Weekend columnist, Margaret McCartney, 22 March 2008
‘If it’s in the mind, it’s still the real thing’
Medically unexplained conditions are common and frequently contentious. Conditions such as myalgic encephalitis (also ME or chronic fatigue syndrome), fibromyalgia (a disorder where pain is felt at various points in the body), repetitive strain injury and irritable bowel syndrome are comparable in that they do not have a diagnostic test, and are usually diagnosed by a process of exclusion. Additionally, none has a clear pathological or biochemical abnormality.
Could they in fact be all part of the same syndrome? This hypothesis was raised a few years ago by Professor Simon Wessely and colleagues in a paper in the Lancet medical journal. Every medical speciality has its own "unexplained" syndromes, from "non-cardiac chest pain" in cardiology to chronic pelvic pain in gynaecology. As the authors of the paper postulated: "The existence of specific somatic syndromes is largely an artefact of medical specialisation."
There are numerous problems with trying to investigate these disorders. For example, many readers tell me that their doctor does not "believe" in their ME.
Here even the naming is problematic; some see chronic fatigue syndrome as a wishy-washy name, whereas ME is thought to sound "more like" a neurological disease. It’s certainly true that many doctors see these kinds of symptoms as an irritating and time-consuming diversion from "real" pathology.
The subject definitely polarises medical opinion. Take this example from the ME Association Website: "With your support we can continue to seek scientific evidence that will show that this illness is a real and physical one. This, in turn, will lead us to better treatments for people with ME/CFS."
Somehow the physical and the psychological have been represented as polar opposites. To me, there is a subliminal message that somehow psychological illnesses are not as real, or as valid, as physical ones.
Last year the National Institute for Clinical Excellence (Nice) published guidelines for the treatment of ME. In response to Nice’s recommendation that cognitive behavioural therapies could be useful, some within the ME community expressed concern that a psychological treatment for the condition implied a psychological cause.
This troubles me, because Nice’s recommendation doesn’t imply this at all; psychological or behavioural treatments can, for example, be used to improve the quality of life of people who have diabetes, asthma, or cancer.
My second concern is that we cannot separate body and mind as neatly as the physical/psychological description implies. This itself implies that illness originating in the "mind" is somehow self-inflicted or a result of the person lacking control – simply not true. Anyone who has witnessed a full-blown panic attack – supposedly originating "in the mind" – is left in no doubt that the distress suffered is very real.
There are mental strategies to help reduce or stop such symptoms. What this really means, though, is that such strategies can help to stop the panic attack and thus the release of the chemicals and stress hormones that would otherwise go on to mediate it. It’s time to stop seeing "mind" and "body" as separate entities.
Take the valuable "placebo effect", which is too often dismissed as being merely psychological and indeed "all in the mind". By having no active chemical ingredient, placebos cannot introduce a biochemically active substance into the body.
But they can have a measurable effect, as true as anything else we might study. A rather small but nice study published recently in the Archives of General Psychiatry indicates that placebos have a neurological effect. Even the "nocebo" effect – when people respond with adverse symptoms to an inactive placebo – generated changes in the brain MRI, indicating a different biochemical response to the stress.
There isn’t really a hard line between the "physical" and the psychological" – in the end, all that we experience is mediated by chemistry that is complex and only just starting to be understood.
Tellingly, the other term for "medically unexplained" systems is "non-organic". This is as compared with the "organic" effects of something visible under a microscope, such as cancer or a stroke. But surely "medically unexplained" just means "medically unexplained as yet"?
I suspect that in another generation or two we shall look back in horror at how minimal our understanding of the brain has so far been. "Somatisation" – or the phenomena of translating mental distress into physical symptoms – is well recognised. The problem remains that it is not well treated.
My concern is that by demarcating some things as "physical" and others as "mental" we are not just missing out on useful interventions but that through a combination of fear, shame, stigma, and isolation we still do not treat mental illnesses as sympathetically as we do other more "socially acceptable" conditions.
Margaret McCartney is a GP in Glasgowmargaret.firstname.lastname@example.org