When Psychological Pain Becomes Physical
An introduction to somatization.
Posted Dec 25, 2018
Somatization is the transformation or conversion of uncomfortable feelings into more tolerable physical symptoms. At its most dramatic, this may involve the loss of motor function in a particular group of muscles. The patient could, for example, present with paralysis of a limb or even paralysis of an entire side of the body (hemiplegia). In some cases, somatization might present as sensory loss, particularly if the sensory loss is independent of a motor loss or involves one of the special senses, most often the sense of sight. In other cases, the psychic pain is converted into an aberrant pattern of motor activity, such as a tic or seizure.
Psychogenic seizures (seizures with a psychological origin) are sometimes called "pseudoseizures" to distinguish them from seizures with a physical basis, such as epilepsy, brain injury, or a brain tumor. Psychogenic seizures can appear very similar to organic seizures. One way of telling them apart is by taking a blood sample 10-20 minutes after the event and assaying the level of the hormone prolactin, which is raised after an organic seizure, but not a pseudoseizure. Another way, more reliable but also more invasive, is video telemetry, which involves monitoring the patient over several days with a video camera and an electroencephalogram that records electrical activity across the skull.
If somatized symptoms are psychogenic, are they any less "real"? Somatization is, of course, an unconscious process. People are not usually aware of the psychological origins of their disability. In some cases, they may even display a striking lack of concern for their disability, a phenomenon referred to in the psychiatric jargon as la belle indifférence. For all that, the disability is not imagined or feigned: The limb actually cannot move, the eyes actually cannot see.... Terms such as "pseudoseizures," and the even more antiquated and pejorative "hysterical seizures," should be replaced with less judgmental terms, such as "psychogenic seizures," that do not imply or suggest that the somatized symptoms are non-existent or in some sense fraudulent.
Somatization, especially after a traumatic event, can be very sudden and startling. But somatization can also be very subtle and, dare I say, mundane. For example, I tend to develop a headache whenever I persist with something that goes against my nature or desires — often something, like a consultancy project, that involves making money. Over time, I have learnt to listen to these headaches, which act like a signal from myself to myself. This has made me very much happier, if also somewhat poorer.
Similarly, it is very common for people with grounds for depression to present not with psychological complaints, such as sadness, guilt, or hopelessness, but with physical complaints, such as fatigue, headache, or chest pain. This is especially true in traditional societies, and many linguistic communities, for example, in India, Korea, and Nigeria, do not even have a word for "depression," which is mostly a modern and Western concept.
The tendency to concretize psychic pain is deeply ingrained in our human nature and should not be mistaken or misunderstood for a factitious disorder or malingering. A factitious disorder is defined by physical and psychological symptoms that are manufactured or exaggerated for the purpose of enjoying the privileges of the "sick role," in particular: the attraction of attention and sympathy, exemption from normal social roles, and absolution from any blame for the sickness.
A factitious disorder with predominantly physical symptoms is sometimes called Münchausen syndrome, after Baron Münchausen, an 18th-century Prussian cavalry officer and one of the greatest liars in recorded history. One of Münchausen’s many "hair-raising" claims was to have pulled himself out of a swamp by his own hair. In Münchausen syndrome by proxy, also called "induced illness by carers," the perpetrator and victim are separate individuals, most often a mother and child.
In contrast to a factitious disorder, the purpose of malingering is to enjoy something other than the sick role. This purpose is usually more concrete and calculated: for example, obtaining sick leave, claiming compensation, evading criminal justice, or obtaining shelter for the night. Unlike factitious disorder, malingering is not classified as a mental disorder.
So it is quite clear, I think, that somatization has little to do with factitious disorder or malingering: People who physicalize psychic pain may, like all sick people, enjoy the privileges of the sick role or more concrete benefits, but these are not their primary purpose.
Psychological stressors can lead to physical symptoms not only by somatization, which is a psychic process, but also by physical processes involving the nervous, endocrine, and immune systems. For example, one Harvard study found that the first 24 hours of bereavement are associated with a staggering 21-fold increased risk of heart attack. Since Robert Ader’s initial experiments on lab rats in the 1970s, the field of psychoneuroimmunology has truly blossomed, uncovering a large body of evidence that has led to the mainstream recognition of the adverse effects of psychological stressors on health, recovery, and aging, and, inversely, of the beneficial or protective effects of positive emotions such as happiness, motivation, and a sense of purpose or meaning.
Here, again, modern science has barely caught up with the wisdom of the Ancients, who were well aware of the close link between psychological and physical well-being. In Plato’s Charmides, Socrates tells the young Charmides, who has been suffering from headaches, about a charm for headaches, which he learnt from one of the mystical physicians to the King of Thrace. However, this great physician cautioned that it is best to cure the soul before curing the body, since health and happiness ultimately depend on the state of the soul.
"He said the soul was treated with certain charms, my dear Charmides, and that these charms were beautiful words."
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E Mostofsky et al. (2012), Risk of acute myocardial infarction after the death of a significant person on one's life. The determinants of myocardial infarction onset study. Circulation 2012.