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Psychic Groans - Anxiety or the Real Thing?
This topic of anxiety symptoms versus real ones has come up a couple times recently and I decided to do a blurb on "Somatization" or the appearance of symptoms that represent anxiety or psychiatric difficulty expressed as physical symptoms.
For the last week I have been doing reading and I will tell you that I come away both suspicious of the medical profession's take on this topic and confused about what I really know and what I want to believe.
I have always believed that people can express their fears, anxiety, and psychological pain with physical maladies. Afterall we all know by now that there is no real separation of the mind and body. As a pediatrician I saw babies children with vomiting and abdominal pain in response to parental fighting, or problems at home. Children with a parent with a back injury would begin to include back pain in their common complaints. My mother was a caretaker for my grandparents. My grandma was rather immature and always had vague complaints - as well as serious real ones. She would invariably end up in the ER within a day of any vacation my mother had planned.
We all know that some of this exists all around us. We all know people who truly live in great fear that every symptom they have is something dread and fatal. Or people that magically develop every symptoms they hear about. Okay. Those people do exist. But, I have also noticed that these people "know" they are anxious, but can't fight it.
I have to say, though, that after 30 years in medicine and another two on this forum, I am beginning to feel that there is a HUGE group of people out there with real disease that the medical profession is completely dismissing - all with good intentions. On one hand there is the recommendation to make sure people do not have something serious, but it is countered by equally strong recommendations to NOT "feed into people's neuroses" by doing a large workup.
When I look at the articles and psychiatric journals that describe this I tried to discern the characteristics of somatic complaints, the type of symptoms that they are calling somatic and how they presume to tell the difference.
First I looked at the lists of symptoms that are given as typical of somatic complaints:
Abdominal pain *
Amnesia
Back pain *
Bloating *
Chest pain *
Diarrhea *
Difficulty swallowing *
Dizziness *
Excessive menstrual bleeding
Fatigue *
Frequent urination *
Headaches *
Impotence *
Irritability *
Irregular menstruation
Joint pain *
Nausea *
Pain during intercourse
Pain during urination *
Pain in the legs or arms *
Palpitations *
Paralysis or muscle weakness *
Poor Balance*
Poor Memory *
Tingling in places*
Sexual apathy
Shortness of breath *
Vision changes *
Weakness *
* = things seen commonly in diseases like MS, Lyme Disease and Autoimmune disorders
I found the lists of symptoms completely unhelpful. Some lists led me immediately to a mental diagnosis of MS!
Then I tried to see what characteristics these symptoms seemed to have. This was "a little" more helpful. These are the things that frustrate the doctors caring for such people.
1) Symptoms are vague, yet described with very expressive and unusual language
2) Symptoms move around from place to place often, or they are fleeting. (I kind of agree with this one)
3) Sensations are felt "all over" with no ability to describe differences from one location to another. Examples, "I hurt all over." Or weak all over. Numb all over.
4) Symptoms that do not correspond with things found on exam. Example, the complaint that the legs are weak, but on exam the strength is completely normal or complaint of blurred vision, but acuity is normal.
5) Symptoms do not change, nothing improves them and no cause is found.
6) A history of many different symptoms for which a cause is never found and that eventually go away.
7) A recurring history of symptoms that occur when stressed, only to resolve.
I tried really hard to think through all of these characteristics and I was still not impressed that they were clues to somatic complaints.
The ones that I found most persuasive are 1) the complaints that are "global" and vague and constantly changing - hurting or numb all over without being able to pinpoint any differences (but, this can happen with people who are not very self-aware or who have poor skill in expressing themselves) 2) a patient's history that over years many complaints would come up and never be shown to have a cause, then would resolve only to be replaced by another, 3) the history that the symptoms dance around rapidly. Another big point here is that these people must never have suffered any kind of deterioration or disability related to their symptoms (but, of course this can be determined only in hindsight. This is not useful if you are looking at a disease which has a disappearing window for effective treatment.
But, when I thought about these points, they still didn't convince me that somatic disorders are widespread. Not all chronic diseases lead to disability. A person with Celiac Disease may just live their entire life with terrible abdominal symptoms (pain, diarrhea, bloating) but otherwise be pretty "healthy."
Another tip-off cited is when a person comes in with complaints in many different systems in the body. Uhhhh, does MS ring a bell? The hallmark of many autoimmune deseases and many infections, like Lyme Disease, is the vast nature of their possible symptoms. So, that criterion didn't impress me either.
Another tip off was "doctor-shopping." The history that the patient sought help from numerous doctors for their problems. This will be a whole discussion soon.
Finally, there was this "tip-off" that was frequently mentioned: The doctor finds himself frustrated and/or angry at the patient that seems to be wasting his time. If he's frustrated maybe it's because the patient doesn't have anything wrong.
So, what did I end up deciding? I still believe that many people have vague discomforts from internal stress. These come and go. But, I am more and more convinced that the medical profession is losing our confidence because of the diagnosis of "It's due to anxiety" is thrown out too fast and too early and is substituting for real thinking. And, too often real abnormal findings (on exam and tests) are ignored in the rush to blame it on the patient.
Finally most of the articles point out that all of the things that are mentioned above can also be seen in people with "real" disease. There are criteria for diagnosing people with somatic complaints. I have read them and need to find them again. And studies have been done to assure practitioners that the diagnostic criteria are quite accurate by following up with people and showing that they didn't actually have some real disease. The articles also comment on how hard it is to treat this "condition." Could this be because talk therapy doesn't undo real disease?
But, I still don't find that reassuring. In my mind our limbolanders might fit that "follow up", but does a lack of diagnosis "really" mean there isn't disease? For two years I was without a diagnosis after having been judged to be one of the Walking Worried. If you checked on me before I saw the right neuro you might have assumed that the diagnosis of "Somatic" was correct.
I am throwing these thoughts out for discussion. How do we know when we are having a "psychic groan" symptom? How does a doctor really know? How many of you have ever had a symptom that you were told was due to anxiety and you could see that it was likely true? When there are real abnormalities on exam, can the diagnosis of anxiety still be true?
The floor is open for discussion.
Quix
For the last week I have been doing reading and I will tell you that I come away both suspicious of the medical profession's take on this topic and confused about what I really know and what I want to believe.
I have always believed that people can express their fears, anxiety, and psychological pain with physical maladies. Afterall we all know by now that there is no real separation of the mind and body. As a pediatrician I saw babies children with vomiting and abdominal pain in response to parental fighting, or problems at home. Children with a parent with a back injury would begin to include back pain in their common complaints. My mother was a caretaker for my grandparents. My grandma was rather immature and always had vague complaints - as well as serious real ones. She would invariably end up in the ER within a day of any vacation my mother had planned.
We all know that some of this exists all around us. We all know people who truly live in great fear that every symptom they have is something dread and fatal. Or people that magically develop every symptoms they hear about. Okay. Those people do exist. But, I have also noticed that these people "know" they are anxious, but can't fight it.
I have to say, though, that after 30 years in medicine and another two on this forum, I am beginning to feel that there is a HUGE group of people out there with real disease that the medical profession is completely dismissing - all with good intentions. On one hand there is the recommendation to make sure people do not have something serious, but it is countered by equally strong recommendations to NOT "feed into people's neuroses" by doing a large workup.
When I look at the articles and psychiatric journals that describe this I tried to discern the characteristics of somatic complaints, the type of symptoms that they are calling somatic and how they presume to tell the difference.
First I looked at the lists of symptoms that are given as typical of somatic complaints:
Abdominal pain *
Amnesia
Back pain *
Bloating *
Chest pain *
Diarrhea *
Difficulty swallowing *
Dizziness *
Excessive menstrual bleeding
Fatigue *
Frequent urination *
Headaches *
Impotence *
Irritability *
Irregular menstruation
Joint pain *
Nausea *
Pain during intercourse
Pain during urination *
Pain in the legs or arms *
Palpitations *
Paralysis or muscle weakness *
Poor Balance*
Poor Memory *
Tingling in places*
Sexual apathy
Shortness of breath *
Vision changes *
Weakness *
* = things seen commonly in diseases like MS, Lyme Disease and Autoimmune disorders
I found the lists of symptoms completely unhelpful. Some lists led me immediately to a mental diagnosis of MS!
Then I tried to see what characteristics these symptoms seemed to have. This was "a little" more helpful. These are the things that frustrate the doctors caring for such people.
1) Symptoms are vague, yet described with very expressive and unusual language
2) Symptoms move around from place to place often, or they are fleeting. (I kind of agree with this one)
3) Sensations are felt "all over" with no ability to describe differences from one location to another. Examples, "I hurt all over." Or weak all over. Numb all over.
4) Symptoms that do not correspond with things found on exam. Example, the complaint that the legs are weak, but on exam the strength is completely normal or complaint of blurred vision, but acuity is normal.
5) Symptoms do not change, nothing improves them and no cause is found.
6) A history of many different symptoms for which a cause is never found and that eventually go away.
7) A recurring history of symptoms that occur when stressed, only to resolve.
I tried really hard to think through all of these characteristics and I was still not impressed that they were clues to somatic complaints.
The ones that I found most persuasive are 1) the complaints that are "global" and vague and constantly changing - hurting or numb all over without being able to pinpoint any differences (but, this can happen with people who are not very self-aware or who have poor skill in expressing themselves) 2) a patient's history that over years many complaints would come up and never be shown to have a cause, then would resolve only to be replaced by another, 3) the history that the symptoms dance around rapidly. Another big point here is that these people must never have suffered any kind of deterioration or disability related to their symptoms (but, of course this can be determined only in hindsight. This is not useful if you are looking at a disease which has a disappearing window for effective treatment.
But, when I thought about these points, they still didn't convince me that somatic disorders are widespread. Not all chronic diseases lead to disability. A person with Celiac Disease may just live their entire life with terrible abdominal symptoms (pain, diarrhea, bloating) but otherwise be pretty "healthy."
Another tip-off cited is when a person comes in with complaints in many different systems in the body. Uhhhh, does MS ring a bell? The hallmark of many autoimmune deseases and many infections, like Lyme Disease, is the vast nature of their possible symptoms. So, that criterion didn't impress me either.
Another tip off was "doctor-shopping." The history that the patient sought help from numerous doctors for their problems. This will be a whole discussion soon.
Finally, there was this "tip-off" that was frequently mentioned: The doctor finds himself frustrated and/or angry at the patient that seems to be wasting his time. If he's frustrated maybe it's because the patient doesn't have anything wrong.
So, what did I end up deciding? I still believe that many people have vague discomforts from internal stress. These come and go. But, I am more and more convinced that the medical profession is losing our confidence because of the diagnosis of "It's due to anxiety" is thrown out too fast and too early and is substituting for real thinking. And, too often real abnormal findings (on exam and tests) are ignored in the rush to blame it on the patient.
Finally most of the articles point out that all of the things that are mentioned above can also be seen in people with "real" disease. There are criteria for diagnosing people with somatic complaints. I have read them and need to find them again. And studies have been done to assure practitioners that the diagnostic criteria are quite accurate by following up with people and showing that they didn't actually have some real disease. The articles also comment on how hard it is to treat this "condition." Could this be because talk therapy doesn't undo real disease?
But, I still don't find that reassuring. In my mind our limbolanders might fit that "follow up", but does a lack of diagnosis "really" mean there isn't disease? For two years I was without a diagnosis after having been judged to be one of the Walking Worried. If you checked on me before I saw the right neuro you might have assumed that the diagnosis of "Somatic" was correct.
I am throwing these thoughts out for discussion. How do we know when we are having a "psychic groan" symptom? How does a doctor really know? How many of you have ever had a symptom that you were told was due to anxiety and you could see that it was likely true? When there are real abnormalities on exam, can the diagnosis of anxiety still be true?
The floor is open for discussion.
Quix
Hi Quix,
Thank you for your post!
I have been in the medical field for about 28 years also as a medical transcriptionist.
In 2003 when something reared its ugly head for me I was truly totally healthy except for occasional migraines.
After my initial episode of right-sided body tingling and severe numbness leading to TN when I first saw my neuro it was "stress/anxiety/worry." Also he said I needed to change professions as being a medical transcriptionist could be my problem as well.
I went back a couple days ago because I had not seen this neurologist in about 2 1/2 years it was "I told you it is not MS, its stress/anxiety/worry." He basically told me to stop shopping around for doctors and that the wrong doctor could "hurt me." I told him that everyone has stress.
Only we know our bodies and when something is terribly wrong. I absolutely dreaded going back to this neuro but all the doctors in my area are in this one particular practice.
(They do not know us) and could not possibly differentiate if we are hypochondriacs or not.
I have always been an extremely positive person and still am. I've tried the whole get over it scenario but it just does not work.
What it is that the doctors are afraid of by not openly talking about this with us? If they would just "talk to us" instead of making us feel like we are crazy, depressed, and stressed out.
Neuro suggested physical therapy, Effexor, and he increased my Neurontin this office visit but if I have no neurological issues, why doesn't he just dismiss me as a patient and send me on my way to a psychiatrist?
Thanks Quix. It is nice to hear your professional/personal take on this post.
Tj
Thank you for your post!
I have been in the medical field for about 28 years also as a medical transcriptionist.
In 2003 when something reared its ugly head for me I was truly totally healthy except for occasional migraines.
After my initial episode of right-sided body tingling and severe numbness leading to TN when I first saw my neuro it was "stress/anxiety/worry." Also he said I needed to change professions as being a medical transcriptionist could be my problem as well.
I went back a couple days ago because I had not seen this neurologist in about 2 1/2 years it was "I told you it is not MS, its stress/anxiety/worry." He basically told me to stop shopping around for doctors and that the wrong doctor could "hurt me." I told him that everyone has stress.
Only we know our bodies and when something is terribly wrong. I absolutely dreaded going back to this neuro but all the doctors in my area are in this one particular practice.
(They do not know us) and could not possibly differentiate if we are hypochondriacs or not.
I have always been an extremely positive person and still am. I've tried the whole get over it scenario but it just does not work.
What it is that the doctors are afraid of by not openly talking about this with us? If they would just "talk to us" instead of making us feel like we are crazy, depressed, and stressed out.
Neuro suggested physical therapy, Effexor, and he increased my Neurontin this office visit but if I have no neurological issues, why doesn't he just dismiss me as a patient and send me on my way to a psychiatrist?
Thanks Quix. It is nice to hear your professional/personal take on this post.
Tj
Hmm...I've been in and out of the fight/don't fight struggle lately. Y'all may have changed my mind yet again....
Keep talking.
Keep talking.
Wow, what a thread! I'm surprised I messed this one...
I was blessed by having a cool Neuro, who, in front of my hubby and all, said "this is all very real. You don't see me handing you a referral to a psychiatrist" Of course, if he did, I would go to the shrink, anyway, to prove I'm OK. This was all at the beginning of my path to diagnosis.
I've been in and out of depression since I was 10 years old, and my best way out was talk therapy. I've never taken an antidepressant, and when things get a little dicey upstairs, I have only to phone my therapist, and just a few sessions get me straightened out and coping. I'm actually amazed I haven't had any major depressive episodes since my diagnosis, or with the addition of Rebif. Hmmmm...Knock wood!
Cheers,
Guitar_grrrl
I was blessed by having a cool Neuro, who, in front of my hubby and all, said "this is all very real. You don't see me handing you a referral to a psychiatrist" Of course, if he did, I would go to the shrink, anyway, to prove I'm OK. This was all at the beginning of my path to diagnosis.
I've been in and out of depression since I was 10 years old, and my best way out was talk therapy. I've never taken an antidepressant, and when things get a little dicey upstairs, I have only to phone my therapist, and just a few sessions get me straightened out and coping. I'm actually amazed I haven't had any major depressive episodes since my diagnosis, or with the addition of Rebif. Hmmmm...Knock wood!
Cheers,
Guitar_grrrl
Hi there.
Just want to say that I've been active in this forum since October '07, and in that time there have been far more than a few members who have graduated from limboland. Several dozen at the very least, most of whom have gotten an MS diagnosis. We've had a fair share of others who have learned they have MS mimics, from Lyme disease to B12 deficiencies, and even cancer. We've also had a small number whose problems were indeed psychiatric and they agreed with that assessment.
Unfortunately there's no way to do an accurate count without going through every post, and that would mean thousands of hours of reading. Quite a lot of members no longer post, or post seldom, but that's the nature of the beast, I guess.
Still, I think my diagnosis estimate is very conservative. Don't give up trying.
ess
former limbolander, diagnosis Jan. '08.
Just want to say that I've been active in this forum since October '07, and in that time there have been far more than a few members who have graduated from limboland. Several dozen at the very least, most of whom have gotten an MS diagnosis. We've had a fair share of others who have learned they have MS mimics, from Lyme disease to B12 deficiencies, and even cancer. We've also had a small number whose problems were indeed psychiatric and they agreed with that assessment.
Unfortunately there's no way to do an accurate count without going through every post, and that would mean thousands of hours of reading. Quite a lot of members no longer post, or post seldom, but that's the nature of the beast, I guess.
Still, I think my diagnosis estimate is very conservative. Don't give up trying.
ess
former limbolander, diagnosis Jan. '08.
Sorry - hit a wrong key and posted before I was finished.
Anyway, if I suffered from anxiety as bad as he said I did, I'd need to be committed, and I certainly wouldn't be able to function well in society.
I'm finally going to get to see an MS specialist Tuesday. She has a very good reputation and is on MS Society board. I've heard that she really listens and wants to help people. I sure hope so because neuro #1 certainly left me with doubts and a lot of dissapointment in the medical profession. He made numerous mistakes in his notes - including sending them to a doctor I don't even see and saying he was waiting on reports from other doctors that he never sent me to. The entire experience was a nightmare, and meanwhile, I continued to have flares, and now I have to use a cane or walker most of the time.
Limboland is a terrible place to be! I've seen were a few on here have finally gotten a dx after many years of living without answers - so there is hope.
Thanks to everyone who posts here - it's certainly comforting to know I'm not alone.
Cassrox
Anyway, if I suffered from anxiety as bad as he said I did, I'd need to be committed, and I certainly wouldn't be able to function well in society.
I'm finally going to get to see an MS specialist Tuesday. She has a very good reputation and is on MS Society board. I've heard that she really listens and wants to help people. I sure hope so because neuro #1 certainly left me with doubts and a lot of dissapointment in the medical profession. He made numerous mistakes in his notes - including sending them to a doctor I don't even see and saying he was waiting on reports from other doctors that he never sent me to. The entire experience was a nightmare, and meanwhile, I continued to have flares, and now I have to use a cane or walker most of the time.
Limboland is a terrible place to be! I've seen were a few on here have finally gotten a dx after many years of living without answers - so there is hope.
Thanks to everyone who posts here - it's certainly comforting to know I'm not alone.
Cassrox
Hi all,
It's been awhile since I've posted. I mostly read and find comfort in the comments of others. But Quix's points really hit home for me. My first neuro seemed to be more interested in dismissing my symptoms as "all in my head" than he was in trying to figure out what's really wrong.
I know my body, and I know how it reacts to stress - and I know that anxiety is NOT what's causing all my problems. Sure, especially the first couple of times I had a flare, I was definitely scared, but I think neuro #1 got it all backwards and said that stress was causing the sympto
It's been awhile since I've posted. I mostly read and find comfort in the comments of others. But Quix's points really hit home for me. My first neuro seemed to be more interested in dismissing my symptoms as "all in my head" than he was in trying to figure out what's really wrong.
I know my body, and I know how it reacts to stress - and I know that anxiety is NOT what's causing all my problems. Sure, especially the first couple of times I had a flare, I was definitely scared, but I think neuro #1 got it all backwards and said that stress was causing the sympto
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