Is it a medical or a psychological condition?

“Sometimes patients believe their physical condition explains psychological symptoms such as depression or anxiety. The diagnosis can, e.g., be hypothyroidism. The patient then believes this is why she has been depressed, sad, without energy and joie de vivre. The physical diagnosis becomes used as another defense, making psychological treatment very difficult. How I can intervene with this type of patient?” Thanks to John Page for this question!

It is well known that people suffering from psychosomatic conditions often believe their problems are purely medical and not psychological. And, to be fair, this is sometimes the case. So we cannot be doctrinaire about this but must take a scientific approach to the problem.

When someone comes for a psychological assessment for a psychosomatic condition we cannot assume that his physical problems are psychological in origin. Instead, we have to explore and find out. Find a specific example where he has psychological problems and then explore his feelings.

As we explore feelings, feelings and anxiety will rise. If the patient’s symptoms emerge or worsen with a rise of feelings and anxiety, the symptoms have a psychological cause. If his symptoms do not emerge or worsen while feelings and anxiety rise, then we refer him back to the physician for further workup and medical evaluation.

Therapists often get into trouble trying to convince the patient that his symptoms are psychological in origin. In ISTDP we don’t do that. After all, we can’t know that in advance! Our job is not to convince a patient of anything, but to jointly explore and learn IF there is a psychological cause for his symptoms.

Pt: I don’t think there is any psychological cause for my problems.

Th: You may very well be right. There is no way for me to know that at this point. Could we explore a situation where you have some emotional conflicts so we can rule that out?

Pt: I don’t want to hear again that this is all in my head!

Th: Good, because it’s not all in your head. You are suffering genuine physical pain. The doctors sent you here so we can rule out whether there is a psychological cause. If we look at a situation where you have emotional conflicts, we can rule out this possibility and ensure you get the further evaluation you need. If there is any psychological element, you and I can eliminate that factor and, if there are still remaining symptoms, we can refer you back so you get the further evaluation and treatment you need. Does that sound like a reasonable plan for us to take?

Pt: Do you think this is all psychological doctor?

Th: I can’t make that assumption. This is too serious a problem for us to operate on the basis of guesses. What we can do, if you like, is do an assessment here so we get accurate information about what is causing your physical problems. If there is a psychological factor, we can remove it. If there is no psychological component, we can make sure the doctors focus on finding the medical cause instead. Shall we go ahead and find out together?

Avoid arguments with the patient over what is a scientific question. Then you will avoid will battles and misalliances. Your job is not to convince or argue with the patient, but to engage in scientific exploration of his feelings, anxiety, defenses, and symptoms. Together you can examine the pattern of responses that arise and jointly come to a conclusion based on the evidence of the session rather than on the basis of guesses or assumptions. If the patient makes his assumption and you make yours, you both make the same mistake: “Don’t confuse me with the facts. I’ve got an assumption going here!”

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