Is it all in your head?

Yes, but that doesn't make the pain any less real.

Published March 6, 2000 5:00PM (EST)

Pussy Bompensiero is a mob hit man with a back problem. There's nothing medically wrong with the fictional character on HBO's "The Sopranos," but the stress of his job is murder on his back.

Pussy may be fictional but his ailments aren't. Tens of millions of Americans are suffering from rashes, headaches, sour stomachs, back pain, panic attacks and other conditions for which doctors have no explanation.

More and more often, physicians are laying down their stethoscopes and uttering words guaranteed to make any patient recoil in shock and fear: "There's nothing medically wrong with you."

It's a polite way of saying, "It's all in your head." But if there's no physical explanation for a backache, does that mean it isn't real? Most physicians would agree that pain with no discernible source is real, but they couldn't begin to tell you why. And they can't begin to tell you how much they wish you'd bother someone else with the problem. In the absence of a medical diagnosis, you're a "pussy" in the eyes of physicians.

Hypochondriacs are ruining it all for us neurotics. Hypochondriacs believe they have illnesses they don't have. The rest of us don't believe we "have" anything, but we still suffer with mysterious pains, rashes, fatigue, hyperventilation and other ailments.

So is your pain real? In the immortal words of President Clinton, it depends on what your definition of "is" is. If by real you mean something you can point to like a broken bone, then, no, it isn't real. If by real you mean something you can't point to but can see the effects of, like a broken heart, then, yes, it is real.

Defining the reality of pain is a little like defining the existence of a supreme being. If it can't be observed or measured, does it still exist? "Absolutely," says Dr. Caroline Carney Doebbeling, board certified in both psychiatry and internal medicine at the University of Iowa. "Pain without an identified source is very real. Science just hasn't advanced to the point it can tell us where it's coming from."

"Psychosomatic" used to be the umbrella term for pain without medical origin. It's Latin for "nuts, but insured." Doctors pretty much took a patronizing attitude toward their well-insured but kooky clients. But as "psychosomatic" cases increased geometrically over the past few years, a lot of medical cynics had to stop rolling their eyes and pay attention. For instance, irritable bowel syndrome (IBS), a common disorder of the intestines with no known cause, now makes up 12 percent of all primary care visits (and a whopping 50 percent of all referrals to gastroenterologists), according to Dr. Richard Gervitz, professor at the California School of Professional Psychology in San Francisco. IBS is marked by crampy pain, gassiness, bloating, constipation and its snotty-nosed twin sister, diarrhea. About 40 million people have been diagnosed with the syndrome.

There is no medical origin for IBS, yet its physical effects can easily be measured. With colonoscopy (using long, thin, flexible tubes containing a tiny, lighted video camera to look inside the colon) gastroenterologists often see "spastic" colons in IBS sufferers. If the pain is all in their minds, then why are their colons flipping like mackerels on the deck of a boat?

Gervitz is at the forefront of research proving connections between mind and body. The word "psychosomatic," loaded as it is with the baggage of the imagined, has been replaced with "psychophysiological." Psychophysiology tracks the physiology of psychologically induced pain. By hooking up IBS sufferers to sensitive instrumentation, for example, researchers have shown how the brain signals the stomach to stop digesting food and assume a fight-or-flight readiness, explaining why digestion is just another word for toilet among those with the syndrome.

The data is in: You're not crazy. You really are having that headache; Pussy really is experiencing that back pain. Research has proved beyond question that measurable physiological activities take place during unexplained pain. That headache for which your doctor can't determine the physical source? It produces the same kind of muscle tension, blood pressure and oxygenation as headaches that do have physical sources.

According to Dr. David Sobel, a primary care physician with Kaiser Permanente and author of the highly respected Mind-Body Health Newsletter, only 16 percent of people who visit their physician for common maladies like nausea, headache and stomach upset are diagnosed with a physical, organic cause. The rest are classified as having a somatic disorder, the expression of bodily symptoms when you're under psychological distress -- or, as Sobel puts it, "the body speaking its mind."

And when the body speaks, it curses. You can wash out its mouth with soap, but it simply doesn't respond to direct commands. You didn't will the rash onto your body when your spouse left you; you can't will it away. This is perhaps the most frustrating part about the mind-body connection, and what Sobel sees as the danger of simplifying the relationship. "It's not true that if you simply think better thoughts your pain will go away," he says. "It's far more complex than that. There is lots of evidence that a positive state of mind increases the chance for healing, but it doesn't guarantee it."

Psychophysiological treatment doesn't necessarily involve learning how to think good thoughts. It's more about learning how to control largely involuntary processes like heart rate, blood pressure and muscle tension. The preferred method is biofeedback, in which patients are hooked up to devices that pick up electrical signals from the muscles, triggering a flashing light every time they tense up. To relax tense muscles, the patients have to slow down the flashing light. By associating sensations from the muscle with actual levels of tension, they learn to undo detrimental physiological effects.

Not only can our minds make our bodies sick, our bodies are more than willing to return the favor. Doebbeling, at the University of Iowa, believes the mind and the body are so intertwined that it's hard to tell which one has the wheel of the car. The only certainty is that whoever's in control has one hell of a back-seat driver.

Take a patient who comes in with symptoms of depression. Does she have a psychiatric disorder with medical symptoms or a medical disorder with psychiatric symptoms? Doebbeling doesn't know until she does a medical work-up. The classic symptoms of depression are fatigue, an inability to concentrate for very long, sleeping too much or too little and constant rumination. But guess what? Those are the same symptoms of hypothyroidism. "Thyroid hormones serve a homeostatic function," says Doebbeling, "regulating body temperature, energy levels, alertness and cognition."

In other words, your body is just as apt to make you depressed as your mind -- and not just because you don't like what you see in the mirror.

Doebbeling approaches psychophysiology like a snake handler, respectful of the beast's existence but fearful of its ability to mislead. "I support psychophysiology," she says. "It's contributed a lot to our understanding of pain. But I think there's a tendency to relabel unpalatable conditions. It's a lot more socially acceptable to say you have chronic fatigue syndrome than major depression."

Doebbeling sees three pegs in the mind-body connection: mental health, physical health and psychosocial health (which includes everything we do as social beings with our job, family and friends). Each influences the other. For example, a female patient came to Doebbeling complaining of a mysterious stomach ailment. After an expensive battery of tests proved there was nothing medically wrong with the woman, Doebbeling found a "psychosocial" explanation: Her husband was beating her.

Somatic disorders like Pussy's backache or the battered woman's stomach disorder are forcing the medical industry to pay more attention to the mind-body connection. "Twenty percent of the patients are eating up 80 percent of the medical costs," says Gervitz, who predicts "mind-body specialists" will eventually be ubiquitous in physician offices and -- surprise! -- covered by HMOs. "Managed care is getting eaten alive by the expensive tests that are being run on patients with somatic disorders," he says.

There aren't any records of people dying from somatic disorders, but there's
plenty of evidence that they die from asinine treatments. "Death from
hepatic failures in IBS sufferers isn't that rare," says Doebbeling.
"The pain and discomfort can be so unbearable that some ...
gravitate to dangerous treatments like massive vitamin dosages that overwhelm
their livers."

Gervitz reports that the medical community has become much more open to psychophysiological research and treatment. "I was always condescended to by physicians," he said. "It was always, 'Sure, give me your card, I'll call you.' Now it's, 'Here, have a seat -- can I get you some coffee?'"

The medical community is just beginning to understand how our thoughts, feelings and behaviors affect us physically. There are more and more challenges to Western medicine's insistence on treating physical health separately from mental health. In the future people will no longer ask, "Is it all in my head?" because the answer is, No, it isn't all in your head. It just starts there.

By Michael Alvear

Michael Alvear is the author of "Men Are Pigs But We Love Bacon," a collection of his sex advice columns, to be published by Kensington Press in May. He lives in Atlanta.

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