Here is the question: I have a family member who never seems to have a good day in their life. They’re always complaining of some ailment, and always running to doctors, who usually find no serious medical cause and, unfortunately, have stopped taking them seriously.
Why are some seemingly healthy people preoccupied with being sick? Is this a psychological problem?
I answer: While psychological factors can and do often play a role in health and illness, every patient should have a thorough medical exam to avoid overlooking relevant physical factors underlying their symptoms. With that in mind, let’s look at a few of the more common mind-body syndromes that may confound medical diagnosis and treatment.
The common feature of somatoform disorders is the presence of subjective physical symptoms that suggest a medical illness, but are not fully explained by a known diagnostic category. Somatoform disorders include several subtypes, and the main ones will be described.
Although these tend to be relatively consistent from patient to patient, some patients may show more than one subtype, a combination of subtypes, or alternation between several subtypes over time. It’s also important to realize that somatoform patients truly believe they are ill; they are not consciously “making it up” or deliberately attempting to deceive.
Somatization disorder describes a history of multiple unexplained physical symptoms and complaints, the “always sick” patient described, is a frequent flyer at multiple doctors’ offices. Symptoms in somatization disorder may closely mimic known medical syndromes or they may be atypical or frankly bizarre in quality, location, or duration.
They may wax and wane over time in response to life stressors, and there is often a dramatic flair to the patient’s overall personality and behavior. The underlying unconscious motivation is frequently inferred to be a quest for support, reassurance, manipulation of the affection of significant others, and/or the satisfaction of dependency needs by reliance on caretakers, or the protective role of medical authority.
In conversion disorder, the essential feature is the presence of sensory or motor deficits that appear to suggest a neurological illness or injury, yet the pattern of symptoms typically fails to follow known neuroanatomical patterns. The unconscious motivation typically involves the attempted resolution of psychological conflicts over dependency, hostility, or guilt by channeling them into physical impairment.
For example, paralysis of an arm may neutralize fears of acting on an aggressive impulse, while pelvic pain or anesthesia may be utilized to squelch conflicts over sexuality.
The conviction that one has a serious illness or injury, despite numerous medical pronouncements to the contrary, is the defining characteristic of hypochondriasis (also known as illness anxiety disorder). Unlike the plethora of symptoms seen in somatization disorder, these patients tend to focus on one or a few chosen symptoms and remain preoccupied with them, although the focus may shift over time from one symptom or disorder to another.
Unlike conversion disorder, there may be no actual observed or experienced impairment per se: It is the fear of hidden dire illness that is the problem. Often, the unconscious motivation involves a deflection of anxiety away from issues of broader psychosocial concern, such as career or relationships, to focus on a more objectifiable source of concern in the form of physical symptoms which, for many people, carry less stigma than “mental problems.”
Factitious Disorder and Malingering
Factitious disorder is diagnostically separated from somatoform disorders because it encompasses the conscious, deliberate feigning, manipulation, or production of physical signs and symptoms. These individuals may go to great lengths to make themselves sick, sometimes ingesting or injecting toxic substances to induce infections, fevers, cardiac arrhythmias, or seizures.
Why would someone do this to themselves? We learn as children that being ill typically elicits care and sympathy from authoritative others, but most of us mature into independent, self-sufficient adults.
However, the individual with factitious disorder tries to replicate this sick role, with all the attendant care, solicitous concern, and relief from responsibilities that this entails, even at the price of substantial costs in health, finances, or freedom.
In many cases, there also appears to be great satisfaction, perhaps only partly unconscious, derived from manipulating the medical system and “fooling the experts.” Some individuals may seek to project a martyred image of the selfless caretaker to a sick child or other dependent person by deliberately inducing symptoms in their ward, in which case this becomes a factitious disorder by proxy. But the basic motive is the same: to accrue attention, admiration, and devotion from medical authorities and others.
Malingering also involves the deliberate faking or production of medical or psychiatric symptoms, but here there is a definite utilitarian motive, usually either to No. 1 avoid some unwanted consequence, such as evading a criminal penalty or military conscription, or No. 2 to acquire some undeserved reward, such as filing a fraudulent insurance claim or pursuing a bogus personal injury lawsuit.
As distinct from the diagnostically ambiguous presentation of the somatoform disorders, in psychophysiological disorders (also known as psychological factors affecting medical conditions), there exists an actual medical disease entity, but stress-related factors:
- precipitate the onset of
- worsen the severity of
- lengthen the course of
- slow or inhibit the recovery from, the illness in question.
Since stress is ubiquitous, there is virtually no physiological system in the body that cannot be affected by psychological factors, although some medical illnesses appear to be more stress-responsive than others. The shortlist includes essential hypertension, gastric ulcer, ulcerative colitis, irritable bowel syndrome, rheumatoid arthritis, bronchial asthma, hyperthyroidism, fibromyalgia, chronic fatigue syndrome, migraine headaches, tension headaches, ectopic dermatitis, type-A personality pattern, and certain types of infectious disease and immunological disorders.
For any of these mind-body syndromes, some people may be more genetically, physiologically, and/or emotionally predisposed than others, and treatment may include both medical and psychological approaches. But it is crucially important for doctors of any specialty to treat these disorders, and the patients who present them, with the optimal combination of science and compassion that good clinical care demands.
Note: Information provided herein is for educational purposes, and is not intended to provide individual clinical or forensic advice or opinions. For such cases, always consult with a qualified legal, medical, or mental health professional.
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