mind and the body to organize information, when the mind and body are not, in fact, separate.

When providers lean into mind-body dualism, it is deeply invalidating to patients, who may walk away from a visit thinking that their care team does not believe them about their symptoms or considers them "crazy." Even if a provider does not agree with mind-body dualism, simply bringing up the option of attending psychotherapy to assist in addressing medical conditions can unintentionally fall into this space - because of the cultural waters in which we swim.

The hopeful news is that practices such as yoga, breathwork, and mindfulness have gained popularity and notoriety in the West, offering a counter-narrative that brings the mind and the body back together again. These approaches also offer an opportunity for patients to learn about their nervous system and practice ways to tend to it. They help to normalize that when medical stress is present, the body, mind, and emotions will all need attention and care.

Recommendations for Providers

Some ways that healthcare providers can avoid falling into the mind-body dualism trap, and honor the mind-body connection instead, include:

• Bring up the option of holistic care early and often, as a consistent part of your visits. This helps to normalize the fact that medical issues impact not only the body, but the whole person.

  • For example, in a first visit, say: "My name is Dr. Mind-Body. Welcome to my practice. I believe in treating you as a whole person, and I want to acknowledge that what you're here to discuss today may be stressful - and even if not, there might be stressful stuff we talk about in the future. So, from time to time I will check in with you about your mood, and I might encourage you to seek therapy. How does that feel to you?"

• Notice signs of distress. If these are present, then slow down, breathe, and check in. Check out those Five Fs above, and if those are present in a visit, pause.

  • For example, when distress is present, say: "I'm going to slow down for a second. It is normal for the stress response to kick in during visits/procedures like this, so let's take a breath and let the body cool off a bit. (Take a breath together.) How are you feeling?"

• When a patient has symptoms that you cannot explain, be honest and direct about it. Help patients understand that medical science is constantly evolving, and that while we can explain many aspects of illness - we cannot explain everything.

  • For example, "I know lack of clarity can be frustrating and frightening. Those are really normal reactions to have when we seem to be hitting a wall. I'll be the first to say that I don't know everything, and even within my field we are constantly learning new things. We've reached a point in care when it might be beneficial to get more people on board to help us think things through and manage this condition - perhaps we could involve some specialists or a second opinion, and a good counselor or someone else you trust to help manage the stress of going through this."

• Remember to give your patients choices and respect their autonomy. Identify trusted sources of support. Not every person will feel comfortable seeking therapy as a way of managing stress, so helping to identify other individuals - such as pastors, family members, friends, or teachers - may be useful.

  
  

Providers, feel free to tweak these scripts to make them your own! Simply validating a person's experience and being in the uncertainty together, without judgement, can go a long way towards offering support and care.

Interested in learning more, consulting about a patient's care, or getting involved in therapy? Let us know! Reach out to us today - we look forward to hearing from you.

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