“Please write something from a medical perspective about anxious people who worry every little thing is some serious disease.” — reQuest 2018
This is quite a brilliant and timely question.
The DSM V was published on May 18, 2013. This is the Diagnostic and Statistical Manual of Mental Disorders version 5, and it redefines various disorders. For example, opiate dependence has disappeared and so has opiate addiction. Instead, there is one diagnosis: opiate overuse syndrome. Which really combines both opiate addiction and opiate dependence and makes it a spectrum.
The DSM V drops hypochondriasis. Wait, you say, that diagnosis no longer exists? Well, yes, correct. So the diagnoses are made up? Yes, as my daughter says, “All the words are made up.” So psychiatry changes and the diagnosis definitions change and some diagnoses disappear. Medicine is like the Oregon Dunes, really. The information is changing daily. I went into medicine thinking it is like a cookbook, where I just have to learn all the recipes. Nope, sand dunes: the wind and waves and new information change the contours daily. It drives my patients nuts. “My insurance won’t cover the medicine I’ve been on for 26 years.” Um, yeah, sorry, work for single payer and shut down the insurance companies, ok? “This combination of medicines has never killed me yet.” Um, yeah, sorry, but you are in fact getting older and we no longer think that combination is safe and first do no harm: I can’t prescribe combinations that I think may kill you.
Hypochondriasis has been replaced by two diagnoses: Somatic Symptom Disorder and Illness Anxiety Disorder.
“Patients with illness anxiety disorder may or may not have a medical condition but have heightened bodily sensations, are intensely anxious about the possibility of an undiagnosed illness, or devote excessive time and energy to health concerns, often obsessively researching them. Like people with somatic symptom disorder, they are not easily reassured. Illness anxiety disorder can cause considerable distress and life disruption, even at moderate levels.”
“To meet the criteria for somatic symptom disorder, patients must have one or more chronic somatic symptoms about which they are excessively concerned, preoccupied or fearful. These fears and behaviors cause significant distress and dysfunction, and although patients may make frequent use of health care services, they are rarely reassured and often feel their medical care has been inadequate.”
So, subtle difference. Broadly, the illness anxiety disorder people are sure they have SOMETHING and are worried about ALL THE SYMPTOMS. The somatic symptom disorder people are worried about A SPECIFIC SYMPTOM OR SYMPTOMS and WHY HAVEN’T YOU FIXED ME.
Some of the people complaining of weird symptoms do have a medical diagnosis that has not been sorted out. Take multiple sclerosis for example. The average time from the start of symptoms to diagnosis is 4-5 years.
Another one is sarcoidosis: https://www.mayoclinic.org/diseases-conditions/sarcoidosis/symptoms-causes/syc-20350358. It’s hard to diagnose, can affect different parts of the body, and it’s still pretty mysterious. Add to that list chronic fatigue, fibromyalgia, chronic pain, and numerous other diagnoses.
With multiple sclerosis, you may be thinking, well, if they had just done the brain MRI sooner, the diagnosis would be made. Not necessarily. I did find a patient with a bunch of MS brain lesions: made the diagnosis. She had had a brain MRI 3-5 years before because of suspicious symptoms during pregnancy. At that time her MRI was entirely normal.
The DSM V does not have a diagnosis called psychophysiological disorder. This is an ongoing discussion:
This site: http://www.stressillness.com/ is my current favorite about psychophysiological disorders. I heard a lecture from the physician who runs the site. He is at OHSU in Portland and gets the gastrointestinal patients where “they can’t find anything wrong” from all over the state. He is really good at this. He and I are in agreement: the symptoms are real. However, the symptoms may come from emotional suffering and from emotional trauma in the past and present.
It is clear that fibromyalgia is a “real” disorder: functional MRI of the brain shows the pain centers lighting up more with a standardized pain stimulus than “normal” patients. PTSD is “real”. It is interesting that there is more stigma surrounding fibromyalgia and chronic fatigue than PTSD: is that because the former two are more often diagnosed in women, and the latter is legitimate (finally) for male (and a smaller number of female) veterans?
And what do I, your humble country doctor, think? I think that chronic fatigue and PTSD and fibromyalgia and illness anxiety disorder and the others all may be variations of the same thing. Our body will handle and “store” or “stuff” emotions that we cannot handle or are not in a safe situation to handle it. Eventually our body decides that we are now safe enough and will notify us that we have to handle the emotions. Currently our culture is terribly unsupportive of this and there is huge stigma attached to dealing with it. We are all supposed to just be nice.
In the end, we can’t judge how a friend feels or whether they are well or not. We have to treat them with respect and kindness.
The photograph is me on my grandfather’s lap. He became a psychiatrist and I am a family physician. Taken in 1962 or 3. We are at cabins in Ontario, Canada. What a pair of grubs, but happy…..
For Wordless Wednesday.
I took this walking in the early morning alone when I was visiting friends in Wisconsin this month.
This is an early morning photograph, downtown, not this year.
It was frightening to fly back from Wisconsin last week and have the plane descend into smoke in Seattle. The smoke from fires in British Columbia and Washington blanketed the city. I am used to descending into cloud, but smoke looks brown and was neither opaque nor transparent. Haze.
I missed the worst air, but the smoke still bothers me. One afternoon my receptionist and I both were having trouble with eye irritation from the bad air. My clinic is in a 1950s building and closing all the windows and doors is hot! No air conditioning.
I am hoping that we make changes to slow and mitigate climate change and global warming: I don’t want the world on fire!
How many summers will it take? My guess is three consecutive summers….
For the Daily Prompt: toothbrush.
Here is a young rabbit. Their front teeth grow and get worn down eating. Their nails keep growing too and need to be worn down or clipped if they are pets.
In my county there are no dentists who take the state Medicaid for dental. And in some states Medicaid covers orthodontia for children but not in mine. Teeth are not covered on Washing ton State for my Medicare or Medicaid. And there are still battles going on about covering mental health including addiction. Is mental health not part of health? Are teeth not part of health? Why do we put health insurance profitable before basic life saving health coverage that covers all of us?
Health care should be like a toothbrush. We all need it. We all should have it.
For Wordless Wednesday, taken in 2010.