Buddhi Stories Featured Unexplained Medical Symptoms

What’s up, doc?

When symptoms defy explanation, an interdisciplinary approach works best.

When I first met Mrs. A, the wife of a practising physician, she had been clinically symptomatic for over two years. Her main complaints were an uncontrolled appetite (she was eating every two hours and in large quantities), weight gain (over 10 kilograms), irritable bowels (she was visiting the loo every two hours as well), vague aches and pains, fatigue and excessive sleep. She had consulted an army of specialists of every conceivable description, undergone (often repeatedly) a battery of investigations, no specific abnormalities being identified and consequently no diagnosis having been made.

Each person who saw her had given her a diagnosis: the gastroenterologist called it “irritable bowel syndrome”, the orthopaedic surgeon “fibromyalgia” and psychiatrist “atypical depression”. None of these diagnosis or treatments thereof had resulted in symptom reduction. Mrs. A was thus at her wits end when we met, desperate for a diagnosis and a cure.

Mrs. A is one of many people who suffer from a distinctly peculiar condition: unexplained medical symptoms. Clinical studies have shown that over 30 per cent of people attending out-patient clinics and emergency rooms have medical symptoms without ostensible cause. Indeed, a plethora of examinations and investigations done in these individuals fail to reveal any specific clinical abnormality, or diagnostic entity.

Shuttling between doctors, hospitals and diagnostic facilities, they often remain clueless about the real cause of their symptoms. Over time they develop a cynicism about the healthcare environment and proceed to explore alternative options. Meanwhile, healthcare professionals also become cynical toward such individuals, labelling them “neurotic”, “anxious”, “hysterical” and other potentially disparaging terms.

A famous study by Dr. Eliot Slater — an eminent psychiatrist in the National Hospital for Neurology, Queen Square, London — followed up over a decade, all those diagnosed with “hysteria” in this pre-eminent institution and showed that a very large proportion (about half) went on to develop “real” medical illnesses. The results of that medical study published many years ago, warned physicians about the dangers of writing off unexplained medical symptoms as being “hysterical” or “in the mind”.

A repeat study in the same hospital in the 1990s, under the guidance of Prof. Maria Ron, an eminent neuropsychiatrist, showed that the rate of erroneous labelling as “non-organic” had fallen to about 10 per cent, aided no doubt by advances in medical technology. It must be noted however, that mis-diagnosis as “non-organic” or “in the mind” continues to occur even in pre-eminent medical institutions staffed by experts with access to best medical technology. Having said that, a number of people with unexplained medical symptoms do have “non-organic” causality.

So why do people have unexplained medical symptoms? A proportion, perhaps, have a genuine medical cause or complaint that has remained undetected. Examples include inflammatory, infectious and metabolic conditions, and rare forms of cancer that may take time to manifest their full avatar. A proportion may have true hysteria — deep psychological trauma that is finding its outlet in physical symptomatology with secondary gain being the attention derived thereof.

A proportion may be addicted to the hospital environment — “Munchausen’s” hospital addiction syndrome — leading them to repeatedly seek contact and reassurance from healthcare professionals. A proportion may have health-related anxiety and engage in so called “abnormal illness behaviour”, with their reactions being out of proportion to the symptoms they are experiencing. A proportion may be engaging in conscious malingering, presenting a medical symptom in order to avoid a social problem, for example, an arrest or a court appearance.

In all people with unexplained medical symptoms, the bogey of an “organic” cause that has hitherto gone undetected, needs to be kept in mind. Repeated and detailed history-taking and clinical examinations are necessary, as is a close and empathetic follow up, with neither the physician nor the patient’s family succumbing to the proverbial “crying wolf” syndrome. In patients in whom an organic cause has been excluded beyond reasonable doubt, hysteria, somatisation (multiple physical symptoms without a physical cause), Munchausen’s syndrome, Abnormal Illness Behaviour and malingering may all be considered and form part of a psychological continuum.

What varies across this continuum is the level of conscious awareness, considered low (hence unconscious) in hysteria and somatisation, and high (hence conscious, deliberate and wilful projection of symptoms) in malingering. What varies also is the motive or intent; preference for the hospital environment in Munchausen’s syndrome, avoidance of a social problem in malingering, or indeed the more fuzzy and less easy to diagnose “secondary gain” of hysteria and somatisation. In all these instances, an empathetic approach, with deep understanding of the client’s background (developmental, familial, social, occupational and marital) is necessary, as is a strong therapeutic relationship rooted in mutual respect and trust.

All the above seem a tall order when demanded from a solitary physician doing her/his best with the constraints of time and resources. Patients with unexplained medical symptoms do well when managed by an interdisciplinary team. Such a team usually is lead by an astute clinically focussed physician, supported by nurse practitioners, physical therapists, psychological therapists and counsellors, nutritionists, and other caregiving professionals.

In the emerging space of integrative medicine, physicians from a host of alternative disciplines like Naturopathy & Yoga, Ayurveda, Homeopathy, Acupuncture etc. participate in care delivery. For the person with unexplained medical symptoms interdisciplinary care provides the opportunity to both understand and manage various symptoms, physical and psychological, better. Learning to live with what cannot be cured, maintaining one’s activities of daily living and quality of life often become reasonable and acceptable goals.

Mrs. A was diagnosed by an interdisciplinary team, after a detailed evaluation, to have clinically significant autonomic dysfunction, a difficult to diagnose problem with myriad physical and psychological manifestations. Combined with this was an element of “Abnormal Illness Behaviour”. Her medical management was suitably augmented to address these complaints and she committed herself to a care program that integrated physical, psychological and nutritional therapy with ayurvedic treatments, mud therapy and yoga therapy.

Over a span of three months her symptoms improved considerably: normalization of appetite, regulated bowel movements, improved energy and enhanced activities of daily living and considerably reduced health related anxiety. Her success story underlines the challenges of interpreting unexplained maladies, the crucial role of personalised clinical medicine, the need for interdisciplinary care for chronic medical conditions, and for our intellectual glasnost as a society towards the wealth of clinical wisdom that resides in our ancient medical traditions.

As Hans Berger, the inventor of the Electroencephalogram (EEG) an instrument that studies brain waves, said, “A machine can replace neither common sense nor intelligence”.

Bipolar Disorder Featured Unexplained Medical Symptoms

Falling men, Failing Neurons

Clinical Autonomic Dysfunction with a plethora of systemic complaints often goes unrecognised. But the right diagnosis and treatment can help speed up the recovery process.

Most of us take standing up for granted. Only when we cannot stand for some reason are we reminded of its importance. Oliver Sacks, the legendary neurologist and author, addressed this rather poignantly in his story On standing on one leg, which documented his experiences after a fall in the Alps. The human species started ‘standing on two legs’ rather late in its evolution. As a consequence, body mechanisms that enable standing — for example ‘preventing all the blood from pooling in our feet, thanks to gravity’ — developed rather late. A complex neural network rich in chemicals and hormones controls postural changes in blood pressure, as it does heart rate, body temperature, digestion, urinary and sexual function… a host of human activities performed, often unthinkingly. This complex network — the autonomic nervous system or ANS — is ‘autonomic’ i.e. ‘independent’ of our conscious control, yet to some extent modifiable. For example, we can hold our urine until we reach the bathroom, well, most of the time!V, a 64-year-old retired headmaster, came to us with a rather peculiar problem. For almost a year, he had been unable to stand up. He would collapse and transiently lose consciousness. Starting with giddiness on standing up, the problem had progressed to intolerable vertigo and eventually episodes of syncope (fainting), leaving him most comfortable when flat on his back. Not surprisingly, V had taken himself to bed, occupying supine repose, in which he was most comfortable. Not surprisingly also, this rendered him severely disabled, dependant on his wife of almost four decades, for all activities of daily life.

When we first met V, he was petrified of standing up, even with our persuasive encouragement and promise of medical support. We had to, therefore, admit him to a partner hospital, and begin attending to him there. Our detailed 360° evaluation confirmed that he had a rare but disabling condition — progressive autonomic failure — with the background of long-standing depression, under treatment with psychotropic medication and a history of generalised seizures (in remission). He had many symptoms of clinical autonomic dysfunction: his blood pressure when taken lying down was 90/50 mmHg; when he stood up, however, his blood pressure plummeted to 50/? — the diastolic so low that it was unrecordable. His postural vertigo, variable heart rate, altered patterns of sweating, pain in the neck and shoulders (coat hanger distribution), unpredictable bowel movements were all symptomatic of his underlying condition: Clinical Autonomic Dysfunction. In addition V had slurred speech and diminished swallowing ability without apparent neuromuscular weakness.

Following diagnosis, V was started on one of the few drugs that can help prevent postural fall in blood pressure. He also was enrolled into our interdisciplinary and integrative rehabilitation programme for autonomic dysfunction. Extended physiotherapy sessions including passive mobilisation, electrotherapy for pain, postural exercise paradigms, gait and balance training, and active exercise protocols delivered over three weeks. He also received acupuncture targeting his neurological symptoms and therapeutic mud for his gastro-intestinal symptoms. Sessions of Jacobson’s Progressive Muscle Relaxation as well as supportive counselling to build confidence and motivation and address caregiver distress were included. At the end of the treatment period, aided no doubt by both drug and alternative therapy approaches, V was back on his feet.

Clinical Autonomic Dysfunction with a plethora of systemic complaints often goes unrecognised as a medical diagnosis; so little being known about ANS and it being difficult to test. Many patients with autonomic symptoms are labelled as ‘psychosomatic’ and do not receive necessary medical attention, leading to avoidable delays in treatment. Indeed the ANS is perhaps one of the last frontiers of neuroscience, requiring significant research focus, as concluded in the recent TS Srinivasan-NIMHANS Conclave on the subject. Not just neurological and psychiatric, ANS symptoms can present with vertigo (ENT), cardiac (heart), respiratory (lungs), gastroenterological (abdomen), genitourinary (urinary and sexual), orthopaedic and rheumatology (bones, joints, musculoskeletal) complaints. A clinical diversity that can test the most accomplished physicians. While falling men like V could well have failing neurons, we also learn from him that people with a plethora of unexplained medical symptoms do deserve an ‘autonomic’ approach and may well benefit from therapy and rehabilitation.