Physical illness caused by psychosocial stress is a clinical dilemma that was known to Hippocrates nearly 2500 years ago. We still don’t have a good solution. Medical clinicians aren’t trained to ask about people’s lives and connect what they find with symptoms. Mental health clinicians don’t see too many patients whose main concern is pain or other body symptoms. But I’m optimistic that in the 21st century will see growing use of good solutions.
Posts Tagged ‘Blind Spot’
Stress Illness and The Health Care System (1)
Thursday, April 22nd, 2010Closing the Blind Spot
Thursday, April 8th, 2010Kauai is a wonderful place to talk about stress, primarily because it is difficult to have any while you are there. Last week I went to the Garden Isle to present my lecture on stress illness to clinicians of a variety of specialties from the Pierce County (Washington State including Tacoma & Mt Rainer) Medical Society. They asked a number of thoughtful questions. They were clearly interested in diagnosing stress illness but felt the need for greater support from mental health clinicians (MHCs) than was available in their community. This referred to the limited number of MHCs and also to MHCs experience evaluating patients with unexplained physical symptoms.
When Stress Causes Pain
Monday, March 29th, 2010I don’t recall ever encountering a conference that included internists, psychologists, psychoanalysts, a gastroenterologist (myself) and a public relations expert all addressing the same clinical issue. Yet this is what came together at UCLA this weekend to address physical symptoms caused by psychosocial stress. Nearly 200 attended and it was remarkable to see the consensus that grew out of such disparate clinical experience.
Stress and Blurred Vision
Thursday, March 25th, 2010For years I would teach medical residents about stress illness by telling the true story of a 16 year old girl who came to clinic with intermittent blurred vision (the full story is in my book). I would ask them to pretend she was in the room and to try to diagnose the cause. They would ask questions about her symptoms and “order” tests and I would give them the results. Very few even got close to the answer though a few, to their credit, were able to look beyond physiology alone and figure out that her vision blurred when she was crying. The crying was from severe depression brought on by regular physical abuse by her father.
5. Medically Unexplained Symptoms in DSM-5
Monday, March 1st, 2010In the last post, I proposed a revision of the Somatoform Disorders section for the next edition of the Diagnostic and Statistical Manual (DSM-5) of the American Psychiatric Association. The DSM-5 group has proposed changing the name from Somatoform Disorders to Somatic Symptom Disorders (SSD) but this term neglects the central role of psychological or cognitive factors. It will also cause confusion with the DSM-5 group’s other new proposal, the term Complex Somatic Symptom Disorder (CSSD). The term CSSD suggests that it is simply a complex form of SSD but that is not at all how the DSM-5 group has defined it. This is why I suggest replacing Somatoform Disorders with Psychosomatic Disorders, not as a diagnostic term (patients consider it stigmatizing) but as a name for this category that is well understood by mental health practitioners, medical clinicians and the public.
Smith and Dwamena (1)
Thursday, January 21st, 2010We have seen that diagnosis and treatment of medically unexplained symptoms (MUS) in a primary care clinic is completely inadequate (see the posts tagged Kroenke and Blindspot). Smith and Dwamena (1) agree. They point out that MUS patients comprise half or more of all outpatients and often are subjected to the risk and cost of “ill-advised lab testing and trial treatments” and seldom receive adequate treatment in primary care. (If the same could be said of, say, diabetes, there would be an international uproar and diabetes isn’t half as common as MUS.)
Kroenke & Mangelsdorff (2)
Friday, January 8th, 2010To continue discussion of the Kroenke & Mangelsdorff research*, let’s begin by looking at what became of all 567 symptoms (in 380 patients). For 2/3 of the symptoms, doctors did diagnostic testing or referred to a specialist. In the other 1/3, no evaluation was done beyond the initial visit. Treatment was recommended for only 55% of symptoms, and this took the form of a prescription in over ¾ of cases. There was nothing to suggest that anyone searched for hidden stresses linked to the symptoms (posts tagged with “Stress History” explain how this is done).
Bringing Vision to the Blind Spot
Sunday, November 15th, 2009The good news is that hundreds of millions of people do not have to suffer needlessly from stress illness. The solution will take time and effort but what needs to be done is clear.
The Blind Spot (3)
Saturday, November 14th, 2009Over nine months, Linda spent 51 days in the hospital for her stress-related illness but two mental health professionals (MHPs) failed to find the cause. Joaquin, age 16, was ill for three months, told his doctors he suspected his pain was caused by stress and was referred to three mental health counselors who failed to find the cause. How can this happen when the issues underlying most cases of stress illness are well known to MHPs?
The Blind Spot (2)
Friday, November 13th, 2009If you developed episodes of chest pain accompanied by shortness of breath, would you call a psychiatrist about it? Of course not, but therein lies another side of the mind-body blind spot in our health care system. In most people who visit a primary care clinician for physical symptoms, the cause is one or more psychosocial stresses entirely appropriate for mental health professionals to manage. Of course it is essential for symptoms to be evaluated by a medical professional first. Ideally though, once medical disease is excluded as a cause of a symptom, patients would be evaluated by a clinician with mental health skills who could then uncover any links to stress. Unfortunately, several problems prevent this from happening in most cases: Read the rest of this entry »
