Are “Psychosomatic” Illnesses a Thing of the Past?

In a recent commentary in the Lancet, Chloe Saunders and colleagues made a compelling point: “We suggest it is time to break taboos based on a dualistic understanding of physical versus mental illness.”

In the article, in which the authors discuss Long Covid, there is a strong argument against the notion that the mind and the body are separate entities and that any co-occurring bodily and psychological symptoms must be solely a result of the mind impacting the body. This got us thinking: Is it time to do away with the notion of psychosomatic illness altogether?

“Psychosomatic” is a term usually meant to imply that a person has psychological symptoms that in some way cause physical symptoms. As a result, there is a general impression, even among clinicians, that psychosomatic illnesses are essentially in the patient’s head. And yet, “psychosomatic” illnesses are quite common. One estimate suggested that up to one-third of patients visiting neurology practices have “psychosomatic” illnesses, in the sense that they have physical symptoms that are poorly explained by current diagnostic tools. While doctors often feel that they don’t have the tools to deal with patients with no obvious physical diagnosis, it is still the case that a substantial minority of people complain of physical symptoms that are never explained using available diagnostic tools like blood tests and imaging studies. Those are the illnesses that are commonly referred to as psychosomatic. Medicine is often not very adept at dealing with these problems.

And then there was the 2012 case of Le Roy, New York, in which a group of socially-connected young women all fell suddenly ill with a combination of psychological and neurological symptoms, which seemed to come and go. Some of the young women twitched and fainted; others couldn’t control their outbursts in class. Others even had what appeared to be seizures. No one has been able to explain what this was about, but many argued that these were simply “psychological” symptoms that were manifesting in the body and that the girls “uust” needed some psychotherapy. In fact, psychotherapy or some other behavioral intervention might be indicated in cases like these, which just means that that the symptoms are at least partially involving the most complex organ of the body, the brain.

There are several problems with the “psychosomatic” model of illnesses. For one thing, there is the fact that separating brain and body in the case of “mainstream” illnesses does not make sense. The brain is involved in everything your body does and feels, so to suggest that some illnesses are purely in the mind and some are purely in the body is not really accurate. Even mental illnesses like depression involve real, physical symptoms, like loss of appetite and low energy, that speak to the fact that disruptions in our brain can obviously cause disruptions in our bodies.

The other problem with calling something “psychosomatic” is that it gives clinicians a “way out” when they don’t know the answer. A patient has mysterious neurological symptoms that don’t cohere into a diagnosis using the tools we currently have. Or there’s a cluster of symptoms in several patients that can’t be explained by environmental causes or an outbreak of a known infectious disease. Just because we don’t know the answer doesn’t mean there isn’t an answer. This should go without saying: there’s a lot we don’t understand about the brain. Practicing some humility about this fact and recognizing that what we don’t know doesn’t mean the patient is making it up (or not experiencing “real” physical symptoms) would go a long way. Undoing the brain-body dualism that tends to be employed in medicine would help, too. If physical symptoms that are relatively unexplained are accompanied by psychological symptoms, this does not mean that the physical symptoms are “not real,” or all in someone’s head, it just means that we don’t fully understand the mechanism of whatever we are currently dealing with.

Even the phrase “all in the head” is to be avoided because it implies that symptoms that arise in the brain are somehow not “real.” Once again, it is important to remember that every organ of the body is controlled by the brain–our hearts only beat and our lungs only draw breath because the brain signals them to do so. So, in a sense, all illnesses are, in part, “in the head.”

When in doubt, repeat the mantra: Just because we don’t know the answer doesn’t mean there isn’t an answer. If the pandemic has taught us anything, it’s that dealing with uncertainty in health and medicine is challenging, and most professionals are not prepared for this. But it doesn’t mean we should give up, especially as new challenges, such as Long Covid, continue to crop up and complicate our traditional understanding of how physiological illnesses work. We must learn that the brain and the body are always connected and that sometimes we might be faced with strange complaints and situations that we don’t fully understand. Practicing empathy, remaining humble, and asking good questions will go a long way in these situations.