Understanding the mental and emotional reasons for physical illness and vice versa plays a key role in diagnosis and cure. Sudha Umashanker explores this fascinating link

What causes disease? An injury, an infection, a deficiency, genes, age, lifestyle, a chemical imbalance or something else? Be that as it may, the mind-body connection is all too evident in several common diseases and even determines how we recover from it. Finding this connect is often the key to a lasting cure.

Case history one. A young couple married for six years were on the verge of divorce. The reason? The periodic outbursts of the wife, sparked off by hormonal mood swings. Help had been sought from psychologists and counsellors, to no avail. With no end in sight to their woes, the husband had withdrawn into a shell but wanted to give the marriage one last shot. A detailed evaluation by a psychiatrist revealed that the woman suffered from a pre-menstrual disorder with behavioural changes manifesting five days before her period and ending with her menstrual cycle. After taking medication, her mood swings disappeared. The husband understood the psychosomatic connection and the marriage is now back on track.

Case history two. A 40-year-old man suffering from severe gastritis and gastro–oesophageal reflux for more than 15 years, had been to various medical and surgical consultants and at best had only enjoyed temporary relief. Finally, a psychiatrist put his finger on the problem. The gentleman was an obsessive personality given to severe anxiety and stress in the most innocuous of situations. This mental state was thought to be responsible for his gastroenterological problems. With treatment of his psychological disorder he has remained symptom-free for the last three years.

‘Psyche’ and ‘soma’

Dr. U. Gauthamadas, professor and senior consultant in neuro behavioural medicine, explains: “The term psychosomatic stems from mind — ‘psyche’ and body — ‘soma’. Hence, psychosomatic disorders are those involving the body and the mind. Although the term is used to mean a physical disease thought to be caused or made worse by mental factors, psychosomatic disorders are varied.

It is known that some physical disorders such as irritable bowel syndrome (IBS) and asthma are caused by stress. It is also known that some disorders of the mind are caused by physical disorders — for instance, depression caused by hypothyroidism. There can be physical effects as a consequence of mental illness such as sleep or appetite disturbances and weight loss/gain.

Normal physiological bodily changes are also known to cause behavioural disorders — pre-menstrual syndrome, adolescent behavioural issues (both due to hormonal fluctuations).

There is a mental aspect to every physical disease too. How we react to and cope with disease varies greatly from person to person. For example, the rash of psoriasis may not bother some people very much. However, it may make some others feel depressed and more ill.

Symptoms of psychosomatic disorder are often dualistic and vary with the condition. “The psychic component may include any or all symptoms of depression, anxiety, personality disorder, etc. while the somatic component can involve any or a combination of organ systems in the body. Some physical diseases are thought to be particularly made worse by mental factors such as stress and anxiety. Psoriasis, eczema, stomach ulcers, insomnia, high blood pressure, heart disease (it is now known the clinical depression could be one of the causative factors for ischemic heart disease) are examples,” observes Dr Gauthamadas.

Throwing light on stomach-related psychosomatic disorders Dr. Raj Vigna Venugopal, head, department of gastroenterology, Manipal Hospital, says, “Non ulcer dyspepsia (impaired digestion) and irritable bowel syndrome are two common psychosomatic gastro intestinal disorders which account for 30 per cent of gastrointestinal outpatient practice. These disorders are chronic and likely to trouble the patient for years. Diagnosis is difficult in IBS and arrived at by excluding other diseases which mimic functional disorders. Treatment focusses more on patient education, dietary modifications, physical activity and psychosocial therapies rather than medication (because this only temporarily relieves symptoms). Many patients need counselling and treatment of underlying anxiety and depression.”

Interestingly even sleep disorders could be psychosomatic in nature. Says Dr. N. Ramakrishnan, senior consultant and director, Nithra Institute of Sleep Sciences: “There are two aspects of sleep — quantity and quality. Some patients could complain of reduced sleep (“I haven’t had a wink of sleep for years which is medically not feasible”) or fragmented sleep. We find that perceived poor quality of sleep or non-refreshing sleep is a common manifestation of a psychosomatic problem. Documentation with tests such as an actigraph (a watch worn by the patient which provides evidence on when a person is sleeping and when he is awake), sleep studies and a sleep diary can corroborate whether there is a discrepancy between patient perception and objective evidence and hence a psychosomatic dimension, in which case, counselling can help.”

Medication and counselling

Adds Dr. Gauthamadas, “Treatment of psychosomatic disorders comprises medication, and surgical intervention to address the symptoms in the case of physical diseases combined with counselling whenever appropriate. A psychiatrist will treat a person as a whole and take into account mental and social factors which may be contributing to a disease. Therefore treatment to ease stress or depression may help if they are thought to be contributing to the physical disease. Psychotherapy (not counselling as it is wrongly termed) is appropriate in the case of physical disorders caused by mental stress but may not be indicated in the case of disorders of the mind caused by physical disorders. Counselling is indicated in the case of physiological changes that cause behavioural disorders — the difference is that psychotherapy aims at correcting the psychological cause while counselling aims at making the person understand the nature of illness and learning how to manage it.”

While it takes a trained psychiatrist (who is first a physician) to correctly diagnose a psychosomatic disorder, he/she may also refer the patient to a specialist physician consultant such as a cardiologist, gastroenterologist or endocrinologist as the case may be for management of the physical component of the disorder and a psychologist for psychotherapy or counselling (psychologists are not qualified to diagnose or treat a psychosomatic disorder as they are not trained physicians). The bottom line is that both aspects of the disease have to be addressed.

Which brings us to the question — is there a cure? “Most psychosomatic disorders are curable” to the extent that symptoms can be relieved with medication and surgery along with change in lifestyle and mindset. However, it may be necessary to continue physical and psychological treatment for a length of time. Discontinuing treatment may result in a relapse if the underlying physical or mental stressors continue to operate,” says Dr. Gauthamadas.

So when a doctor says a problem is partly in the mind, don’t discount it altogether.