I am a psychiatrist practicing in New Jersey, USA. Like many psychiatrists trained in the early 70s my initial training was psychoanalytic. I have always had an interest in attempting to explain and treat the cases we refer to as being “treatment resistant”. It was clear that neither psychodynamic nor biologically based explanations alone were sufficient to explain these cases and a more comprehensive approach was needed.
First experience with psychiatric complaints caused by infections
Although I am sure I have been seeing psychiatric illness caused by Lyme and tick-borne diseases for my entire career, I became much more involved after an infectious disease colleague referred an extremely ill patient to me.
The patient had a history of Lyme disease and was considered to have been cured with a prior course of antibiotics. After a 3-month psychiatric hospitalization and administering another course of antibiotics, the patient’s suicidal, homicidal and other psychiatric symptoms improved. This case expanded my diagnostic and treatment capabilities and it was subsequently published.
After researching the literature, consulting with colleagues and seeing many more similar patients, it became clear that much of what we call mental illness is caused by prior infections and chronic infection, including tick-borne diseases and Lyme disease.
Difficulty to understand complexity
I shared my observations of the association between Lyme/tick-borne diseases and mental illness with my infectious disease and medical colleagues and was puzzled when some had difficulty in seeing this association and a few became highly defensive. It was clear that some were unable to think on a more complex level and some had very little training in psychiatry and have great difficulty understanding how general medical conditions and infections can cause psychiatric symptoms.
In attempting to understand their view of the etiology of mental illnesses, it appears many of these physicians believe psychiatric illness can just appear without any biological pathophysiological basis. In addition, many physicians have a belief if their assessment reveals no findings they can understand, it is acceptable to label the symptoms as being “subjective,” “non-specific,” “medically unexplained,” functional and psychiatric.
Rigidity of payment systems
Besides limited problem-solving approaches and flawed view of the interaction between psychological and somatic functioning, healthcare systems in which third party payers aggressively promote rigid diagnostic and treatment criteria adds to the problem. Although rigid criteria may be a viable approach for conditions that are well understood, it is a serious failure when applied to more complex and difficult to understand conditions.
The combination of limited problem-solving capabilities, poor training in the brain-body interface and the rigid design of many third-party payer healthcare systems has created a “perfect storm” that discriminates against individuals with complex, chronic, costly and poorly understood illnesses who aren’t aligned with organizations that can neutralize these three hazards.
Complex problems with multiple variables, whether in medicine or any other field, are best understood by using a systems approach. When evaluating a case involving both medical and psychiatric components it is important to first identify if it is psychosomatic, somatopsychic, multisystem illness or some combination of these.
Psychosomatic illness occurs when mental distress results in somatic symptoms. Somatopsychic illness occurs when somatic illness results in mental symptoms. Multi-system illness can result in pathology affecting the brain and body causing both psychiatric and somatic symptoms. The presence of a psychiatric diagnosis does not eliminate the possibility of a comorbid somatic diagnosis or a comorbid somatic diagnosis causing psychiatric symptoms.
The onset of a multisystem illness in a person who is reasonably healthy throughout most of their life is rarely, if ever, associated with a psychogenic etiology. Psychosomatic illnesses invariably begin in childhood, are life-long and vary in intensity depending upon life stressors. A psychiatric diagnosis is never a diagnosis of exclusion. Mental illness is always caused by something, including psychodynamic, neuroimmune, neurochemical, neural network contributors.
Bodily Distress Syndrome in ICD11?
An excellent example of the failure to comprehend the interface between the brain and body is the concept of so called “bodily distress syndrome,” which is a very distressing concept. The term was never given any validity in any edition of the American Psychiatric Association Diagnostic and Statistical Manual (APA DSM) and was not even recognized as a condition needing further research. “Bodily distress syndrome” is basically a synonym for “Medically Unexplained Symptoms,” a concept that is recognized to lack validity in the APA DSM-5.
A term associated with “Bodily distress syndrome” is “Bodily distress disorder”. “Bodily distress disorder” is found in the draft of the 11th version of the International Classification of Diseases (ICD11) currently under development by the World Health Organization (WHO). According to the creators of “Bodily distress syndrome”, “Bodily distress disorder” is one of the many somatic disorder terms that fall under the broader category of “Bodily distress syndrome.”
The proposed definition of Bodily distress disorder is “the presence of bodily symptoms that are distressing to the individual and excessive attention directed toward the symptoms, which may be manifest by repeated contact with health care providers. If another health condition is causing or contributing to the symptoms, the degree of attention is clearly excessive in relation to its nature and progression. Excessive attention is not alleviated by appropriate clinical examination and investigations and appropriate reassurance. Bodily symptoms and associated distress are persistent, being present on most days for at least several months, and are associated with significant impairment in personal, family, social, educational, occupational or other important areas of functioning. Typically, bodily distress disorder involves multiple bodily symptoms that may vary over time. Occasionally there is a single symptom—usually pain or fatigue—that is associated with the other features of the disorder.”
This diagnosis is then used to inappropriately lump many conditions into one and may include Fibromyalgia, Chronic Fatigue Syndrome Irritable Bowel Syndrome, Chronic Pain Disorder, Multiple Chemical Sensitivity, Chronic Acute Whiplash Associated Disorders, cardiopulmonary autonomic arousal, gastrointestinal arousal, musculoskeletal tension, concentration difficulties, impairment of memory, excessive fatigue, headache, dizziness, chronic chest pain, chronic pelvic pain, etc.
This definition raises serious concerns. What is the objective criteria by which “excessive attention” is determined? How is “appropriate clinical examination and investigations and appropriate reassurance” determined? How are the thoroughness of the physician’s exam and the adequacy of their knowledge, experience and judgment determined? How can we be reassured there are no conflicting interests when a physician makes this diagnosis?
Since psychosomatic symptoms rarely involve multisystem disease that are quite consistent and repetitive over time, how can the illness be defined with “typically, bodily distress disorder involves multiple bodily symptoms that may vary over time?” Since “pain or fatigue” can be such disabling conditions they are understandably a reason for significant concern on the part of the patient and how can any “appropriate clinical examination and investigations and appropriate reassurance” reduce appropriate concern for these symptoms?
The synonym of bodily distress syndrome, Medically Unexplained Symptoms, is not included in the APA DSM-5 because “no medical condition is totally explained or unexplained. Instead, knowledge is on a continuum and all conditions are partially explained to different degrees. This label is impacted by the bias and level of knowledge of anyone calling it ‘unexplained.’ These symptoms are often unexamined rather than unexplained.”
After the “medically unexplained symptoms” concept was discredited by the American Psychiatric Association, a group with certain belief systems and special interests dealt with this defeat by changing the name of “medically unexplained symptoms” to “bodily distress syndrome.”
It appears no psychiatrists and no psychiatric organizations have ever endorsed the bodily distress syndrome concept and the physicians mostly involved are a handful of family physicians in Denmark, but significant financial interests seem to be indicated as the prime movers. Furthermore, there are now significant efforts to have “Bodily distress syndrome” overlap with the “Bodily distress disorder” presented in the WHO’s ICD11 codes.
To give a brief case example of the hazard of the concept of bodily distress syndrome, I was asked to do a consult with a young female patient in a hospital who was unable to walk. The treating physician could not find anything physical to explain her complaint. In spite of appropriate reassurance, the patient’s bodily symptoms and distress persisted and were associated with significant impairment.
According to this proposed diagnostic category, she would be given a diagnosis of bodily distress syndrome and her treatment would be psychosocial interventions. I performed a thorough psychiatric examination, a history, a review of systems and a limited general medical examination. The patient did not have la-belle-indifference and there was no psychodynamic explanation to explain her inability to walk. The physical exam demonstrated point tenderness of the right sacroiliac joint with signs of inflammation. Fluid from the sacroiliac confirmed the diagnosis of gonococcal arthritis.
Conflicts of interest
The concern here is that any patient who is more complex and beyond the competency or the thoroughness of the examining physician or may have a condition impacted by the examining physician’s conflicts of interest can be easily misdiagnosed as having “bodily distress syndrome.”
Basically, “bodily distress syndrome” is a highly subjective, poorly defined and non-specific condition that basically lumps a number of complex, chronic and costly conditions into one diagnosis. There is no evidence to support the diagnostic category, only a group of articles and authors quoting each other. The treatment for “bodily distress syndrome” is described as being psychosocial interventions.
Dismissing the biological validity of a large number of patients with this diagnosis category would be very harmful to those patients and a threat to human dignity although it would invite abuse by those who are motivated to discriminate against these patients, in particular medical and disability insurance companies and payers or others who may have liability related to the targeted medical impairments.
Complex, poorly understood diseases are often considered to predominately have a psychological basis until proven otherwise. Tuberculosis, hypertension, and stomach ulcers were once considered to have a functional basis. To properly understand the mind/body connection, a knowledge of general medicine, psychiatry, and the systems which link the soma and the brain are required.
No one has a complete knowledge of all fields of medicine. We must, therefore, retain a sense of compassion and humility, recognize that not all diseases have been discovered or properly understood and be aware that much remains to be learned about the brain/body interaction.
Robert C Bransfield, MD, DLFAPA
(c) Robert Bransfield
References and links
Fallon BA, Schwartzberg M, Bransfield R, Zimmerman B, Scotti A, Weber CA, Liebowitz MR. Late-stage neuropsychiatric Lyme borreliosis. Differential diagnosis and treatment. Psychosomatics. 1995 May-Jun;36(3):295-300.
Gotcha F's improved version of “Bodily distress syndrome: A new diagnosis for functional disorders in primary care?"
Robert Bransfield testimony to the New York State Senate committee
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