Thursday, April 14, 2016

“Psychosomatic” Illnesses

The British Broadcasting Corporation (BBC) recently published a piece titled The Very Real Pain of Imaginary Illness. The headline caught my eye. A great many of the cases that appear in workers' compensation venues around the country involve deciding the extent of disability or impairment. Those decisions are deeply dependent upon the opinions of various medical care providers, diagnostic tests and medical procedures. And, a great many of those cases involve someone that is complaining of pain and other symptoms. 

The medical process is driven, in large part, by symptoms. This is why the doctor asks the patient "what hurts," or "where does it hurt," or "what does it feel like," or similar questions. This is why the doctor, armed with that information, then touches, palpates, various locations, moves the body part in an effort to identify exactly what tissue is injured. There is a method to the process, in which various potential causes are serially ruled-out, ultimately leading to the conclusion that some particular tissue is responsible and thus that treatment for that tissue is appropriate. 

This is referred to as the "differential diagnosis" process. Through it, various distinct disease or injury processes can be distinguished from others that present similar symptoms or complaints. In some instances, treatment may be part of the process. The physician may try a treatment, and the success or failure of that treatment may provide information as to what the injury or illness is or is not. In the process of diagnosing and treating injury or illness a physician is highly dependent upon the perceptions and reporting of the patient. It is critical to remember that while medicine is a science, it also involves a significant degree of art, and this it is called a "practice" of medicine.

The BBC article follows some thoughts and prognostications of a physician named Suzanne O’Sullivan. She has decided she is an expert in "psychosomatic illness." There are always those who express curiosity or doubt about self-proclaimed experts. Dr. O'Sullivan purports to have studied these illnesses, and asks us to reconsider our perceptions and beliefs. There is always benefit in re-examining our thoughts and perspectives. 

Dr. Sullivan outlines the subject for us by describing a patient who was involved in a work event. The patient "had been stacking the fridges in a supermarket" ("stocking?), "when a colleague had accidentally sprayed a fine mist of window cleaner in her face." This is the sort of thing that can easily happen in almost any retail setting. There are window cleaners, floor cleaners, air fresheners, and a variety of other substances in use in most such stores. 

The patient washed her eyes and left work. When she awakened the next day, she complained that "her vision was worse." Twenty-four hours later, "she could not tell night from day." Complete blindness with an almost instantaneous onset. Dr. O’Sullivan’s "colleagues assumed (she) was faking it, perhaps for some kind of lawsuit." And six months later, the patient remained blind, but "doctors could find nothing wrong" with her eyes. In fact, "it certainly seemed like her eyes were responding to her surroundings, yet she continued to claim that she was enveloped in an impenetrable darkness."

Dr. O'Sullivan described this in a recent book It’s All in Your Head. She claims to have "become an expert in 'psychosomatic' illnesses." Her cases have included "people who are paralyzed from the waist down, or who have such severe cramp in their fingers that their hand has become little more than a claw; one woman could not even empty her bladder without a medical catheter." In all of these cases, physicians have been unable to find any "physiological cause." So, Dr. O'Sullivan concludes that "the problem originates in the mind, not the body."

Such cases would be difficult from the medical perspective. The physician process described above is dependent upon finding the right tissue to treat. When there is no injury or illness found to treat, the physician may be discouraged. The law and medicine do not always coexist as cordially as one might expect. The two are not adversaries in the true sense of the word, but one might accurately think of them as siblings. And as with all sibling relationships, there are times when they do not agree with each other, struggle with each other, miscommunicate with each other. 

The law has struggled with the "subjective" nature of some medical complaints. The Florida legislature has required that objective evidence support a diagnosis in Florida Workers' Compensation. Fla. Stat. 440.09(1) includes the following (italics are direct quote) requirement of "objective relevant medical findings":

The injury, its occupational cause, and any resulting manifestations or disability must be established to a reasonable degree of medical certainty, based on objective relevant medical findings, and the accidental compensable injury must be the major contributing cause of any resulting injuries. (emphasis added)

In Florida workers' compensation, there must be something "objective," that is, observable by someone other than the injured worker/patient. This might be visible to the physician, such as a bruise, inflammation, or dislocation. It might be something the physician can feel, such as a "pop" or "click" or "spasm" when a joint is moved. It might be the result of a x-ray, magnetic resonance image (MRI), or computerized axial tomography (CAT) scan. It might be a multitude of things that a physician or technician can observe, independent of the perceptions and reactions of the injured worker/patient.

The existence of an objective injury is a foundational element of Florida work injuries. Dr. O'Sullivan argues that the lack of objective evidence does not make the injury less real. She asserts that symptoms which exists only in the patient's mind are nonetheless real. She says that "patients often struggle to understand how their real, physical symptoms could originate in the mind." She discounts at the outset, apparently, any suggestion that these symptoms might not be real.

There is evidence that the human mind can accomplish some interesting results. For example, scientists have documented "the placebo effect." When testing medications, doctors often provide the new medication to half of a test-group, while the other half of the group receives an inert (the old "sugar pill") substitute. This process allows them to measure the effectiveness of the medication by comparing the progress of those who receive the medication to the progress of those receiving the sugar pill. 

Incredibly, however, multiple studies have documented improvement in the group receiving the sugar pill, called the "control group." That is, some of the people receiving the sugar pill get better. As interesting, there have been documented instances in which members of the control group also sufferred side-effects from taking the inert, fake medication. In this method, scientists have proven that the human mind is involved in perceptions of symptomatology. They conclude that patients sometimes enjoy better response when they believe they will enjoy better response. 

Some of the patients documented by Dr. O'Sullivan are actually fraudulent. Dr. O'Sullivan describes one instance in which a patient was "suffering seizures as the side-effect of chemotherapy for leukemia years before." A camera surveilled a hospital ward into which she was admitted. The patient later described a seizure with a fall "so hard that she had apparently fractured her hand." But the video showed the patient "simply raised her hand and hit it hard against the wall four times, before lying down gently on the floor, pulling down a plate with her to attract the nurse." The doctors later discovered that the patient "had never suffered from leukemia, either."

Despite the demonstrable existence of some such outright frauds, Dr. O'Sullivan claims that she has "often" seen cases of "debilitating seizures" that left patients "writhing around on the floor, limbs flailing, helpless." These patient's examinations "showed none of the signature brain activity of epilepsy." She described them therefore as "psychogenic seizures." She suggests that medical journals need to spend more time on studying these patients, whose symptoms, which she believes are genuine, are coming from their brains. 

Her diagnosis is not always popular, even with the patient. Dr. O'Sullivan says that patients resent the "psychogenic" label, finding it stigmatizing. She says that they perceive that this label accuses them of "doing it on purpose" or that "it’s not real." The answer, she contends, is to "refer her patients to psychiatrists or to a cognitive behavioral therapist (CBT)." The ultimate goal she advocates is to "unknot the distress or trauma that is leading to the illness." She concludes, that the absence of any objective finding does not mean it is not an "illness." 

The article is not clear as to whether it would be accurate to refer to such "illness" as a mental illness. Dr. O'Sullivan prognosticates that one root common to several of her patient's complaints have been stress-related. The suggestion being that stress results in a load on the patient's systems or ability to cope, and that their mind resultingly reacts in a manner that produces the perception of, or presentation of, symptoms that are seemingly inexplicable. 

Dr. O'Sullivan encourages us to confront the existence of difficult-to-believe symptoms with what we know about ourselves. She claims there are a multitude of "psychosomatic phenomena" we all experience. She contends these include "every time we cry, or laugh, or shake with anger, if we feel so sad that it is hard to lift ourselves from our bed, or queasy with nausea after we hear of a friend’s food poisoning." She essentially seems to conclude that the difference between these mental/emotional reactions and the "psychosomatic illnesses" in which she is a self-prclaimed expert, are a matter of degree. 

Dr. O'Sullivan claims that "30% of people visiting their family doctor or GP (and 50% of women seeing their gynecologist) are enduring symptoms that cannot be explained with a physical cause." And, if not explainable, then arguably "psychosomatic in origin." The article seems to concede that some of these might also arguably be explained physically if there were further exploration of the symptoms, but that they are simply not explained by a "physical cause" at the time of the doctor visit. 

The real emphasis of Dr. O'Sullivan's writing is her contention that these "psychosomatic illnesses" are disabling despite their "psychological origin." She argues that despite the absence of physical, scientific evidence to support the existence of disease process, the patients "really are disabled. They are more disabled than most people with a physical disease.” The article is unclear how one with "psychosomatic symptoms" is more disabled than one with physical symptoms, but perhaps that is detailed elsewhere. 

Dr. O'Sullivan stresses that the lady with exposure to window cleaner, "after psychiatric help," was able to learn "to see again." Her theme appears to be a belief in and reliance upon therapeutic psychological care not to treat the "psychosomatic symptoms" themselves (blindness) but to treat the underlying mental illness or emotional impairment from which the symptoms result. The suggestion is that psychological care for the underlying stress will alleviate that malady, and then the "psychosomatic symptom" of blindness will resolve. 

Dr. O’Sullivan also argues that physicians misdiagnose these patients, ignore the lack of physical findings, and proceed "prescribing the patients drugs, or even admitting them for harmful surgery." Her argument is that physicians are inclined to believe the patient's complaints, even when the objective evidence does not, or does not yet, support a physical diagnosis. Then, they proceed with unsupported physical treatment. 

She contends that when the lack of physical findings fails to support the diagnosis, the appropriate response is to provide treatment, but not the physical symptom treatment to which the medical doctor ordinarily defaults. She contends instead that treatment rendered for physical complaints that do not exist can themselves be harmful to the patient. Thus, her conclusion is that treatment for complaints that cannot be diagnostically verified should be treatment of a psychological nature. 

In the realm of workers' compensation, this may be a difficult path. The law does not seem to contemplate the existence of psychiatric issues that themselves result in physical symptoms. If the supermarket stocker was sprayed with window cleaner in an American workers' compensation accident, would her seemingly resulting industrial blindness be compensable? Should it be?

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