Nov 04 2009

It’s All In Your Head

The recent discussion of the Desiree Jennings case has prompted speculation and misinformation about the nature of psychogenic illness. I therefore thought it would be useful to discuss the concept of psychogenic illness in general. The following is cross-posted also at Science-Based Medicine.

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I have never used those words to a patient or about a patient.  I have also never heard a colleague use any similar term to a patient. And yet on many occasions I have had patients ask me, “So you’re telling me it’s all in my head?”

The concept of what are now called psychogenic symptoms is a tricky one for various reasons. There is an unfortunate stigma attached to the notion that our brains can cause physical symptoms. Making the diagnosis is complex. Outcomes are variable and are hampered by the difficulty in communicating the diagnosis to patients. Psychogenic symptoms often mask underlying physiological disease. And the risks of both false positives and false negatives are high.

This complexity leads some to argue, in essence, that psychogenic symptoms do not exist at all – that the diagnosis is a cop out, a way to blame the patient for the failings of the physician. But this approach, ironically, is a cop out, because it seeks to white wash what is a real and complex disorder with an overly simplistic and moralistic approach.

What are psychogenic symptoms?

Various terms have been used over the years to refer to symptoms that are generated by psychological stress or other factors. Hysteria is an unfortunate term which was invented to refer to the uterus, as if such symptom were uniquely female. For obvious reasons the term “hysteria” is no longer used. Psychosomatic is still a proper term, meaning physical symptoms with a mental cause, but the term does have a bit of a stigma attached. The term psychogenic is most widely used today, simply meaning having a mental cause.

A related concept is embellishment or psychogenic overlay. In these cases there is an underlying physiological disease or disorder which then results in stress and anxiety which further generates psychogenic symptoms on top of the physiological symptoms. What this means is that the presence of even demonstrably psychogenic symptoms does not necessarily mean that there is no underlying disease, and a thorough workup is still indicated.

Psychogenic signs and symptoms are real – the patient really experiences them, and often they lack insight into the origin of their symptoms. Psychogenic is not a synonym for fake, they are usually not voluntary, and patients cannot just stop their symptoms. A psychogenic disorder is a real disorder  – it is just that the problem is with the brain’s software, not hardware (if you will excuse the geek metaphor).

Sometimes people have a depressive or anxiety disorder, which may be reactive or may be primary and due to a biochemical disorder in the brain. Anxiety puts a lot of stress on the body and can absolutely manifest with physical, and sometimes very dramatic, symptoms. Stress itself can also manifest with physical symptoms.

This should be no surprise to anyone familiar with neurobiology. The brain is an organ, just like any other organ in the body. It is made of tissue, and it is connected to the rest of the body through the nerves as well as the neuroendocrine system. Thoughts alone can speed up your heart by releasing adrenaline, they can cause butterflies in your stomach or nausea through increased vagal activity, or can flood penile tissue with blood causing erection. A fright can cause your blood pressure to drop resulting in fainting. Stress can chronically increase blood pressure.

So we all have psychogenic symptoms at some point in our lives, and we take them for granted. The fact that more dramatic symptoms can also result from purely psychogenic causes should not be that surprising.

How do we known when symptoms are psychogenic?

Often knee-jerk critics of the psychogenic diagnosis claim that it is purely a diagnosis of exclusion – an expression only of lack of knowledge on the part of the diagnostician. Excluding underlying physiological causes is an important part of the diagnosis – but not the only part.

In neurology (my specialty) for example, there are many situations in which positive evidence can be brought to bear to demonstrate that a patient’s symptoms cannot be neurological. There is a well-described entity known as pseudoseizures or non-epileptic seizures in which patients have involuntary seizure-like episodes.  A seizure is an abnormal electrical discharge in the brain, firing neurons in unison and causing symptoms based on where in the brain the neurons are firing. There is a limited number of patterns that seizures can have, because they are “sloppy” and just spread directly to neighboring neurons (not following complex networks of neurons). There are some patterns of convulsive movement, for example, that are simply impossible – they cannot be due to motor seizures.

Also, at times patients will have psychogenic weakness, either partial or complete paralysis of a limb. True neurological weakness has certain features which cannot be simulated (voluntarily or involuntarily) and there are techniques we use in the neurological exam to look for these features. Likewise there are features that are very suggestive of what we call effort-dependent weakness (which does not imply insight or deliberateness). Essentially, different causes of weakness have different features on neurological exam that we can distinguish, often quite easily.

Further still, without a detailed knowledge of neuroanatomy, patients with psychogenic symptoms will tend to display distributions of symptoms that do not follow anatomical pathways. Or they will display patterns of movements that do not correspond to any part of the motor system.

Another feature that is suggestive (but not proof) of a psychogenic disorder is that the hard or objective findings that normally accompany a neurological deficit are absent. These include reflexes that do not require any cooperation, voluntary effort, or subjective feedback from the patient – they come pretty close to a direct examination of a circuit in the nervous system.

To summarize, there are cases in which patients exhibit neurological symptoms which seem to defy neuroanatomy, reveal features of effort, do not correspond to known systems in the nervous system, and lack any hard or objective finding that should be present. Even in these cases, we are likely to do a full workup looking for an underlying problem (as stated above, psychogenic symptoms may simply be overlaying a physiological lesion or disease). In psychogenic cases thorough neuroanatomical scans are normal, as are physiological tests for nervous system function.

In cases where there are positive features of a psychogenic disorder, and a thorough absence of other demonstrable causes, the diagnosis of a psychogenic disorder is perfectly reasonable. It is not a negative judgment about the patient, it is simply an attempt to make an accurate diagnosis.

False positives and false negatives

Nothing in medicine is 100%, and all diagnoses have false positives and false negatives. Physicians learn to deal practically with this uncertainty. For example, even though we may have made a confident diagnosis, we will still rule out alternatives we cannot afford to miss. The diagnosis of a psychogenic disorder is no different.

The public tends to focus on the risks of the false positive – diagnosing a symptom as psychogenic when there was a missed underlying physiological disorder. While this happens, it is again no different than any form of misdiagnosis. This is, admittedly, the worst-case-scenario. But to put it in perspective, this often occurs after a thorough workup that has failed to reveal the diagnosis. So the failure to make the underlying diagnosis occurs whether or not the alternate diagnosis of psychogenic is entertained.

Putting the notion of a psychogenic cause aside, physicians often face the situation in which patients have symptoms that cannot be diagnosed. The body is complex, and we cannot always explain every symptom. Workups are designed, in fact, to look for entities which can be treated, not necessarily to explain symptoms at all costs. So when we say we don’t know what is causing a symptom what we really mean is that we have ruled out anything that we could treat. What we are left with are all the subtle biochemical or physiological causes that we either cannot rule out, or are simply not worth investigating because they will not change management.

Sometimes patients are simply uncomfortable with this situation (perhaps because it was not communicated to them well). They may seek a diagnosis until they find someone willing to make one, and then they will blame their previous doctors for “missing” the real diagnosis. Sometimes the actual diagnosis is missed, and patients were right to seek other opinions. But at other times the new diagnosis is the fake, but it is more acceptable to the patient than the stigma of  stress or anxiety induced symptoms.

It should also be pointed out that sometimes there is an underlying disorder causing psychogenic symptoms – serious anxiety or depression. These are just as much “real” disorders as anything else.

In short, we see every permutation of diagnostic misadventure because the human body is complex, our knowledge and technology are limited, and the doctor-patient relationship is increasingly complex.

There are also risks to the false negative, however – missing a psychogenic disorder when that is the proper diagnosis. Patients who have disturbing symptoms due to psychological stress or anxiety will often seek multiple opinions. They will get what we call “the million dollar workup” – sometimes over and over again. There are real risks associated with so many tests. Sometimes the tests themselves are invasive and contain risks. But even safe tests, if you get enough of them, are bound to result in false positives, which could lead to a misdiagnosis, further invasive testing, and improper treatment with risks and side effects.

I have seen this scenario play out as well. I have had a few patients who, in my opinion, had entirely psychogenic symptoms, but through their tireless seeking of medical attention ended up being on numerous medications they did not need, and being subjected to many invasive procedures which then led to complications. In the end the patients had physiological and anatomical disorders and symptoms, but all ultimately resulting from the failure to properly diagnose their original symptoms as psychogenic. They would have been much better served if they were aggressively reassured that they did not have the diseases they feared, and if they were directed toward gentle quality of life interventions, as well as psychological attention for their underlying disorder. In one case the patient had what can only be called mental illness, and needed to be aggressively redirected toward psychiatric treatment.

The point is – there are risks both ways (like in all of medicine). There are risks to prematurely making the diagnosis of a psychogenic disorder or missing an additional underlying trigger, and there are risks to missing the diagnosis of a psychogenic disorder.

Conclusion

In a perfect world the unfortunate stigma attached to the psychogenic diagnosis would disappear. It is very counterproductive. We need broader understanding that the brain is also an organ and can manifest symptoms in a variety of ways. Psychogenic causes are just another item on the differential diagnosis.

Physicians, for their part, should likewise remove any stigma attached to patients with psychogenic symptoms and need to approach the diagnosis as if it were any other – with positive and negative signs, and risks to false positives and false negatives.

21 responses so far

21 Responses to “It’s All In Your Head”

  1. Eternally Learningon 04 Nov 2009 at 11:05 am

    Hi Steve,

    Thanks for dedicating an article to this, I was really wanting to know more about these types of disorders. That being said, I find myself confused by your reasoning to say that the psychogenic diagnosis is not one of exclusions. To recap what I think I just read, it seemed to me that your main points towards there being positive evidence for psychogenic disorders were:

    – A patient may display symptoms that cannot be neurological (ex. Seizure patterns)
    – True neurological disorders’ symptoms can sometimes not be simulated
    – A patient may display patterns of symptoms that are incompatible with their anatomical pathways
    – A lack of hard evidence pointing towards an actual neurological disorder implies a psychogenic cause

    So unless I’m missing something, from my perspective none of these seem like the type of positive evidence that you would see in a neurological disorder. They also seem to be leading towards a diagnosis of exclusion, albeit a reasonable one, in that it sounds like you are saying that if the symptoms cannot be explained neurologically (which seems oddly confident given the uncertain nature of science) then a psychogenic explanation is the next step. Since there is nothing physical to see though, it seems to me like this could be another case like hysteria where simply due to our level of technology and knowledge we are unable to diagnose the true cause and instead use a general term to refer to a broad range of disorders that we are unaware of.

    All that being said, I do not mean to imply that I have somehow “caught you,” I simply have a complete lack of understanding and have some questions. Also, I do not mean for this to imply that if my analysis is correct that neurologists should not be doing what they are doing in treating seemingly psychogenic symptoms, merely that they should keep searching for a more definitive cause.

  2. Steven Novellaon 04 Nov 2009 at 11:54 am

    I am being a bit vague on some details because I do not want to write a primer on how to fake neurological disorders. Some of the “tricks of the trade” are like magician’s tricks – they work best when the general public is not aware of them. So I am skimping on some of the technical details.

    But to look at this another way, all neurological appearing symptoms come from the brain. The question is not so much whether they are real or fake, or whether or not they are from the brain – but what part of the brain are they from.

    Do they come from a subconscious part of the brain or from a part over which we have conscious control (even if we lack insight into this fact).

    So part of the psychogenic neurological diagnosis is that the symptoms being displayed can be (or must be) produced by conscious parts of the brain. That is part of the positive evidence.

    But there is more. We can use exam techniques to get apparent deficits to disappear – which is impossible if they were due to any lesion in the circuit.

    And further keep in mind – what we are really concluding in such cases is that symptoms are functional – they are coming from the conscious part of the cortex, because of evidence of effort dependent symptoms, or of patterns that are not subcortical or peripheral.

    Sometimes all we can say is that symptoms are functional, and not pathological (because we ruled out pathology as best we can) but we cannot say anything further. If there is no evidence that the functional symptoms are also triggered by or at least correlated with stress or anxiety, we cannot conclude that they in fact are.

    There are many cases where functional symptoms do correlate with anxiety, and when you treat the anxiety the functional symptoms resolve.

    There are other cases where we just say the symptoms are unknown, but not pathological.

    One final point – you can portray all clinical or functional diagnoses as ultimately diagnoses of exclusion or based on ignorance – but only in the generic way that all science is. If people are having headaches and we find no pathology, we may diagnosis migraines (which is really a functional diagnosis). If people are having chest pain and we find no problems we may diagnose angina and treat accordingly, but that is really just an assumption about heart function without pathological evidence.

    My point is, that the psychogenic diagnosis is really no different. It is part of clinical decision making. The only difference is the social stigma.

  3. JeffGon 04 Nov 2009 at 12:02 pm

    Forgive me, Steve, for referencing a TV show, but I saw an old episode of House where mass hysteria in an airplane led to multiple people getting the same rash and vomiting. I’m wondering to what degree a sufferer of a psychogenic symptom can actually direct how the symptom will be manifested?

  4. Steven Novellaon 04 Nov 2009 at 12:19 pm

    Jeff – sometimes the symptoms are an essentially random manifestation of stress or anxiety – the person has no control over how they manifest.

    Other times, the manifestation is consistent with the patient’s fears or expectations. For example, if they have a family member with seizures they are more likely to have psychogenic seizures than if they do not know someone with seizures.

    There are also numerous documented cases of mass-delusions where people come down with symptoms that are spreading throughout the community, even when it is later discovered that there was never any problem in the first place.

  5. daedalus2uon 04 Nov 2009 at 2:18 pm

    A very nice discussion of psychogenic disorders, and one that also illustrates the difference between SBM and quackery and how patients and their problems are perceived and handled; one sees a patient in need of diagnosis and effective treatment tailored to that diagnosis and what the patient needs, the other sees something to exploit for PR and fundraising and then blaming the patient if the patient doesn’t respond to the quacks’ “treatments”.

    In the Desiree Jennings case, without knowing what was wrong, how could the marketing arm of GR know that they had the expertise to treat what ever it was that she had? Then when they found out that she wasn’t a sufficiently good “poster-child” for their anti-vax agenda, they kick her to the curb with no explanation.

  6. son 04 Nov 2009 at 2:29 pm

    Steven,
    Very nice article, but I do not wholly agree with your optimistic view. How many patients have the economic means and perseverance to get that “million dollar consultation” you talk about? That most likely will exclude any currently known disorder. A select few.

    The risk of just getting fobbed off by a convenient psychogenic wastebasket diagnosis is in my opinion greater. How many conditions have not initially been explained as psychogenic/psychosomatic (or deviltry or oedipal complexes or refrigerator mothers etc) until science found a likely physiological explanation?

    Autism, ADHD, myotonia, HPP, epilepsy, stomach ulcers are all examples.

    And “hand on heart” how many docs would recognize subtle early symptoms of pellagra, beriberi or B12-deficiency? Would not these patients rather be fobbed off as psychogenic or stress-caused?

    If anything, medical history has taught us to approach unexplainable symptoms and signs with a huge modicum of meekness.

  7. Eternally Learningon 04 Nov 2009 at 2:57 pm

    S,

    I think you misunderstood what Steve was saying. He wasn’t saying that people need the “million dollar consultation,” in fact he’s saying the opposite; that excessive consultation and testing is detrimental to the wallet and the patient’s health. I think his point was that if you keep searching past what is the most likely answer, you can still end up with false positives.

    Steve,

    Thanks for the detailed response. I guess the only thing I am confused about is that you stated in the article that the psychogenic diagnosis is not strictly one of exclusion, yet in your response you say that it is, and in fact all diagnosis are. Is there evidence in these situations that points to a psychogenic cause that is not strictly an interpretation of the symptoms combined with the lack of any evidence for a neurological problem?

  8. son 04 Nov 2009 at 3:59 pm

    @Eternally
    Uhm, you misunderstand me, I am not saying they need that consultation. I am saying that *very few have the money* to get those. And that most others run a distinct risk of being fobbed of by a less expert or interested practician. My post is about them and the strong medical history of psychologising and blaming the patient for unexplained symptoms. (NYT had a concise article on that topic on October 21, 2008: When All Else Fails, Blaming the Patient Often Comes Next by RA Friedman, professor of psychiatry at Weill Cornell Medical College.)

    “A vast majority of patients want to feel better, and for them the burden of illness is painful enough. Let’s keep the blame on the disease, not the patient.”

  9. Eternally Learningon 04 Nov 2009 at 4:41 pm

    S,

    Ok, so I can understand:

    – You are saying that people do not need the excessive consultation.
    – You are also saying that very few people can afford the excessive consultation.
    – You then say that those that cannot afford it therefore run the risk of being misdiagnosed by a sub-par practitioner.

    If you are saying that people who cannot afford the consultation are subsequently more at risk from a less professional consultation, then how can you say they don’t need the high-dollar one?

    Can you restate exactly what your point is then? I’m a little lost.

  10. ballookeyon 04 Nov 2009 at 5:21 pm

    Thank you for this great summary. It gives me a much better understanding of psychogenic illness. Truly—thanks.

    @s:
    I can’t speak for a doctor on this, but when Dr. Novella described the “million dollar diagnosis” situation, it immediately reminded me of an acquaintance of mine who periodically goes to some new doctor, has a three hour intake, dozens of tests, for what is probably a psychogenic illness. At the end of all of this she is given some diagnosis and she rails for weeks about how could her previous doctors have missed THAT? It’s certainly been costly, as she always notes that these lengthy intakes and diagnostics are never covered by insurance. She has often spent her last dollar on these diagnoses and the ensuing treatments.

    A literal million dollars? No—she doesn’t have that. But if she truly has a psychogenic illness, rather than fibromyalgia, or multiple sclerosis, or hypothyroidism (just her last three diagnoses) then all of those thousands of dollars have been misplaced and might as well have been a million for all she could afford to spend it.

  11. Enzoon 04 Nov 2009 at 5:22 pm

    S,

    There is also the point Dr. Novella makes that dismissing a psychogenic cause can do more harm than accepting it. A physician could not doubt throw a barrage of tests at a patient even when the first, most commonly used tests turn up negative. More tests can lead to more mistakes and a possible accumulation of “side-effects” etc.

    Saying that “psychogenic” simply means “not yet understood” is misleading; ultimately it may be a term used to cluster together a hugely complex system in which a yet undefined brain state affects the physical…But that doesn’t mean we don’t understand something about it. It isn’t a wastebasket diagnosis, it is simply identifying a condition and treating accordingly. We may not have defined the precise physiological cause because we do not understand how the brain process thought to physiology — the same is true for some of the conditions you listed (ADHD, etc.).

    Also, it is very damaging to liken this to a case of “blaming the patient.” I will have to read the article you cited, but Dr. Novella went out of his way to make sure that psychogenic disorders are not perceived this way. It is not the patient’s fault. In this case we do not know the trigger of the disorder, but hopefully a physician would not lump psychogenic disorders in the same basket as say cigarette smoking or obesity — which is what the phrase makes it sound like.

  12. Steven Novellaon 04 Nov 2009 at 6:05 pm

    The “million dollar workup” is a metaphor – not literal. But a couple MRI scans, blood work, EEG, another round of blood work, etc. and you are talking a fair amount of money.

    I do not think this is the exception. In fact, the entire discussion of rising health care costs in the US is largely about excessive procedures and diagnostic workups. If anything, we do too much, not too little.

    And most people still have insurance – they are not paying out of pocket.

    What I advocate and teach is that an appropriate workup is done in each case, but that searching for a pathological diagnosis should not be endless. At some point you conclude that all plausible treatable diagnoses have been ruled out, and then you can focus on symptomatic and quality of life management. This is not giving up or copping out, it’s considering the risk vs benefit of continued workups.

    But also, a good clinician will then monitor response to treatment and reconsider the diagnosis and further workup if warranted. Or refer to a specialist if necessary.

    A lot of judgment and experience is involved. There are many pitfalls on all sides.

    You cannot simply dismiss the whole concept of functional symptoms as a cop out – it is a necessary component of the clinical evaluation. Without it you cause more harm than good.

  13. son 04 Nov 2009 at 7:41 pm

    @Eternally
    <You are saying that people do not need the excessive
    I see why you are confused, my double negation in the first answer to you ended up being a singleton. Sorry, should have read "I am not saying they **do not** need that consultation…"

    <You are also saying that very few people can afford
    "Very few" was maybe a bad choice of words. You need to have insurance willing to pay or earn enough. Full neurological workup and a PET scan is not cheap, but that still does not mean someone would not be willing to pay his last dollar or even mortgage the house to get that workup. But in the latter case you definitively could not afford it…

    <You then say that those that cannot … sub-par practitioner.
    No I say "less expert", meaning the potential risk of getting the wrong diagnosis because of lack of specialized knowledge.

    @Enzo
    <Saying that “psychogenic” simply means “not yet understood” Notice that I say "*likely* physiological explanation", so we essentially agree with each other.

    My point is that before we reach Stevens perfect state of almost definitively having excluded any currently known cause, many more patients will have ended up erroneously having been dismissed as "psychogenic". (Do not forget Marmors statement that 50-75% of patients consulting have mental or emotional problems…)

    As medicine progresses patienst with MUS will of course be fewer. And that was my point with my examples. Autism/ADHD are e.g. no longer regarded as a caused by "refrigerator mothers" or "obstinacy" and "ant-authority complex", but as a conditions based in a physiological malfunction. Albeit not well understood. And that is great as neither mother, father or child are accused. The disease is the focus.

    But we still have way to go with other disorders like e.g. certain pain disorders, CFS and fibromyalgia or plain borderline deficiency states or just chemicals in our environment (Chemical Exposures: Low Levels and High Stakes by Ashford&Miller–yes it's a textbook, intro: http://dspace.mit.edu/bitstream/handle/1721.1/1586/NGO_Implications.pdf?sequence=1).

    As I said: If anything, medical history has taught us to approach unexplainable symptoms and signs with a huge modicum of meekness.

    And that hindsight makes me vary of psychogenic models, as they can, and are, used for that cop out I mention. Although I agree that it sometimes may not be feasible to state that "I do not know what ails you" or "currently we do not know enough to tell what causes your symptoms".

    But that does still not take away the everyday reality. And to quote Martin L Pall from his eminently readable book "Explaining unexplained illnesses" (page 198-200, also see http://www.thetenthparadigm.org, a clue: NO — and I just hope Daedalus does not totally disagree with Pall 😉

    "Negative labels such as crock, troll, turkey, gomer are often invoked to characterize such patients who do not fit into the traditional sick role model. Once patients get labeled in this manner, physicinas often feel less obligated to follow through [on their medical obligations]."

    "So both the training of physicians in medical schools and their human weaknesses as clinicians cause them to be receptive to the psychogenic views of multisystem illnesses despite the flaws in these views."

  14. daedalus2uon 05 Nov 2009 at 11:08 am

    S, I do disagree with Pall. He thinks that those unexplained illnesses are caused by peroxynitrite damage caused by too much NO. This is incorrect. The peroxynitrite damage is caused by not enough NO.

    NO and superoxide react at diffusion limited kinetics. Peroxynitrite is only observed when there are near equimolar quantities of NO and superoxide. When there is an excess of either one, no effects of peroxynitrite are observed (in vitro). Peroxynitrite is pretty reactive and oxidizes the zinc-thiol couple in nitric oxide synthase, causing it to become “uncoupled” so that it generates superoxide and not NO.

    Superoxide is easy to make. There are many sources. Physiology makes superoxide when it wants to lower the NO level, for example to respond to a stress. When that superoxide is made, it promptly lowers the NO level, physiology shifts to the low NO state which turns off lots of stuff and turns on lots of other stuff. During that transition, the formation of peroxynitrite is a “feature” because it accelerates the switch by causing nitric oxide synthase to become uncoupled.

    When the stress is over and physiology needs to switch back to a high NO state, that is a lot more difficult. There isn’t as much evolutionary need to quickly go from a high stress state to a low stress state as there is to go from a low stress state to a high stress state. If you notice a bear chasing you, you need to ramp up your “fight or flight” response ASAP. That is where making lots of superoxide fast comes in. After you have escaped from the bear, there is no corresponding need to rapidly stand down. Triggering fight or flight needs to be done in seconds (or less), standing down from that state can take tens of minutes (or longer).

    The low NO fight or flight state exhibits hysteresis. It takes a positive action to switch back to a high NO state. This is where more NO helps. More NO accelerates the transition, so there is less lingering at the intermediate state where near equimolar levels of NO and superoxide are formed, which produces peroxynitrite, which results in the nitrated and oxidized proteins observed in the disorders discussed by Pall. A more rapid transition through that state where NO and superoxide are produced in equimolar quantities will reduce the total amount of peroxynitrite produced and reduce the damage from it.

    Peroxynitrite is produced all the time. Peroxynitrite damage accumulates only because it is not dealt with. During the high stress state there is little peroxynitrite because there is little NO. Because there is little peroxynitrite, there is little peroxynitrite damage (even though damage repair is greatly reduced during periods of stress). In the low stress high NO state, damage is rapidly repaired. It is only when organisms linger in the transition zone that damage occurs and is not repaired. The damage does not occur during the high NO to low NO transition because that transition is very fast because superoxide is easy to make in large quantities. The damage occurs in the reverse transition, from the low NO state to the high NO state because there isn’t enough basal NO to make that transition rapid.

    The only way this can be fixed is by increasing the basal NO level. Trying to reduce the superoxide level with antioxidants won’t work because the body actively regulates the superoxide levels and will simply make more (which it has unlimited capacity to do). I know of only one way to increase basal NO levels and that is with the bacteria I am using.

  15. Steven Novellaon 05 Nov 2009 at 12:14 pm

    s – I am not claiming we are at or near our perfect world. I am describing the standard of care – how optimally to approach this issue. Stating what is optimal care is not the same as claiming that everyone is achieving it. I can say patients at risk for heart attacks should be on aspirin, and yet about half of people who should be on aspirin aren’t – that does not invalidate the underlying principle.

    I disagree, from my own clinical experience, that the problem of weighted largely toward the false positive. I think it is more even between under and over diagnosis.

    But still you are arguing within a narrow concept of what is “psychogenic” so let me break it out more explicitly:

    It is helpful to put patients with undiagnosed ailments into at least three broad categories in terms of how to approach them:

    1 – Patients who have identifiable pathology – a lesion or physiological abnormality that correlates with their signs and symptoms, but without a specific diagnosis. In these patient an aggressive diagnostic approach is appropriate. They have a known lesions, but of unknown etiology. Still, you have to consider risk vs benefit, and how debilitating and progressive is the pathology is of extreme importance. These cases are not diagnosed as psychogenic, just unknown or idiopathic.

    2 – patients with symptoms or presentations that are plausible and appear physiological, but are not currently diagnosed and with no identifiable pathology. This is the category you are assuming. In these cases an open-ended attitude is best. Workups should be targeted with careful thought to risk vs benefit. Course and response to symptomatic treatment should be monitored, and the workup should be extended if symptoms or signs change, or new thoughts or options become available. It is reasonable to treat underlying psychological risk factors or exacerbating factors and see how patients respond, but they should never be “dismissed” as psychogenic.

    3 – patients who present with signs or symptoms that are very suggestive of a psychogenic syndrome, or are anatomically or physiologically impossible or self-contradictory (what I have termed “positive” signs). Still, it is important to rule out underlying disease. Most of these cases, in my experience, are cases of psychogenic overlay triggered by underlying biological disease.

    But there are cases where you have positive evidence for psychogenic symptoms, all plausible underlying disease has been ruled out, and there are identifiable psychosocial stresses or triggers (sometimes dramatically so). In these cases the diagnosis of a psychogenic disorder is reasonable – as reasonable as any other diagnosis in medicine – and should be treated appropriately.

    What I am saying is that type 1-3 patients exist, and the approach to them depends on the features I discussed above. Many commenters, however, are assuming that only category 2 patients exist and that all psychogenic diagnoses are purely exclusionary and based on current ignorance. This is wrong.

  16. Draalon 05 Nov 2009 at 1:36 pm

    I do not think this is the exception. In fact, the entire discussion of rising health care costs in the US is largely about excessive procedures and diagnostic workups. If anything, we do too much, not too little.

    If I could, I’d hug you. This is one topic that affect almost all of us in the US and needs to be rammed down the public’s throat. In a study published ealier this year, half the public believes someone is getting unnecessary healthcare but only 16% thought it was them. http://www.newamerica.net/blog/new-health-dialogue/2009/health-politics-its-other-guy-getting-unnecessary-care-11265

    I wish SBM blog would come out with a multi-part blog outlining the issues with unnecessary treatments. In some cases, it’s the doctor’s fault, in others, patients demand it.

  17. […] opinion agreed that the signs she was displaying on the public video were most consistent with a psychogenic movement […]

  18. son 07 Nov 2009 at 2:04 pm

    Steven,
    thanks for clarifying your points. I do not disagree with your categories, but with the usage of “it’s all in your head” labels. Historically those come with a heavy baggage of stigma. You were a witch, beset by the devil, accursed, suffering from some mental disease and so on. And psychosomatic/psychogenic labels are definitively *still* associated with this stigmata even if individual physicians, like you, are very nuanced in the usage of the label and see it as sort of a last resort.

  19. […] As promised, I watched the Inside Edition segment last night following up on the Desiree Jennings case. If you remember, she is the 25 year old woman who claimed to have a neurological disorder called dystonia following a seasonal flu vaccine. Her story never added up, and the video of her disorder that was made public (and disseminated, of course, on YouTube) did not show dystonia. Every neurologist who viewed the video and commented publicly, including me, were of the opinion that her symptoms were psychogenic. […]

  20. 365earthon 28 Dec 2013 at 5:13 pm

    I am a 54 year old women who has been told I have psychogenic disease. I am one of those “million dollar” people who continues to struggle to find an answer. After dealing with the frustration and pain of not getting answers for over 4 years I planned a suicide attempt.

    The medical community attached the depression to the cause of my illness. I contribute the lack of diagnosis to the reason for my depression. At this point in time it does no matter to me if it is being caused by my body mis-processing information (stress), the environment or some reaction in the brain which is yet to be understood.

    Even if I can no longer work or function in my daily life I still must accept the medical community does not have answers for nor a treatment plan which will solve this problem in my life. The brain is very complex. I know I do not knowingly think myself into this state of disability. I must accept my body and mind do not play well together.

    That said I am interested in learning if there are connections between DID, PTSD, and psychogenic disease.

  21. Mlemaon 29 Dec 2013 at 3:47 am

    365earth
    I believe that ptsd often manifests with physical problems. If you can find a psychologist skilled in cognitive therapy, whom you trust enough to expose your thinking, and who has your well-being as his or her ultimate goal, it is possible to “restructure” your vantage point on the world.
    http://ptsd.about.com/od/treatment/a/PTSDtreatments.htm

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