Do Your Physical Symptoms Have an Emotional Explanation?

Every system of the body is vulnerable to physical illness. This is common sense. But did you know every system of the body is vulnerable to emotional discord as well? The nervous system, an elaborate network of cells that facilitates communication between our brains and the rest of our bodies, directly links our physical selves to our emotional life. Voluntary muscles, involuntary muscles, and our five senses can all be influenced by the emotional responses of our bodies, so we can manifest a nearly infinite variety of physical responses to stress. While these reactions can sometimes be adaptive and helpful signals (e.g., preparing for flight when in danger), they can also cause distress, leading to visits to doctors.

When our physical symptoms are caused by an injury, bacteria, or an allergen, for instance, medical treatments can work. A visit to primary care, emergency care, or a specialist will likely yield desired results, at least eventually. However, when our physical ailment is caused or worsened by emotional factors, the potential of traditional medicine is limited. At best, a placebo effect may create some relief; at worst, the frustration caused by failed medical treatments can lead our emotion-driven symptoms to worsen.

In this article, I will identify and elaborate upon four empirically supported ideas that may be useful to all of us. No one is immune to the physical reactions caused by emotional stress, so we are all equally vulnerable to developing medically unexplained physical symptoms when emotions overwhelm our coping capacities. If we can more readily identify them and seek appropriate treatments, we may be able to significantly reduce the burden on ourselves (and our health care system) that these symptoms can cause.

1. Emotional Factors Can Contribute to or Cause a Range of Physical Conditions

Emotional centers in the brain link with many important structures of the body, including our large voluntary muscles (anything you can flex) and our involuntary muscles, such as the gastrointestinal system (Janig, 2003). As you will read below, anxiety can trigger activation in any of these muscles, triggering a huge variety of physical symptoms that can be misdiagnosed as having a purely medical origin.

• Voluntary muscles: When anxiety is channeled into the voluntary muscles of our musculoskeletal system and causes involuntary tensing, a large variety of conditions can result, including fibromyalgia, TMJ, sciatica, tension headache, hyperventilation, muscular pain, tingling hands and feet, choking sensation, cramps, and tremors.
• Involuntary muscles: When anxiety is channeled into the smooth muscles that line the gut, veins, capillaries, arteries, bronchi, and urogenital system, conditions such as hypertension, IBS (stomach acid, spasms, diarrhea, nausea), migraine, ulcerative colitis, reactive airways, bladder spasm, abdominal pain, or sudden urge to urinate or defecate can be caused or worsened.
• Thinking/perception/sensation: High levels of anxiety can disrupt our abilities to think and perceive the world. Symptoms such as dizziness, blurry or tunnel vision, sensations of physical weakness, itching, fainting, tinnitus, and difficulty thinking or speaking can all be caused by dysregulated anxiety.

Any of the symptoms described here, and many more, can be triggered by anxiety-provoking emotional experiences, and may be most effectively diagnosed and treated by the methods discussed below.

2. Emotional Factors Contribute to a Large Percentage of Costly Emergency Visits

Medically unexplained physical symptoms can have a sudden onset and can be terrifying to the person experiencing them, which can lead to visits to emergency services and referrals to specialists. It is important for all health care consumers and practitioners to be aware of the high rate of patients who present with medically unexplained symptoms—and the significant efficacy of a short course of psychotherapy for treating these symptoms.

One unpublished study cited by Abbass, et al. (2010) found that 16% of emergency department (ED) referrals leave the hospital without a medical explanation for their presenting symptoms. This included 75.8% of people who presented with chest pain. Other common health concerns that left the ED without a medical diagnosis include headaches and abdominal pain. Regarding visits to specialists, Abbass (2004) reported on studies that found:

Eighty-four percent of 567 common internal medicine complaints—such as chest pain, dizziness or weakness—yielded no new diagnosis and cost a great deal to investigate. A recent British study found that one quarter of all new specialty referrals studied resulted in no diagnosis. This included almost one-fifth of surgical referrals and over one-third of some medical specialty referrals (p. 6).

According to this data, between 10% and 20% of ED visits and between 20% and 84% of specialist referrals yield no medical explanation, and it seems the most common medically unexplained symptoms can be linked with the bodily manifestations of anxiety described above. Fortunately, advances in mental health assessment and treatment are helping to change these worrisome statistics.

3. Emotional Contributors to Physical Symptoms Can Be Diagnosed Quickly

In his article about “emotion-focused interviewing” to diagnose somatization (the term for the process by which emotional factors affect physical health), psychiatrist and researcher Allan Abbass (2005) provides examples of brief conversations between doctor and patient that help reveal a clear link between emotional upsets and increases in symptoms. This interviewing technique, which has become an important part of my practice, is based on principles and techniques from a model of brief psychodynamic psychotherapy called intensive short-term dynamic psychotherapy, or ISTDP (Davanloo, 2000).

Clinicians who learn ISTDP are trained to monitor a variety of verbal and bodily signals so they can detect an increase or decrease in the physical symptoms as thoughts and feelings are explored during an interview. According to Abbass (2005):

An increase in symptoms with emotional focus suggests that emotions aggravate or directly cause the problems. A decrease in symptoms during the test also suggests a linkage to emotions. Disappearance of the symptoms by bringing emotional experiences to awareness is the best direct evidence that somatization of these emotions was causing the patients symptoms (p. 235).

Abbass suggests this diagnostic process can be accomplished in as little as 15 minutes of conversation. Considering the financial and time costs of the procedures that are often used to diagnose medically unexplained physical symptoms (e.g., fMRI), Abbass makes a compelling case for the utility and efficacy of an emotion-focused interview based on ISTDP that can help establish whether emotional factors are playing a role in physical symptoms.

4. Psychological Treatments Show Cost-Effectiveness

Seeing a psychotherapist to rule out emotional factors earlier in the diagnostic process can save money and heartache, which is especially important because the emotional upset associated with failed medical procedures and treatments can cause symptoms to worsen.

Seeing a psychotherapist to rule out emotional factors earlier in the diagnostic process can save money and heartache, which is especially important because the emotional upset associated with failed medical procedures and treatments can cause symptoms to worsen.

Abbass (2003) calculated an average health care cost reduction of $1,573 per patient by one year after a course of ISTDP. Only two of the seven studies reviewed for cost-effectiveness by Abbass (2003) were specific to medically unexplained physical symptoms (irritable bowel syndrome and chronic functional dyspepsia); however, even those who were being treated specifically for psychological concerns experienced a large reduction in their overall health care cost burden. This is strong evidence for the cost-effectiveness of ISTDP in reducing health care costs for folks with medically unexplained physical symptoms and general mental health concerns.

Another finding that supports this line of research is that the use of ISTDP therapists in the ED described above led to a 69% reduction in ED visits by those who had a very brief course of psychotherapy (3.2 sessions on average). Those who did not have the therapeutic consultation had anywhere from a 15% reduction to a 43% increase in ED use over the course of the next year (Abbass, et al., 2009). Average health care cost savings among the treated group was $910 in the follow-up year (Abbass, et al., 2010). This is strong evidence for the potential advantages of a medical system that takes emotional factors into account, both for those suffering and for the health care system overall.

Looking at the Data and Looking Forward

Thanks to the work of Davanloo, Abbass, and others, we have helpful tools for understanding the ways emotions impact the body and create medically unexplained symptoms. We know medically unexplained symptoms burden the people who experience them and the medical system with lost time, lost resources, dashed hopes, and continued suffering. Finally, we have tools and methods for diagnosing and treating somatization of emotions that have shown efficacy and cost-effectiveness. To me, as Abbass (2004) has argued, these data make the case for the importance of heightened awareness of this information among health care consumers and practitioners.

It is my hope that with greater awareness of the ways emotions can impact health, doctors and patients alike will be more open to referrals to emotion-focused assessment services like the one described by Abbass (2005) and to therapies, such as ISTDP, that have demonstrated efficacy in treating medically unexplained symptoms. However, until this becomes part of standard medical practice, we can advocate for ourselves by asking questions about whether our symptoms could possibly be linked to stress, anxiety, or other issues, and by seeking out appropriate assessments and treatments.

While we should not flip radically in the opposite direction and assume all our physical woes are psychosomatic, we may save ourselves from needless expenditures of time, money, and hope by having an emotion-focused interview early in the diagnostic process to establish whether emotional factors are contributing to our medically unexplained physical issues.

References:

1. Abbass, A. (2003). The cost-effectiveness of short-term dynamic psychotherapy. Expert Review of Pharmacoeconomics Outcomes Research, 3, 535-539.
2. Abbass, A. (2004). The case for specialty-specific core curriculum on emotions and health. Royal College Outlook, 1, 5-7.
3. Abbass, A. (2005). Somatization: Diagnosing it sooner through emotion-focused interviewing. The Journal of Family Practice, 54, 215-224.
4. Abbass, A., Campbell, S., Magee, K., & Tarzwell, R. (2009). Intensive short-term dynamic psychotherapy to reduce rates of emergency department visits for patients with medically unexplained physical symptoms: Preliminary evidence from a pre-post intervention study. Canadian Journal of Emergency Medicine, 11, 1-6.
5. Abbass, A., Campbell, S., Hann, G., Lenzer, I., Tarzwell, R., & Maxwell, D. (2010). Cost savings of treatment of medically unexplained symptoms using intensive short-term dynamic psychotherapy by a hospital emergency department. Journal of the Academy of Medical Psychology, 1, 34-43.
6. Davanloo, H. (2000). Intensive short-term dynamic psychotherapy: Selected papers of Habib Davanloo, MD. Chichester: Wiley.
7. Janig, W. (2003). The autonomic nervous system and its coordination by the brain. In Davidson, R. J., Scherer, K. R., & Goldsmith, H. H. (Eds.), Handbook of affective sciences (pp. 135-187). Oxford: Oxford University Press.

The preceding article was solely written by the author named above. Any views and opinions expressed are not necessarily shared by GoodTherapy.org. Questions or concerns about the preceding article can be directed to the author or posted as a comment below.