Geetha’s illness began 4 years ago when after a period of religious fasting. She developed abdominal pain and was initially treated with antacids, however, the pain persisted through short periods of apparent recovery. She also began developing severe neck pain and pricking sensations over the back. She also had constant joint ache which prevented her from doing daily work. She would also have constipation on and off. All these physical symptoms were extremely distressing she was unable to do her daily work. She sometimes worried that these symptoms might be secondary to something bigger, Her relationships also began to suffer secondary to her being ill all the time. She has been evaluated extensively by multiple physicians and all her tests and imaging remain unremarkable. Despite repeated reassurance from multiple physicians including specialists, Geetha remains symptomatic and is referred to a psychiatrist for evaluation.Geetha was confused as to why she needed to see a shrink! But decided to give it a go as she had already tried everything!
Chronic pain is a source of biological and psychological stress. Unremitting pain and unexplained physical symptoms can lead to changes in the brain eventually leading to mental illnesses such as depression and anxiety. Mental illness can also lead to chronic pain. Our brain perceives both physical and mental pain similarly!
Somatisation involves both mind and body. Unexplained somatic symptoms and somatoform disorders generally occur more commonly in females than males with a ratio of 5:1. The lifetime prevalence is under 2% in females and around 0.2% in males. Symptoms usually begin in the teen years. People with somatoform disorders are usually convinced that their symptoms have a physical cause.
Psychosomatic illness can be extremely distressing and confusing to the sufferer. The biological basis of psychosomatic pain is discussed below.
The neuroscience science of psychosomatic pain
Pain is transmitted via the pain fibres, which enter the grey matter in the spinal cord and also send out branches to one or two segments of the spinal above and below. Specific receptors that detect pain and other noxious stimuli are connected to a part of the spinal cord called the dorsal root.
This pain stimulus ascends the spinal cord and reaches the thalamus in the brain, four thalamic areas respond to noxious input. Relevant to us is the nucleus submedius where the pain signals are projected to the forebrain (the seat of cognition, mood and emotion). The affective/motivational pain pathways that send projections to the nucleus submedius are modulated by descending pathways called bulbospinal pathways. These descending tracts are inhibitory in nature and stimulating these tracts blocks response to pain.
Pain is modulated in these pathways by neurotransmitters, especially serotonin and noradrenaline. Abnormalities in these neurotransmitters have a significant role to play in depression and anxiety. The basic relationship between serotonin and pain appears to be inverse; that is, drugs that increase serotonin generally produce a decrease in pain (and vice versa). Noradrenoceptor agonists have been shown to attenuate pain responses. Psychosomatic pain can arise when these modulatory mechanisms are altered. There are no commercially available tests to identify these neurotransmitter abnormalities.
Symptoms such as palpitations, increased sweating, dizziness, bowel and bladder problems and abdominal discomfort can also have psychosomatic origins. This can be due to increased threat perception and a sensitive and hyperactivated autonomic nervous system.
The pain is real and sometimes severe, it is not imagined or “in the head”.
Fortunately, with the right treatment which may include medication aimed at correcting these abnormalities, psychosomatic syndromes can be managed effectively. Further multiple psychotherapeutic measures such as mindfulness and hypnotherapy have been effective in managing pain.
Geetha was reassured by her psychiatrist and her suffering acknowledged. Her distress and the pain were validated, regardless of the absence of a physical explanation. She was educated about her illness and the need for compliance with treatment. Though sceptical at first, Geetha continued treatment and over time her pain subsided and she back to her former self.
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