All medical professionals will recognise a large number of patients who present with symptoms that are difficult to explain or are out of proportion to the condition from which they appear to suffer. These patients present a serious challenge to a medical system which has become increasingly guided by scientific evidence. Under this western medical model, a patient will present with symptoms which can be investigated with various tests or scans, the investigations will confirm a diagnosis and then appropriate treatment can be instituted. Appropriate treatment is considered to be that which has been proven beneficial by scientific method.
There are many occasions, however, where investigations for quite significant signs and symptoms turn up nothing abnormal. Pain is common but other symptoms including chronic headaches, fatigue and some abdominal complaints fit into this category. Such a scenario often leaves both doctor and patient confused and frustrated. Few doctors have effective means for helping these patients and the patients may seek an answer through alternative practices. The description ‘medically unexplained symptoms’ has been coined.
An awareness that mind and body are connected on a continuum and that many presentations of illness or disability carry varying components of mind-related effects and physical signs helps to make sense of what can be otherwise bewildering. This concept is not new. It is widely accepted in societies practising “traditional medicine” but in western medicine has largely been left behind by the advance of science and technology in the treatment of most conditions.
Neuropathic pain is a great example of the interplay between mind and body. Within the broad spectrum of neuropathic pain lies the condition now known as complex regional pain syndrome (CRPS). Reflex sympathetic dystrophy was its former name. CRPS is characterised by pain which is disproportionate in duration, severity and distribution to the expected clinical course for the inciting event. At some stage there will be evidence of autonomic dysfunction such as colour or temperature changes and excessive swelling. Abnormal sensitivity of the skin in the involved area is often present.
A few years ago I met a nine year old girl who developed CRPS after a simple ankle sprain. She was treated with reassurance, analgesics (including amitriptyline and gabapentin) and physiotherapy, and received a pain clinic assessment, but after 18 months was showing no signs of recovery. She was struggling to walk with crutches and becoming isolated within her peer group. Fortunately, she undertook a course during which she was taught about mind-body relationships and how to use her mind to cure her problem. The response was spectacular and within a few weeks she had returned to normal and has never had a recurrence.
It is very difficult to believe how simply just thinking in a different way can eradicate pain and physical signs such as swelling and colour changes, and not surprisingly, such an approach is often met with initial scepticism. However, seeing is believing, and through my own version of mind-based therapy I have regularly seen children eradicate their CRPS within a few weeks. Adults too can achieve the same results, but it is more difficult as there are usually more cognitive and emotional impediments to changing their thought processes. The ability of the mind to achieve such remarkable changes where conventional methods have been unhelpful has come as a stunning revelation to me.
Now, I find myself continually looking for elements of “abnormal” pain in the presentations of my patients. Patients, like doctors, can get stuck in the mindset that the presence of pain must mean there is an identifiable physical cause for their symptoms and that there must be a correspondingly physical treatment. The inherent trap is that the patient may be subjected to a long series of fruitless investigations and opinions from multiple specialists without any clear explanation for the symptoms being found. Doctors face the dilemma of not wanting to attribute symptoms as being “mind-related” for fear of missing some serious pathology and some level of investigation is appropriate. It would seem inexcusable for a doctor to tell a patient their problem was “in their mind” and miss an underlying cancer.
On the assumption that there is no specific “conventional” treatment necessary after appropriate investigation, I have found many people are quite open to discussions concerning mind-body relationships. The response is variable, however, ranging from statements such as “that is the first time anyone has been able to explain what is happening to me that makes sense”, to polite attention but lack of committal to the ideas, to anger that it should even be suggested the mind might be in part responsible.
Nevertheless, it is very apparent to me that that mind and body are inseparable in our expression of illness. The balance can lie anywhere along the continuum from one to the other. An understanding of this opens whole new avenues for helping our patients and where I was once faced with a sense of helplessness and frustration when faced with patients with medically unexplained symptoms, I now feel potentially I have something to offer them. I look back and wish I had been taught about this in medical school or that the realisation had come to me earlier in my career. The concepts are not difficult and should be something that a wide range of health professionals can adopt without feeling that such an approach lies strictly in the realm of the psychologists and psychiatrists. It is now my desire to ensure that the new generation of health professionals understands the full extent of the mind-body relationship.
Mr John Dunbar: Mr Dunbar is an orthopaedic surgeon at Dunedin Hospital, Dunedin, New Zealand.