Why Don’t Doctors Want to Hear About Psychosomatic Problems?

It happens all the time: symptoms without lesions. You feel awful, have pains here and there, but physicians can’t find anything organically wrong with you.

Even worse, your internist or family physician, for lack of anything better, refers you to a psychiatrist. Psychiatrists hate these patients. You turn up in their office with a complaint of chronic chest pain, with no organic findings.

The psychiatrist’s unspoken but heartfelt response, “What am I supposed to do about this?” You apparently don’t have any other psychiatric illness, no depression, no psychosis, anxiety yes but not disabled. The consultation will be a waste of her time, and a waste of yours.

This subject of symptoms-without-lesions is back on the medical radar, after decades of not being discussed. Medical schools are increasingly offering programs in “communication,” in the hopes that physicians who communicate better will be able to deal better with patients like this. But medical students normally hate all this “communication” stuff and see it as a complete distraction from the business of organicity, which is what they’re in medical school to learn about.

The realization is dawning that “functional” patients are costing the system an enormous amount of money. In general medical practice, up to half of all patients may have nothing organically wrong with them. Yet they are the objects of cover-your-ass half-million-dollar investigations. And then the patients move on and the investigation begins all over again. Nothing is ever found, but it runs up enormous insurance bills.

Yeah, functional is back on the radar.

It is not that doctors are unfamiliar with symptoms without lesions, which are as old as medicine itself. Over the years, different specialties have developed different terms for describing them.

In ear-nose-and-throat medicine, dizziness is a huge problem. Patients who don’t have an organic explanation of their unsteadiness are called “avestibular,” meaning there’s nothing wrong with the vestibular system in the ear that controls balance.

In psychiatry, women with unexplained somatic symptoms were, until 1980, described as “hysterical,” later “psychosomatic,” and ditched as quickly as possible. Hysteria as a diagnosis was abolished in psychiatry with DSM-3 in 1980. And one rarely hears psychiatrists today using the “h” word. (This is partly a result of the declining influence of Freud’s psychoanalysis, with “hysteria” a favorite diagnosis.)

Neurologists for decades have called these patients “functional,” originally meaning a disturbance of function but quickly reaching code-word status for non-organic.

“Non-organicity” has become a recent across-the-board favorite. The meaning is clear.

What is the problem? The brutish, unfeeling doctor unwilling to deal with patients who cannot be pigeonholed into neat categories of organic diagnosis. No, not at all. Medicine has been familiar with this for two centuries.

It’s not that physicians are uncomfortable around non-organicity. Their desire to turn these patients to another colleague is born of another cause entirely: The only thing that works in dealing with non-organic patients is the gift of time.

You’ve got to give them the gift of consultation time. Nothing else works. No meds, no physio, nada. You’ve got to spend time with them, let them tell their stories, and share the feeling that a sympathetic medical ear is attending to their woes. And, guess what? They slowly get better.

Who knew? Medical insiders have long known this, and ever since the “Patient as a Person” movement in the 1920s, this has been bruited around the seminar rooms.

But think of the implications for a busy medical practice of giving each non-organic patient 45 minutes of your time regularly. This would work for the patient, but your income would collapse. This simple economic reality is what prevents many physicians from undertaking the main known effective treatment of the functional patient: the gift of time is horribly expensive for the system because if you don’t give it, the patients doctor-shop; and it is ruinously costly for individual doctors, insightful and understanding though they may be, because insight here can lead to economic catastrophe.

This is probably the biggest systemic problem in medicine. The discipline’s collective embarrassment, not communication issues, is what prevents its discussion.