Monday, October 27, 2008

Somatization

I haven't yet studied the theories of the etiology of somatization, but I'd like to put forth a few ideas of my own.

The term "somatic" simply means "of the body", so what I'm referring to are bodily symptoms that cannot be explained easily by bodily findings. "Psychosomatic" may be more accurate, as nearly all physical symptoms are actually "somatic"--only people with phantom limbs feel pain outside their bodies, for example. Somatoform disorders are those where mental disorders present largely as physical complaints. There are complex syndromes like somatization disorder that require multiple different types of complaints from pain to GI to neurologic, etc; conversion disorder, where neurologic findings don't make anatomical sense and don't have an organic basis that can be found; pain disorder, body dysmorphic disorder, hypochondriasis, and others.

There are people who don't necessarily fit these categories, but just have a lot of "somatic" complaints, especially pain. Patients with lipomas who complain of extreme pain, patients who have a ton of "allergies" to medications (like palpitations from a vaginal metronidazole preparation?), etc. I've seen a few men with small hydroceles/spermatoceles (no redness, no swelling, no pain on palpation during my exam) who complain of severe, disabling pain; a few women with small ovarian cysts, non-ruptured, who complain of the same. Some of these patients have a small physical finding that seems to bother them so much that they have constant pain and disability from a condition which should only rarely be painful. Is it anxiety? I'm not sure.

Sometimes, of course, there's an inciting trauma or injury that induces chronic pain or symptoms. Acute back pain has a pretty high chance of leading to chronic back pain. I've seen multiple patients who had car accidents and end up with years of pain afterward. Why is it that children break their bones all the time and only rarely end up in chronic pain, yet so many adults end up with unending pain?

Is it that having pain for too long leads to chronic pain? The body can become conditioned to things, so perhaps pain leads to more pain. Of course, pain is a poor example, though one of the most common, because pain is neurologically mediated. Other conditions, which have a lot of crossover between "physical" and "mental", such as irritable bowel syndrome, have some reliable clinical findings and may have more organic basis than was originally thought.

Is it possible that some of these syndromes have an organic basis? After all, if thoughts ultimately come from release of neurotransmitters and electrical pulses, then technically everything we think, feel, and do is "organic". The line is pretty hard to see.

Many of these conditions, even if they are ultimately found to have a neurologic basis, are still intimately tied in with psychiatric disorders. Multiple sclerosis patients often have comorbid depression, for example, and experience symptoms when under stress. In my very limited experience, many of these "hypersomatic" individuals, the ones who react badly to most medicine, the ones with chronic vague symptoms and normal physical exams (not the ones looking for drugs, either), often seem unhappy. My life sucks because of this knee pain. I can't work because my back pops because I was tackled at the age of 10. My marriage ended, but now I have 10/10 pain from a bruised finger. Some patients end up on disability, but still aren't happy and have symptoms. One man had vague symptoms every time he walked into his apartment--and then would come to the emergency room for a nosebleed which had stopped, nausea that didn't start until after leaving the apartment (but must be related), etc. He never found it strange that no one else got sick while inside his apartment, even when spending significant time there; he only knew that he felt extremely ill, with widely varying complaints, and his symptoms were not going to stop until he got a new apartment.

Is there a link between unhappiness and somatic complaints? Intuitively, I would say yes. I haven't looked up any data tonight, but I wonder how many happy people suffer from chronic pain or chronic complaints. Or if they have chronic pain, they attempt to go about their life, not spend all their days in the emergency room.

Of course, illness can make you unhappy, which can make your illness worse, and make you more unhappy. Perhaps the answer is just to sing "Don't Worry, Be Happy" all the time. Except that song really doesn't make ME very happy, but oh well.

1 comment:

Carrie said...

TS, if you haven't already, you should read Anatomy of Hope by Jerome Groopman. The book addresses examples of how a positive/negative mindset can influence the course that an illness takes. Some of the stories were pretty incredible, i.e., one man coming back from "terminal" illness.