An experiential mind–body approach to the management of medically unexplained symptoms

Summary

This article outlines an experiential mind–body framework for understanding and treating patients with medically unexplained symptoms. The model relies on somatic awareness, a normal part of consciousness, to resolve the mind–body dualism inherent in conventional multidisciplinary approaches. Somatic awareness represents a guiding healing heuristic which allows for a linear treatment application of the biopsychosocial model. The heuristic acknowledges the validity of the patient’s physical symptoms and identifies psychological and social factors needed for the healing process. Somatic awareness is used to direct changes in coping styles, illness beliefs, medication dependence and personal dynamics that are necessary to achieve symptom control. The mind–body concept is consistent with and supported by neurobiological models which draw on central nervous system mechanisms to explain medically unexplained symptoms. The concept is also supported by a recent hypothesis concerning the role peripheral connective tissue may play in influencing illness and well-being. Finally, somatic awareness is described as having potential to enhance understanding and conscious use of inner healing mechanisms at the basis of the placebo effect.

Introduction

Medically unexplained symptoms (MUS) are defined as physical symptoms that prompt the sufferer to seek health care but remain unexplained after an appropriate medical evaluation [1]. Symptoms that are not explained from a medical standpoint are generally assumed to be psychological rather than psychobiological in origin. This assumption is especially troublesome for doctor–patient interactions because doctors come to view the symptoms as “psychiatric” while patients resent the “all in your head” implication. Both parties need a shared or common conceptual framework for understanding and working together in the management of the symptoms.

Patients with MUS represent the some of the most frequently occurring conditions seen in primary and specialist care [2]. Common symptoms/syndromes include non-cardiac chest pain, chronic headache, fibromyalgia, dizziness, fatigue, anxiousness, repeated infections, tinnitus, low back pain, insomnia, and depression. The symptoms constitute a significant management issue. Patients with MUS are often extensively investigated, over-referred and treated with symptomatic medication.

Although physicians suspect that the patient’s psychological or emotional reactions are behind the symptoms or illness, there is an inner frustration of being unable to identify the real problem. Even after exhaustive investigations and reassurance, patients continue to fear that their symptoms are caused by undiagnosed physical problems. ‘Heartsink’ is a term that has been coined to describe the physician’s frustration with seeing these patients [3]. Patients may further alienate physicians by challenging their investigations and reassurances. Physicians begin to feel that they are being controlled by the patient.

Even if psychosocial factors are suspected by both parties, such as job stress or marital dissatisfaction, there are no immediate tools to manage the situation. Some physicians may be tempted to probe defence mechanisms in their patients in order to find underlying psychological causes, such as traumatic life events, abuse or incest. While a high percentage of these patients have experienced trauma and suffer from symptoms of anxiety, depression and insomnia, uncovering evidence of trauma or unconscious dynamics does not generally resolve the symptom.

Cognitive behavioural therapy represents the widely adopted non-drug treatment for all medically unexplained symptoms. The successfulness of the approach has been overstated, especially in terms of the providing relief of the actual symptom(s). From a mind–body framework, the cognitive model is limited by a failure to address the pathophysiology of the patient’s symptom experience.

One of the most frequently occurring medically unexplained symptoms is non-cardiac chest pain. More than 50% of patients with chest pain seen in cardiology and primary care settings do not have identifiable ischemic heart disease or another serious medical disorder to account for their physical symptoms [4]. Despite receiving a favourable medical diagnosis, patients with non-cardiac chest pain continue to experience chest pain symptoms as well as distress and interference in their activities of daily living. “There’s nothing wrong” does not reassure patients and may result in iatrogenic concern and worry about undiagnosed cardiac problems. The central component of this model is attribution or cognitive appraisal. It is assumed that the patient is interpreting benign or ‘normal’ physical sensations catastrophically as indicative of something dangerous, such as heart attack. The goal of treatment is to correct the misattributions regarding physical symptoms (e.g., chest pain) as being harmful. The attribution model fails to convince the MUS patient that the bodily experiences are normal and that nothing unusual under the skin is taking place. This explanation often does not resonate with patient symptom experiences who find the approach “too psychological” and dismissive of underlying pathophysiology.

This paper extends the cognitive approach to include somatic awareness, an experiential body heuristic which assumes a degree of psychobiological veridicality of the patient’s presenting symptom. That is, it assumes that there is a central and peripheral physiologic substrate to the patient’s condition. Somatic awareness involves the direction of attention to bodily experience and associated feelings for the purpose of achieving health. The heuristic cuts across the biological, psychological and social domains of human functioning. It serves as a powerful clinical tool to facilitate communication and humanistic care between physician and patient. Somatic awareness in a pure sense of the term is the feeling of well-being within the body.