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Mental health and what is normal.

Are Your Physical Symptoms in Your Head?

Illogical thinking by medical doctors.

Unexplained physical symptoms have been part of the human experience for as long as there have been humans.

A great deal of ingenuity has gone into explaining and treating them. The shaman assumed the symptoms were caused by angry spirits, the pagan priests by punishing gods, and monotheistic Job just gave up looking for explanations and accepted medical afflictions as part of God's plan.

Biological models have been around for at least four thousand years. The most popular and enduring theory invoked an imbalance of the bodies four 'humours' or fluids—blood, phlegm, black and yellow bile. The smartest doctors on earth believed this completely wrong but plausible theory from the time of Hippocrates till the mid nineteenth century.

The enormously powerful tools of scientific medicine have since explained many previously unexplainable physical symptoms- sometimes even to the cellular level of understanding which are the specific causative genes and proteins involved in producing them.

But the explanation for many physical problems remains elusive. And doctors don't like unsolved mysteries. There is a strong tendency for the (often male) doctors to tell their (often female) patients that an unexplained physical symptom is 'in her head'.

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In an article published last year in 'Medical Hypotheses', Laurie Thomas says that doctors making this kind of diagnosis are committing a serious error in logic that can have terrible medical consequences for their patients.

Ms. Thomas sent me this email: "The problem usually goes like this: A patient has symptoms and seeks medical help. The doctor has no luck in finding a physical disease that would explain the patient's symptoms and is tempted to assume, without evidence, that the medically unexplained symptoms are due to some undefined psychological problem that is 'in her head'."

"What's wrong with this? The doctor is incorrectly stating that there is a cause-and-effect relationship between the patient's mental and physical problems—despite the lack any scientifically valid proof that there is a mental problem or that it is causal. It is the logical fallacy of 'circular reasoning' to assume that a patient with unexplained physical symptoms must have a causative mental disorder. The doctor has just begged the question by assuming the very thing that he should have to prove."

"Getting an illogical and essentially meaningless 'it's all in your head' diagnoses can create two types of serious problems for the patient- the underlying medical illness may go undiagnosed and untreated and/or being inaccurately labeled as mentally ill may lead to unnecessary and sometimes harmful psychiatric treatment."

Thank you, Ms. Thomas, for pointing out how illogical are the physicians who jump to a mental disorder explanation when they can't pin down a clearly defined medical disorder.

This brings up the important question: Is it ever okay for a doctor to refer a patient to a mental health practitioner to diagnose and treat physical symptoms?

Yes, of course, psychiatric care can be very helpful—but only under two very specific circumstances. First, some mental disorders cause previously unexplained physical symptoms that can be readily explained once the proper psychiatric diagnosis is made.

Best example: the hyperventilation typical of panic attacks presents with dizziness, pounding heart, shortness of breath, and a feeling of pins and needles in the fingers and toes. I have seen dozens of patients with these previously unexplained physical symptoms who had received extensive, unnecessary medical testing because the proper diagnosis of Panic Disorder had been missed. Depression also frequently presents first with physical symptoms that are misinterpreted.

Second, some patients with unexplained physical symptoms benefit greatly from a cognitive/behavioral therapy that is targeted to help them cope better with the day to day experience of their symptoms—even if their ultimate cause may never be understood.

But the patient has to want the referral to a mental health professional—to see it as a gift, not a rude dismissal. Too often, 'it is in your head' is in fact (and is felt by the patient to be) an insult occasioned by the medical doctors' frustration at not finding a definite cause and not having an effective cure for the problem.

'Somatic Symptom Disorder' is an overly inclusive diagnosis of mental disorder that was introduced by DSM 5 to describe patients who doctors judge to be too worried about their physical symptoms. It will do much more harm than good because it explains nothing, was far too loosely defined, and depend's on the subjective and arbitrary judgments of doctors who have no reliable way of judging what constitutes 'too much' worry. 

'It is all in your head' is no more helpful an answer to the patient's puzzling and troubling question than were 'the spirits are angry' or 'the gods are punishing you' or 'your four humors are unbalanced'. Better to say, 'we don't know what is causing your symptoms, but will do our best to find out and in the meantime will help you cope with them."

Many patients have physical symptoms that defy explanation, even after the most thorough of medical and psychiatric evaluations. It is best for doctor and patient to accept this reality and focus attention on doing everything possible to reduce the distress and impairment caused by the symptoms.

Allen Frances, M.D., was chair of the DSM-IV Task Force and is currently professor emeritus at Duke.

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