P. VALENT
Psychophysiological Symptoms
Because the sympathetic and parasympathetic nervous sys-
tems and stress hormones reach and influence every organ of
the body, their arousal in stress can result in a very wide range
of symptoms that include potential arousal and dampening of
every bodily system. Musculo-skeletal tension symptoms in-
clude headache, neck ache, chest pain, and back ache. Digestive
system symptoms include loss of appetite, weight loss, weight
gain, nausea, constipation, diarrhoea, etc. Cardiovascular symp-
toms include palpitations, shortness of breath, chest pains, high
blood pressure. Urino-genital system symptoms include bladder
pressure, frequency, dysmenorrhea, painful intercourse.
Psychophysiological symptoms can mimic at least in part
most physical disorde rs.
Case 5: A woman who attended her GP with recurrent head,
neck, and back pains was found to suffer from tension that re-
sulted from bracing against her husband’s violent outbursts.
Case 6: The first time a patient developed migraine was
when she witnessed Nazis vandalise her grandmother’s shop in
Vienna on Krystallnacht. She felt a fury toward those who
made her grandmother collapse in the street. However she was
impotent to vent her rage. Throughout her life migraines re-
curred at times when she had to bottle up her anger.
Reliving Traumatic Situations
Dissociated aspects of traumatic situations may be relived as
physical symptoms.
Case 7: A combat veteran kept returning to hospital with
chest pain which he was convinced was sign of a heart attack.
The pain did not conform to heart disease and all tests were
normal. On closer questioning the pain was a wrenching of the
heart, as if it incurred a wound, or as if it was broken. It was the
exact pain he felt when his buddy died in his arms. Grieving
relieved the physical pain.
Case 8: A woman experienced severe physical pain each
time her husband penetrated her. The pain was a replica of the
pain she suffered when an uncle penetrated her as a child.
Identification wit h Ill ne ss es of Others
Patients often identify with symptoms and illnesses of those
they love, especially of those who had died. This is a result of
empathy, guilt, and not having let go. Symptoms often arise
during the loved person’s terminal illness, after bereavement, at
anniversaries, and when attaining the age of the loved person
(such as a parent of the same sex).
The symptoms are often unusual because they reflect pa-
tients’ concepts of what others suffered, and such concepts may
be anatomically untenable.
Case 9: A month after her husband’s death of a heart attack,
a woman presented with a sharp stabbing pain over her left
nipple. She believe d that she was having a hea rt attack like her
husband.
Case 10: A 12-year-old girl was brought to hospital after she
carelessly rode in front of an oncoming car. Two years earlier
her sister, then 12 was killed on her bike in a collision with a
car. The younger sister blamed herself for her sister’s death and
had fantasies of joining her in heaven.
“Cherished” Illnesses; Hysteria
It goes against the medical grain to consider that suffering
may be cherished. Patients who cherish their symptoms arouse
frustration because they do not comply with treatment, their
symptoms migrate, and they adopt fashionable diagnoses that
are difficult to diagnose and treat.
Once suspicion is aroused, diagnoses only thinly veil anger.
Diagnoses include “secondary (financial) gain”, “hysteric”,
factitious disorder, Munchausen’s syndrome, and malingering.
In reality, apart from the few cases of malingering, cherished
illnesses obey classical rules of hysteria. The symptoms are
produced through unconscious processes; they symbolise a
major stress or trauma ; whose consequences the symptoms help
to resolve this being primary gain; and they are secondarily
used for other gains (secondary gains). The classical example
was the World War One soldier whose paralysis of the right
arm necessitated his withdrawal from combat.
Case 11: A previously somewhat pampered inductee was
bullied by his army colleagues who teased him as not having
“guts” or “stomach” for the army. After a mild punch to his
stomach he developed severe abdominal cramps that did not
respond to treatment. Eventually he was “honourably” dis-
charged.
Case 12: A previously hard working man developed back
pain after lifting a heavy object. His disability was beyond any
objective pathology. The man’s wife withdrew from sex after
her doctor advised her that she would die if she had another
child. The man, however, suspected that his wife had a lover
while he was at work. Staying at home enabled him to keep a
watchful eye over her. Secondarily, his disability evoked con-
cern from his wife, as well as worker’s compensation.
Discussion
The six categories of illnesses present a heuristically useful
way of conceptualising illnesses. Rather than consigning symp-
toms that do not meet typical somatic criteria to a waste-basket
of therapeutic nihilism, a checklist of illness categories may
find that the symptoms fit precisely into one of the non-somatic
categories.
Considering the frequency of MUPS, this has clinical impli-
cations for approaches to all patients. Such approaches have
been called holistic, and biopsychosocial. I prefer to call for a
wholist approach (Valent, 1998a) that includes both biopsy-
chosocial and whole. In addition to biological, psychological,
and social interactions, the approach concerns itself also with
moral dilemmas and existential meanings. They were very rele-
vant in the abov e cases.
Pragmatically, a somatic approach like “Tell me about the
pain”, is replaced with an open-minded question such as “Of all
the things that worry you what worries you the most?”.
All histories should include questions such as “Have you
been under stress or experienced trauma recently/when the
symptoms started?”, “Apart from these symptoms do you have
any others/any other worries/frustrations/conflicts?”, “Have you
been depressed/anxious/experienced other strange symptoms?”,
“Have you known anyone else who suffered these symptoms?”,
“If you could have any desire fulfilled, what would it be?”.
When patients reveal the emotions and contexts of their wor-
ries, it is not so much that a Pandora’s box opens with ever-
more problems, but rather that a box under pressure opens akin
to the release of an abscess.
The categories enable making positive psychosocial diagno-
ses. Further, diagnoses are confirmed when symptoms recur
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