Psychic Groans - Anxiety or the Real Thing?

[Quixotic1]

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

[Quixotic1]

bump

[jensequitur]

Part of what clouds a diagnosis, I think, is that neurological problems can cause symptoms similar to panic attacks.  Shortness of breath, pounding heart rate...  I've had all of those, but without feeling 'panicked.'  I know what feeling panicked feels like!

[tjammies]

This is a really interesting topic and for me very relevant. I have posted elsewhere about waiting the results of an mri and have had an appointment with a neurologist having been in hospital after having paralysis down one side, blurred vision and .not being able to speak. they told me i had a stroke. the neurologist said not a stroke and that i either have inflammation of the brain which could lead to ms or i have functional/dissociative symptoms. I had collapsed in the supermarket one day and had further episodes of paralysis and then numbness, shakiness, tremors and fatigue. Having looked up about functional symptoms i've found various labels meaning the same thing, conversion/somatization/hysteria/functional weakness/ and closely associated with dissociation/depersonalization. Most info seems to point to stress and anxiety being the root cause. having been in hospital and having a load of tests being told i had a series of strokes (at 47) and having now been given 2 very different ideas of what i might have wrong, i am certainly anxious now. I feel I know  a lot about anxiety depression, my husband has had ME for years and depression, I try to live a day at a time and meet my troubles head on, i dont think i fit any of the labels of functional weakness or dissociation. I dont neccessarily think i fit ms either. I agree with opera about the episode thing,how does your body convert anxiety into episodes of strange symptoms over 3 months? I also agree with doni about how can the docs make an instant diagnosis of depression anxiety when they have only met the person that day.and spoken to them for 20 mins.thing is i do get panic attacks and told a&e docs that but said this wasnt like anything i've ever had before. maybe they latched onto that though. i would like to know what is wrong with me though as my life has changed totally in the last 3 months.

[biowham]

Just today, I was thinking of the first time a doctor blew me off. I was 19. I entered college when I was 17, and to that point had only ever seen our family practice doc and a couple of specialists in my hometown for real, bona fide things. I'd never had a doctor just dismiss me as crazy. At college, in my first three semesters, I had a severe UTI, I fell and cut the **** out of my arm, and I had another "real" problem that was completely documented at the school health center. Well...at the end of my sophomore year--my fourth semester there--I went in with stomach pain. The doctor came in, said, "You're barely 19. You've only been in college for a few months and you already have this thick file?!?!? You're obviously just crazy." I mean, he really practically said that. I was stunned and tried to explain that I'd actually been at the school now for almost 20 months, that I wasn't a freshman but about to be a junior, that I'd been there far longer than he was assuming, that everything in that file was "real" if he'd just look---but he completely ignored me and sent me away. Well...ultimately, it was determine that I had a real stomach problem that required medical intervention.

And from then on...I've felt very wary of doctors and their attitudes about mental health.

Bio

[Sandpuff]

I like what you said about believing conversion disorder is very rare.  I think you are right.  Any normal person would get concerned with some of the symptoms we experience.  This is the first time I've looked at this forum for a couple weeks or so, and I am totally involved in something else that is fun and exciting in my life.  But yesterday out of the blue I started feeling some strong vibrating at my waist which I'd never had before and I started getting electric shocks in my hands, and mid-day while typing some things for work my fingers couldn't hit the right letters.  

Now, I can understand if I was going around worrying about that happening and looking for it that maybe it could just possibly happen (not sure how, but I guess anything is possible), but if I'm doing other things, having a good time and not even consciously thinking about what my body's doing, wouldn't it be reasonable to think that it's possibly not from anxiety?  

But I'm ok with where I'm at right now.  I've had the testing and everything they've done has come back normal.  I've decided to not be hard on myself for all the money that was spent for the testing, it needed to be done, and I'm not going to feel foolish anymore.  Whatever it is, it's real, and if no one else knows or thinks that, that's ok for now.  I'm following doctors orders, and out of this whole deal I got some medicine that has helped tremendously with my fatigue.

[doni54]

bump for Katie...............................................