A while ago I posted a piece on medically unexplained symptoms.1 This was in response to an article by Louise Atkinson in the Daily Mail on chronic back pain and how this might be caused by stress and tension rather than any underlying physical problem.2
One of the reasons I wanted to write this current post is that I think there is still a great deal of misunderstanding when it comes to terms like ‘medically unexplained symptoms’ (which has the rather unfortunate acronym ‘MUS’), and ‘psychosomatic’. To start with, strictly speaking ‘MUS’ and ‘psychosomatic’ are not synonymous, even though there seems to be tendency to treat them as if they were. In fact, ‘psychosomatic’ disorders could be seen as a subset of the much broader category ‘medically unexplained symptoms’. According to Tim Webb in an article in Therapy Today, such symptoms account for around 33% of presentations in GP surgeries, and over 50% of presentations in some hospital outpatient clinics.3
At the same time though, psychosomatic symptoms should not be confused with conversion symptoms. One of the aims of this current posting is to explain why these differences are important; both in terms of understanding such symptoms, and in terms of their treatment.
Another misconception, which is unfortunately probably much commoner than the fine distinctions between MUS, psychosomatic and conversion symptoms, is the idea that any physical problem that might be attributed to a person’s psychology must be ‘unreal’, ‘all in the mind’. This idea seems rather peculiar, bearing in mind that there is nothing in the terminology which suggests that such symptoms are anything but physical. For example, the term ‘psychosomatic’ simply refers to the relationship between psyche (mind) and soma (the biological organism, or, in more common usage, the body). And the term ‘medically unexplained symptoms’ simply means just that, i.e. that there is no medical (or more precisely, biological) explanation for the person’s symptoms. In spite of this, many patients get very upset if their GP suggests that there might be a psychological explanation for their (very real) symptoms.
From a psychoanalytic position, there are two particular types of ‘psychosomatic’ (using the term rather loosely for the time being) symptoms that are of interest: those that can be attributed to repression and those that cannot. With regards to the former, these are usually treated (both theoretically and clinically) as symptoms of psycho-neurosis (to use Freud’s original terminology); whereas the latter tend to be associated with the somewhat contentious clinical category of actual neurosis.
If we start with the psycho-neurosis, here we are looking at classic conversion symptoms, e.g. fainting, vomiting, loss of voice, etc. These are the product of a symbolic conversion, and are the effect of repressed, i.e. unconscious, desires. Freud’s case histories are full of such examples and, in fact, it could be argued that the phenomena of conversion was one of the driving forces behind his development of psychoanalysis.
Freud’s ‘Dora’ case contains a number of instances of conversion symptoms, including aphonia (loss of voice), coughing, and fainting.4 With regards to Dora’s aphonia, Freud attributes this to her being apart from the man she loves, Herr K (a family friend whose wife Dora’s father is having an affair with). Being unable to talk with one another, they would correspond by letter instead. Freud argues:
Dora’s aphonia, then, allowed of the following symbolic interpretation. When the man she loved (Herr K) was away she gave up speaking; speech had lost its value since she could not speak to him. On the other hand, writing gained in importance, as being the only means of communication with him in his absence.
The key point here, according to Freud, is that the loss of her voice symbolised, for Dora, her separation from, and thus her desire for, the man she loved.5
Not all psychosomatic symptoms are the result of symbolic conversion however. In other words, the physical (somatic) symptoms are not the result of repressed desires. Rather, they are a direct, physical expression of the individual’s distress, without any repression.
Technically speaking, in fact, only these types of symptoms, i.e. those that have not been subjected to repression, deserve the name ‘psychosomatic’. Many psychoanalysts have argued, and still argue, that psychosomatic disorders are a modern day term for what Freud called the ‘actual neuroses’, within which he included neurasthenia, hypochondria and anxiety neurosis. Irritable bowel syndrome (IBS), ulcerative colitis, and even sudden cardiac failure, could all be seen as examples of psychosomatisation. Things get a bit more tricky with conditions such as chronic-fatigue syndrome (ME) because some have argued that this is a modern day form of hysteria, in which case we are looking at (symbolic) conversion symptoms.6
A particularly controversial example of (potential) psychosomatic symptomatology is that of chronic pain, which Webb discusses in his article:
For decades we have known that if clinical depression and painful injuries or illnesses co-exist there is a chance that the one will exacerbate the other. The depressed brain will often register pain that is mild to moderate and occurs occasionally as being severe and lasting for much of the time.
We know that there are typical changes to the pattern of pain in many such cases. Pain is worse in the morning; spreads into neighbouring areas of the body; worsens in direct or indirect proportion to mood; and can be felt in unconnected parts of the body simultaneously.
This example raises a number of issues regarding physical pain and its relation to psychology. One of these is whether chronic pain should be regarded as psychosomatic at all. Webb appears to be arguing that when a person is depressed, what a ‘normal’, i.e. non-depressed person, would consider to be mild to moderate pain that only occurs occasionally, is experienced as severe and ongoing.
Does this mean that depression causes chronic pain? In the article I referred to earlier by Louise Atkinson, she was discussing a book by Nick Sinfield in which he argued that a great deal of back pain was caused by the stresses and tensions of modern life. If Sinfield is to be taken seriously then it would seen that psychology (and, more broadly speaking, lifestyle) is a major contributor to pain.
And just to complicate things even further, somatisation is also fairly common in psychotic illnesses such as schizophrenia. Apart from anything else, this raises the question as to whether we should be redefining ‘actual neurosis’ as psychosis. However, what it also shows is that symptoms should not be equated with the underlying clinical structure.7
If we are prepared to accept that at least some physical symptoms have a psychological cause, then it follows that they can be treated psychologically. However, things are not quite that simple. As argued above, not all ‘psychosomatic’ symptoms have the same cause. Or, more precisely, the same symptoms may have different causes.
In terms of psychoanalytic treatment it is helpful to differentiate between those symptoms that are the result of repression and those which are not – even though, in some cases these may be exactly the same symptoms. The reason that such a differentiation is important is that the way a therapist or analyst would work with repression is somewhat different to the way he or she might work with someone whose symptoms are not the effect of repression.
Of course, the first thing in therapy would be to establish whether indeed the person’s symptom were the effect of repression or not. This would involve exploring, in some detail, the individual’s history; and, linked to this, the history of their symptoms.
To illustrate some of difficulties with identifying and working with people with psychosomatic symptoms I would like to end by giving a clinical example from my own practice. A number of years ago I met someone whom I began to think was exhibiting a number of psychosomatic symptoms. This was before I realised the term ‘psychosomatic’ was problematic at all. I then spent some time working with this client and in doing so he revealed certain aspects of his personal history which led me to confirm my initial hypothesis. He had suffered from ulcerative colitis for number of years, culminating in the removal of his bowels. He then suffered from a number of muscular problems which recently culminated in a ‘diagnosis’ of rheumatoid arthritis. He has also experienced liver problems and a number of side effects from the various medications he has been taking for his arthritis and other physical conditions. He made it clear throughout the work with me that he thought his problems were genetic and biological, which is why he had agreed to surgery and sort medical advice in the first place.
Tragically this client died before I had the chance to develop the work. and before he had the chance to possibly gain some insight into his situation.
This man had spent virtually the whole of his adult life (he was approaching forty when he died) in and out of hospital for various physical problems. He had also experienced a lifetime of abusive relationships – including physical violence, starting with his father, then his school teachers, and in adult life with a number of ‘friends’. His father suffered from rheumatoid arthritis, and he believed that this was something he had inherited – in spite of the fact that when he had the operation for the ulcerative colitis he was told that it would seriously affect his immune system.
It is undoubtedly possible to make a case that ulcerative colitis was the somatic representation of something in this person’s sexual history; that what could not be spoken in words was ‘spoken’ through the bodily organs. I think this would be misplaced. The man certainly had a sexual history, fragments of which were beginning to emerge, and which included a large amount of physical and psychological abuse. But in my view this abuse (trauma) stayed at the level of the somatic; in other words, it was never subject to repression. I say this because this person seemed to have no difficulty at all in recounting the stories of abuse; and perhaps it is important to add that he did not have prior experience of analytically informed counselling or psychotherapy, and thus was unlikely to be acceding to any supposed expectation on my part that he ‘should’ be talking about abuse because he was in therapy. What also struck me was the sense of rapture with which this man seemed to be experiencing in his suffering, which is also a sign that we are dealing with something other than (psycho) neurosis.
Hopefully, this vignette illustrates several important points. Firstly, it is essential to gain an understanding of the individual’s psychological history before jumping to any conclusions regarding the nature of their symptoms. With this particular client, he might have been saved a great deal of needless surgery and medical treatment if someone had taken the time to find out more about his background. Secondly, it is essential to understand the mechanism behind such symptoms; in this particular case this was not repression but a direct somatisation of sexual trauma.
And thirdly, I think it illustrates a common difficulty in working with people who are exhibiting such symptoms, which is a strong resistance to any notion that their problems might be, in some way, ‘psychological’ and therefore, ‘unreal’. I can only reiterate at this point that nothing could be further from the truth. Such symptoms are very real indeed; the mystery is how something from a person’s psychological history manifests itself in their biology.
- http://www.therapeia.org.uk/wp/blog/2012/10/17/psychotherapist-in-guildford-area-chronic-pain-all-in-the-mind-2/ [↩]
- http://www.dailymail.co.uk/health/article-2218216/Back-pain-mind-A-provocative-new-book-suggest-physical-problems-cause-backache-emotional-tension.html)) I have also published a paper on psychosomatic disorders which explores the whole field of medically unexplained symptoms from a psychoanalytic perspective. ((http://www.therapeia.org.uk/documents/Psychosomatics.pdf [↩]
- http://www.therapytoday.net/article/show/1843/ [↩]
- Freud, S. (1905) Fragment of an Analysis of a Case of Hysteria. In: The Standard Edition. London, Vintage/The Hogarth Press, pp.1-122. [↩]
- Except that further analysis revealed, belatedly as it turned out for Freud, that Dora’s real object of desire was Herr K’s wife, i.e. her father’s lover. [↩]
- See for example Elaine Showalter’s study of modern day ‘hysterical epidemics’, which also include alien abduction, Gulf War Syndrome, and recovered memories. Showalter, E. (1997) Hystories: Hysterical Epidemics and Modern Culture. New York, Picador. [↩]
- For a more detailed discussion of Lacanian clinical structures please see my recent posting on the DSM V http://www.therapeia.org.uk/wp/touching-the-real-2/does-mental-illness-exist-2/ [↩]