Recently, former Prime Minister Édouard Philippe wondered about the possible effects of stress on the unusual changes in his body hair. Could such a change in appearance actually be a sign of the mind’s effects on the body? In other words, a psychosomatic disorder?
While this concept enjoyed popularity in both scientific and popular circles during the 1960s and 1970s, it has since fallen into relative disuse.
What is the current state of scientific knowledge on this issue? And what are—or should be—the implications of current knowledge for the medical management of such disorders?
Released in 1980, Alain Resnais’s film *Mon oncle d’Amérique* is a good illustration of a time when many illnesses were attributed to “stress.”
In particular, the film depicts the character played by actor Gérard Depardieu, who, after a meteoric rise to success, faces obstacles that have devastating effects on his mental and physical health, while biologist Henri Laborit discusses the effects of stress on physical health, based on experiments conducted on laboratory rats.
Stress, a concept developed by Hans Selye three decades earlier, was then used to explain skin diseases, high blood pressure, and heart disease, as well as peptic ulcers and digestive disorders—and, for some, even cancer. Psychological factors were thus believed to be the cause of many ailments, for which the individual himself was ultimately to blame, given his state of stress…
The discovery that peptic ulcers were caused not by stress but by the presence of a bacterium in the stomach— Helicobacter pylori—and could therefore be treated much more effectively with antibiotics than “through talk therapy,” severely undermined this line of thinking. Ultimately, biological, environmental, and/or genetic causes took precedence over psychological causes.
However, this shift away from the psychological did not resolve two major problems. First, on a theoretical level: dismissing a psychological cause in favor of a biological one actually reflected a dualism from a bygone era, drawing an artificial and illusory boundary between mind and body.
From a practical standpoint: today, just as in the past, at least one-third of the people who see a general practitioner or a specialist have very real symptoms that cannot be explained medically.
Emotional states—which are physical states first and feelings second—have an impact on the regulation of many systems, as neurologist Antonio Damasio explains in his famous works *Descartes’ Error * and *Spinoza Was Right*. As early as 1884, British psychologist William James addressed this concept in an article titled “What Is an Emotion?”.
In fact, psychological factors appear to play a role—one that is still poorly understood but can be quantified through epidemiological studies—in the exacerbation of chronic diseases, inflammatory flare-ups, or immune modulation.
Studies have shown that depression doubles the risk of all cancers and quadruples the risk of breast cancer. A recent meta-analysis also highlights that a clinical diagnosis of depression and anxiety is associated with an increased risk of developing cancer.
Be careful, however: it is important to note that the field of study examining the impact of psychological factors is susceptible to confounding factors. In other words, an association does not imply a causal relationship. In the case of depression, for example, the increased risk of cancer might not be directly linked to the illness itself, but rather result from the fact that people with depression tend to be less concerned about their health than others, pay less attention to their symptoms, or are less diligent in following recommendations for cancer screening.
Addressing this type of bias is the responsibility of epidemiology, on the one hand, and basic research, on the other.
Even today, there are still patients whose symptoms are “medically unexplained.” In these individuals, not only are all biological, functional, and imaging tests normal, but there is also no valid hypothesis of a physiological dysfunction. For example, a tremor that affects sometimes an arm, sometimes a leg, disappears when attention is diverted, and varies in frequency depending on movement, cannot be attributed to a specific impairment of the motor circuits. A link to the monitoring of attentional resources had already been suspected more than a century ago by the psychologist Pierre Janet.
“Medically unexplained” does not, therefore, mean that medicine is unable to correctly identify the symptoms, but rather that current physiological knowledge does not allow us to explain their manifestations.
In fact, contrary to a widespread misconception (even among doctors), when dealing with this type of disorder, the diagnosis is not one of exclusion. The doctor does not order every possible test only to conclude, when all results come back negative, that “it’s all in the head.” On the contrary, the goal is to establish a positive diagnosis—in the sense that solid evidence rules out the presence of any organic pathological factor.
We must, however, be careful not to revert to a dualistic view that would separate, on the one hand, “organic” illnesses—which have their origin in clear physical dysfunctions—and, on the other, “psychogenic” functional illnesses—which are believed to be generated by the psyche.
Not only because this dualistic view portrays patients as the “authors of their own misfortune”—to paraphrase the title of the book by health activist Angela Kennedy (“Authors of Our Own Misfortune”)—but also because it amounts to ignoring the fact that psychological factors are also embedded in our neural structures.
“It’s all in the head” does not mean that the clinical complaint is imaginary, fabricated, or feigned. In fact, functional brain imaging can reveal changes in neuronal activation in response to certain contexts. Functional disorders are therefore indeed associated with abnormalities in specific neural networks.
This is the case, for example, with a patient suffering from functional paralysis who has a limited ability to take control of his or her own actions due to reduced connectivity between the brain’s information-integration areas and its motor and sensory areas. However, the brain of a person who is feigning such a condition does not exhibit these changes.
This reduced connectivity might be the result of abnormalities in the emotional regulation system.
Another example: A few years ago, a 29-year-old man was admitted in critical condition to the emergency room of a North American hospital after swallowing the contents of a bottle of antidepressants he was taking as part of a clinical trial. Extremely low blood pressure, breathing difficulties, and generalized tremors led the medical team to administer an intravenous fluid replacement.
When contacted urgently, the laboratory agreed to lift the blind, which made it possible to determine which group the subject was in. The result: he had taken the placebo. His symptoms could therefore be attributed to the “nocebo” effect: taking a substance with no pharmacological effect had caused him to experience harmful effects. As soon as the nature of the product was revealed, the symptoms disappeared…
When physical symptoms are distressing or cause clinical signs (fatigue, tremors, pain, dizziness, etc.), they must be addressed, even if the medical cause is not immediately apparent. Indeed, these symptoms are real and are actually being experienced—they are not imagined.
However, in such situations, patients are often disappointed: the doctor, at a loss, offers a phrase meant to be reassuring but which, in this context, is particularly ill-chosen: “There’s nothing wrong…” The doctor-patient relationship becomes bogged down. This opens the door to medical nomadism—a endless cycle of visits to specialists—until a positive finding is discovered, whether from an imaging result or after yet another serological test. But does that necessarily mean this explanation is the correct one? It’s not certain, because we’ve all been exposed to infectious agents at one time or another. But at least “we’ve found” something…
The real challenge in treating “psychogenic” disorders lies in understanding the role of psychological factors without resorting to an artificial separation between body and mind. To do this, it is best to start with the body—with the changes brought about by situations, lived experiences (particularly traumatic ones), and the expectations associated with them.
Often, Our bodies slip away from us. It is affected by life events: emotions, which in some cases can manifest as symptoms. But these are less about illness than about suffering. Suffering that modern Western medicine—certainly mistakenly—tends to regard as of little importance.
