A wonderful woman who has been meeting with me off and on for a couple of years, and who initially came in to see me for some fairly classic symptoms of bipolar type 2, just sent me a “goodbye” e-mail. In it, she noted that she has uncovered the strong likelihood that she has Lupus. Lupus is one of those rare medical conditions that can present with classic symptoms of bipolar.
As it happens, Lupus is also one of the hardest of the inflammatory disorders to diagnose because a fair number of patients with Lupus don’t have the typical physical symptoms and usual laboratory test results associated with the disorder. That was the case for her. Her screening lab tests were normal.
Anyway, she said in that e-mail that she was glad to be rid of me, in part, because when she was seeing a psychiatrist, her family had strongly intimated that her symptoms were “all in her head.”
This is a phrase that I find particularly annoying. It is often something that family and friends will say when they are frustrated with someone who is depressed.
An example of why I find the phrase annoying was provided by a patient with chronic pain who came in to see me for a consultation two years ago because she was developing pretty severe depression symptoms. She also was coming in with great reluctance. She said that going to see a psychiatrist meant that her pain doctor felt that her pain was “all in her head.”
To which I replied, “Well, where else would you experience pain?”
Long pause.
And then she realized that in fact pain is experienced in the brain. There may be signals that are associated with pain that originate elsewhere in the body, but the actual experience of pain takes place in the brain. And the brain is “in your head.”
The problem here is our continuing fascination with Renee Descartes’ notion of mind/body dualism. The idea that the mind (conscious self awareness) exists separate from our physical body.
In a certain sense, this statement is true. The experience of “mind” is different from the examination of “body”. We have a sense of subjective self-awareness, and intuition and creativity, and these experiences are different from the knowledge of neurotransmitters and neurons and how the body functions.
But the difference between the experience of mind and the knowledge of brain is best understood as two different realms of discourse.
Everything that we experience we experience subjectively, but from our subjective experience we develop a clear sense that there exists an objective reality.
A classic model of psychiatric disorders is the “bio-psycho-social” model.
But it’s not as though psychiatric disorders can be parsed out into those which are psychological, and those which are biological. As I’ve mentioned elsewhere on this website, stronger and stronger evidence exists that all psychological phenomenon are associated with a biology.
We can understand and talk about things as biological (meaning objective) or psychological (meaning subjective), or in terms of our relationships (meaning social) or in terms of our values and sense of purpose in life (meaning spiritual). Everything can be understood from each of those perspectives. It is not that there are experiences (depression) that are inherently psychological and other experiences that are inherently biological (lupus). We can understand the psychological aspects of lupus, just as we can understand the biological aspects of depression.
My patient was stuck in this false dichotomy. She and her family held the notion that her mood symptoms were either psychological or biological. If her symptoms were psychological, then she should go to see a psychiatrist (and, by the way, these symptoms weren’t “real” . If they were biological, she should go to see a “real” doctor, because her problems were caused by real illnesses.
But this distinction is not accurate. Things we consider purely psychiatric disorders are clearly biological, and, although it’s often ignored, almost all chronic medical illnesses are associated with profound psychological challenges that can benefit from therapy.
I was sad to say goodbye, but glad that she had found a disorder that might explain her symptoms and that might respond to different treatments than those I use, but I wondered if the treatments for lupus might not entirely address the mood symptoms that brought her in to see me in the first place.