"Maybe this is all from anxiety."
"You think? I mean, yeah, I am anxious, but it feels more like it's from the symptom than causing the symptom."
My colleague and friend—and physician—and I were discussing the sudden onset of intense nausea I'd started to experience roughly three weeks after I'd been released from the hospital, as I detailed in a previous post, Overcoming The Fear Of Death. After a pulmonary embolus, I'd been left dealing with a clostridium difficile infection, for which I was taking Flagyl, a drug known to cause nausea. The only problem with concluding that the drug was the cause was that I'd been on it nausea-free for a full week already, not to mention I'd been on it previously without nausea for a full course the first time we'd treated the clostridium difficile infection (I'd relapsed, as commonly happens). Why after a previous full course and then seven days would it suddenly cause this side effect?
It wouldn't. Side effects from medications almost always manifest as soon as a drug reaches its therapeutic level in a person's bloodstream, if not sooner. This is rarely more than a few days for antibiotics.
The nausea was so intense I could hardly move. When I'd been a child and had felt nervous, I'd sometimes develop an upset stomach—an extreme version of "butterflies"—but the intensity of what I was feeling now was several times what I'd felt then-or since. In the past, I'd always been able to tell how my nervousness was connected to whatever minor physical symptom it had produced, whether that symptom was sweating, flushing, palpitations, or those classic "butterflies." But I sensed no connection between my anxiety and my nausea at all.
But I told my friend and doctor that I was open to the possibility that he was right. He suggested I talk with a psychiatrist who specialized in anxiety disorders, which I did the next day. He, in turn, diagnosed me with mild PTSD (as I detailed in Overcoming The Fear Of Death) and put me on clonazepam, a long-acting anti-anxiety medication.
My nausea vanished after only one dose. I was astounded. I thought I'd known myself and my body's reactions intimately well and yet this took me completely by surprise. That clonazepam had resolved my nausea proved to me the cause of the nausea had indeed been anxiety.
What is somatization?
Somatization is defined as the tendency to experience psychological distress in the form of physical symptoms. Astoundingly, in one study of 1,000 patients presenting over a three-year period with 567 new complaints of 14 common symptoms (including chest pain, fatigue, dizziness, headache, edema, back pain, shortness of breath, insomnia, abdominal pain, numbness, impotence, weight loss, cough, and constipation), a physical cause was found only 16% of the time. This doesn't mean that only 16% of all these complaints had a physical cause and the other 84% had a psychosomatic cause; rather, it means that 84% of the symptoms had no known physical cause. We still don't know what causes migraines, for example, but that doesn't mean we should conclude migraines have only a psychological cause.
On the other hand, another study suggested that as many as 20% of patients who present to primary care doctors are experiencing physical symptoms that have a purely psychological cause. What's fascinating to me about this aren't the various characteristics that circle somatization-some of which include a predisposition to amplify symptoms, the potential benefits of playing the sick role, the emotional effects of trauma, and denial—but that somatization happens at all.
On one level, of course, the brain and the body are intimately intertwined, the brain sending out innumerable signals and instructions to the body every second, the body receiving them and sending back perhaps just as many. In Buddhism, the mind and body are considered "two but not two," a concept meant at least partially to reflect their complex interdependence. Further, evidence is beginning to mount that our physical brains and our subjective experience of them—that is, our minds—are also "two but not two" (as I discussed in a previous post, The True Cause Of Depression), so the idea that an emotional disturbance could be translated into a physical symptom shouldn't be too surprising.
And yet it often is. I've not only read about conversion disorders (where the pain from an intense emotional trauma too awful to face becomes "converted" into a paralyzed limb, a paralyzed voice, or, paradoxically, an inability to stop moving a limb or limbs), I've seen and cared for them myself. And yet when my nausea was shown to have a purely psychological cause, I still had a hard time accepting it. It took incontrovertible proof to bring me to acceptance. But then from acceptance came awe—awe at the power inherent in my own mind.
Why, I chastised myself, would I have thought an anxiety as intense as mine would have been confined only to my mind? I, who have a greater understanding, both as a doctor and a Buddhist, of the interconnectedness of mind and body than most people should have known better. I suppose it only goes to prove, once again, that intellectual understanding is one thing and experience quite another.
Now I'm not only more cognizant how often symptoms I see in my patients are likely psychosomatic but more sympathetic to their resistance to that idea. Couple those two facts with a third, that most physical symptoms do have a physical cause, and the business of sorting out any symptom shows itself to be a tricky one indeed.
So tricky that I worry when patients try to sort it out themselves without a doctor's help. The chest pain you're having could be due to stress—you and I may both want to believe it is (you especially, explaining why you delayed coming to see me until it passed a certain threshold of intensity), but it could just as easily be a heart attack. The specific details surrounding it need to be pored over carefully to distinguish between the two. No degree of certainty that you "know your own body" can deliver the diagnosis definitively—a refrain I hear many times which, though sometimes accurate, more often in my experience is not.
Yet even when a patient accepts their symptom is being caused by an emotion—an exceptionally difficult barrier to surmount—the trauma that caused the symptom in the first place is often shown to be so ugly that both patient and doctor can readily understand why the patient's mind converted it into a physical symptom in the first place. Even the mind itself believed the emotional trauma to be easier to handle that way. Physical symptoms often get better with a pill. Emotional traumas often take years to heal, if even then. The technology we have to heal the scars caused by some traumas—as advanced and helpful as psychology can be—still lags behind the technology we have to treat ailments with purely physical causes.
But we shouldn't be discouraged. We may all experience psychosomatic symptoms to some degree, but when our symptoms are shown to be so and we accept it, that acceptance becomes the most important step toward resolving them. After all, how can we find a contact lens we lost by looking near a lamppost when we lost it in the shadows? The real work begins, of course, once we start looking in the right place. Dealing with somatization only requires us to bring to the table one quality: courage. (Though here I have to sound an important caution: when faced with a symptom they can't readily explain by physical means, many doctors will reflexively turn to somatization as the explanation without bothering to unearth what experience or emotion might be causing it, as I wrote about in a previous post, When Doctors Don't Know What's Wrong).
I was on clonazepam for several months and then gradually tapered off it as the proximity of my brush with death receded. I haven't yet resolved the questions it raised but am no longer plagued by the immediacy of my fear of death-and therefore no longer by the intense anxiety it stirred up. But every day since, I've chanted with the determination to know the truth: are we eternal, luminous beings whose lives continue in some real way, incarnation after incarnation, as Buddhism teaches, or not? I fully recognize that I may spend the rest of my life trying to discover the answer and in the end still not discover it, either because of a failing in myself or because the answer I'm looking for isn't actually there. But what else is there to do—what else is there for any of us do—but battle our demons to the death, either theirs or ours?
If you enjoyed this post, please feel free to explore Dr. Lickerman's home page, Happiness in this World.