Under DSM-IV, a “diagnosis” of somatization disorder entailed a history of physical symptoms for which, despite thorough medical evaluation, no satisfactory physical etiology could be established. In DSM-5, this “diagnosis” was replaced by somatic symptom disorder. This is essentially similar to DSM-IV’s somatization disorder – with one critical difference. The newer “diagnosis” can be assigned even if there is an identifiable physical illness. The essential requirement for the new “diagnosis” – indeed the only requirement – is that the individual is excessively or disproportionately preoccupied with the symptoms. And who, one might ask, decides if a person’s preoccupation is excessive? A psychiatrist, of course, whose vast training in drugs and ECT equips him with the wisdom, empathy, and insight to make such judgments. As the eminent Dr. Biederman proclaimed in a public courtroom on February 26, 2009, a psychiatry professor is second only to God in status and ability!
During my career, I worked with a great many people who were preoccupied with medical concerns. Some of these individuals had serious illnesses, and my task essentially was to help them adapt to their medical status and still find ways to have a fulfilling and meaningful life. In other cases, the matter was less clear cut. Some didn’t seem to be all that sick, but I stress the word “seem,” because I didn’t know. My fundamental perspective was that everything a client says should be taken seriously. I found that in all cases, if I listened carefully, respectfully, and humbly, I could come to an understanding of the client’s perspective.
I remember working with a young woman in her mid-20’s. I’ll call her Julie. She was truly terrified that she had cancer. She had incurred the irritation of several physicians who accused her of wasting their time, and had been referred to a psychiatrist who gave her a “diagnosis” of hypochondriasis and prescribed an antidepressant. The young woman chose not to fill this prescription, and instead came to see me.
We talked – or rather, she talked and I listened. It emerged that during a one-year period, when she was five years old, three family members (an uncle, aunt, and grandmother) had died of cancer! Obviously the feelings of devastation were crippling – not only for her, but for all the surviving members of the family. So at the very time when she needed an enormous amount of support, her primary caregivers were themselves reeling in shock and grief.
What made things particularly difficult for Julie was the fact that the impending deaths were never discussed with her. For her, as a five-year-old child, these individuals were just snatched away into oblivion – by this thing called cancer. For Julie, there really was a bogey man under the bed. And when she came to me for help, the bogey man was still there. For me, whether Julie’s fear of cancer was “proportionate” or otherwise was never an issue. I started from the simple premise that her fear was valid, from her perspective, and that my task was to help her manage this fear in a way that still allowed her to enjoy life and do the things she wanted to do.
After much discussion, she came to the conclusion that the way forward was: to recognize that because of her family history, she probably did indeed have an increased risk of contracting cancer; to take appropriate counter-measures (including diet and regular medical checks); but to not allow the concern to destroy her life. Once she had formulated her objectives in these terms, she was remarkably successful in keeping her concerns about cancer in a reasonable balance. I asked her if she had told the psychiatrist about the three family deaths. She replied: “No, he never asked about anything like that.”
The truly appalling thing about this is that the psychiatrist, within the context of his profession’s conceptual framework, was not being negligent. All he needed for his “diagnosis” at that time was the DSM-III-R list of symptoms:
- preoccupation with the fear of having a serious illness
- no actual evidence for the illness
- the fear is not allayed by medical reassurance
- the fear has lasted for six months
- the belief/fear is not of delusional intensity
For psychiatry, that’s all that was needed to “make the diagnosis” and to legitimize the prescription.
The essential point here is that we humans are strange creatures. During our childhood years we develop all sorts of ideas and feelings. Some of them are helpful, others less so. Some are disastrous. But they are all understandable, if someone will take the time to listen. Note that it was no part of my role to “fix” Julie, or even to say that she needed to be “fixed.” Perhaps the most significant thing I said to her during the time we worked together was: “If I had walked in your shoes, I would also be terrified of cancer.” My job was to provide an unhurried setting of trust and mutual respect in which Julie herself could explore the sources of her fear, catalog the extent to which it was derailing her goals and her relationships, and formulate remedial action. At all times, Julie was in the driver’s seat.
But that is not the psychiatric way. People whom psychiatrists consider excessively preoccupied with these matters are “diagnosed” with somatic symptom disorder, usually on the basis of a short interview and perhaps a five-minute phone consultation with a general practitioner. And the patient is given neurotoxic pills – to correct the “chemical imbalance” or the “neural circuitry anomaly” or whatever trite and deceptive rationalization is current at the time. And if, with the passage of years, the hapless client is irreparably damaged by the drugs, then there’s always a locked psych ward and ECT.
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This article first appeared on Behaviorism and Mental Health,
Philip Hickey’s blog