The psychosomatic self

Ben Hoban is a GP in Exeter.

The only people who really want to hear that their problem is psychosomatic are those for whom the alternatives are worse. As a diagnostic label, it is a way of reassuring someone that they don’t have cancer, or of validating their sense that something they are dealing with in life has started to affect their health in a more tangible way. To a patient who is struggling  with persistent physical symptoms that may be difficult to explain fully, it is likely to suggest something less welcome: it’s all in your head.¹ From a doctor’s perspective, the utility of such a label is also dubious: it may allow a specialist to discharge someone, but their GP continues to be  responsible for their care and may feel burdened by a formulation that gives them little to work with. Where there is an obvious psychological trigger for someone’s symptoms, or where they make sense in the context of a clear mental illness, the connection between psyche and soma may be straightforward. On the other hand, trying to persuade an emotionally well-adjusted person that their symptoms are due to some kind of repressed neurosis is unlikely to end well. If the only reason a doctor labels symptoms as psychosomatic is that they can’t come up with a better explanation, they might as well blame the fairies at the bottom of the garden.

Perhaps the reason that psychosomatic illness is so well established as a concept at all is that we tend to adopt a dualistic worldview, which splits reality into paired categories. These are complementary in theory, but in practice have a winning and a losing side: church and state; science and faith; mind and body; real and imagined. Scientifically trained doctors working for a national health service will naturally look for the cause of someone’s somatic symptoms in the body, and when they find no explanation there, what can they do but attribute them to the mind, and how could this feel anything other than second best, or worse?

The term Medically Unexplained Symptoms also (MUS) implies that only what can be properly explained is valid. A proper explanation here is one based on accepted forms of evidence and ideas of causation within the biomedical model, typified by pathological lesions in a specified organ producing a characteristic pattern of symptoms, signs, and abnormal findings on laboratory or radiological investigation. Patients whose illnesses do not conform to this model and are therefore “contested” in fact often uphold the same orthodox view.² This can result in disputes between advocacy groups and the medical establishment over how to interpret the available evidence, rather than a wider discussion about what sort of evidence or causation we should consider valid.

It is easy to be blinkered, and there is no logical reason why the fact that organ damage causes symptoms should mean that symptoms can only be produced by damaged organs, any more than the observation that all sailors have blue eyes would mean that all blue-eyed people were sailors. We can certainly recognise a class of illness which is neither psychogenic nor fabricated, and yet which diverges qualitatively from the classical model in lacking a simple pathological cause and in having as its primary source of evidence the experience of our patients.^3-5 The symptoms and signs of such an illness may be difficult to pin down, and clinical tests designed to catch out malingerers may be falsely positive. Diagnosis does not depend on first excluding every possible alternative, and special investigations may or may not be normal because ultimately, anything that takes place within the mind-and-body, the psychosomatic whole, will have some kind of biological correlate if we look closely enough for it. We can observe changes in any number of organs without strictly being able to say whether they are the cause or effect of an illness, or even whether in a complex system those are valid distinctions to make in the first place. It is sobering to consider that at least a fifth of patients with advanced osteoarthritis of the knee experience ongoing symptoms after a joint replacement: however clear-cut a pathological model of illness seems, there is obviously something else going on too.⁶

Our experience of reality is more than just a passive awareness of what is happening in and around us, and our ability to interact with it depends on more than just the smooth running of our body parts. The brain acts as an operating system for both the mind and the body, a common factor organising our function as well as our perception. If there is something in our head with a hidden role in illness, it therefore makes better sense to think of it as neurological than psychological. It may seem like splitting hairs to tell a person that something is happening in their brain rather than their mind, but we need to find ways of communicating more subtly with a group of patients who often feel let down and dismissed by their doctors. There is a real danger that those whose symptoms cannot be explained within a narrowly biomedical framework come to be seen as somehow beyond the pale. They are not, and we should either give up talking about  psychosomatic problems in this group altogether, or admit that all problems that take place within the psychosomatic self can be described in this way, whether they are attached to a more concrete disease process or not.

It can be easy as doctors to talk a good talk about holistic care, while only offering it if a lack of alternatives forces us to, and it is therefore hardly surprising that patients smell a rat when we do. The solution is not to avoid practising holistically, but to do it more consistently, regardless of someone’s diagnosis. The results can be surprising: perioperative psychological intervention has been shown to improve outcomes in knee arthroplasty.⁷ Separating the physical from the psychological is not just an unhelpful distinction, but ultimately a false one.

Most ill health is likely to represent a balance of peripheral and central phenomena, and it is likely that aspects of any ongoing medical problem will be dysfunctional, just as any functional disorder will also have more concrete elements. Our preoccupation with the concrete is misguided, though, a consequence of the way we split illnesses and the patients who suffer from them into groups which we consider more or less valid. Reintegrating the psychosomatic self should enrich our care of all our patients, not exclude those whose experiences we find it difficult to make sense of. There is a whole spectrum of illness, ranging from the acute, simple, and pathological to the chronic, complex, and functional, and all of it is real. Coming to a shared understanding of where each person’s needs fall on this continuum should make it clearer how we can best help them. Whole people need holistic care, whatever is wrong with them.

References

1. Elke Hausmann, The Age of Diagnosis: Sickness, Health, and Why Medicine Has Gone Too Far; the curious characterisation of Long Covid as a psychosomatic condition, British Journal of General Practice 2025; 75 (754): 228-229 org/10.3399/bjgp25X741525
2. Contested Illness in Context: an Interdisciplinary Study in Disease Definition, Harry Quinn Schone, Routledge, 2019
3. Medically Unexplained Symptoms, Somatisation and Bodily Distress: Developing Better Clinical Services, edited by Francis Creed, Petter Henningsen and Per Fink, Cambridge University Press, 2011
4. ABC of Medically Unexplained Symptoms, edited by Chris Burton, Wiley-Blackwell, 2013
5. Functional Disorders and Medically Unexplained Symptoms: Assessment and Treatment, edited by Per Fink and Marianne Rosendal, Aarhus University Press, 2015
6. Lewis, G.N. et al, Predictors of persistent pain after total knee arthroplasty: a systematic review and meta-analysis, British Journal of Anaesthesia, Volume 114, Issue 4, 551 – 561
7. Sorel JC, Overvliet GM, Gademan MGJ, den Haan C, Honig A, Poolman RW. The influence of perioperative interventions targeting psychological distress on clinical outcome after total knee arthroplasty. Rheumatol Int. 2020 Dec;40(12):1961-1986. doi: 10.1007/s00296-020-04644-y. Epub 2020 Jul 29. PMID: 32728837; PMCID: PMC7591436.

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