Commentary

A new mental illness?
Call it ‘hysterical medicine,’ with no apologies for a knee-jerk diagnosis

By Frank Albrecht, Ph.D.

My daughter is the only person I've ever known who can sprain an ankle while standing still on a carpeted floor. If you look at her too hard, one of her joints can pop out.  Her life is filled with sprains, strains and dislocations-name something bad you can do to a muscle, joint or ligament and she's done it more than once. "Accident prone," people said. "School avoidance," "attention getting," "drug seeking," they said. All those kinds of things. Finally she was diagnosed with Ehlers-Danlos Syndrome, an inherited collagen disorder that is common among YPWCs (young persons with CFS)-and which causes sprains, strains, dislocations and pulls! It wasn't mental or attitudinal after all, though none of those who said it ever apologized.

She also has had severe abdominal pain. Sonograms, X-rays, CAT scans, MRIs-nothing! All in her head, they said. Exaggeration, bad family dynamics, could be it's Munchausen Syndrome by Proxy, but certainly there is No Physical Cause! The TESTS are negative, they said, and that proves it! It's mental!
 
Finally a specialized scan showed a condition my wife and I had never heard of-varicose pelvic veins. Most doctors have never heard of it either. It's an extremely painful condition that's hard to detect. 
 
The veins were fixed and the pain is gone. But again, no apologies.
 
It's certainly common for persons with CFIDS to face disbelief from practitioners, friends and relatives. People get just absolutely sure you have a mental condition. I call this hysterical medicine. The doctor does his exam. It's negative. He rounds up the standard suspects by doing whatever tests occur to him. These too are negative. So he decides without further consideration that the cause is in the mind. "Been under a lot of stress lately?" he asks.  "Problems at school?" he asks the kids. "How's your marriage doing?" he says to adults. And if the patient says, "No, no problems, except that I'm sick," then of course the point is proven. She's in denial!
 
This doesn't just happen to PWCs. Recently a physician told me about the case of a woman with projectile vomiting caused by paralysis of the stomach. The treatment should be a surgically implanted feeding tube. But the surgeon insisted the patient had anorexia nervosa and put her in a psychiatric ward. Eventually she was diagnosed with an atypical multiple sclerosis (and got a feeding tube), but not before she had to endure months of frustration and humiliation-and no apologies, either!
 
Hysterical medicine has a long history. In the 13th century, for instance, people "knew" you wouldn't get bubonic plague if you lived a simple, carefree life with many enjoyable but not overly stimulating activities. In the 18th century, gout was regarded as a payback for overindulgence in liquor and luxury foods. In the 19th century everyone understood that it was emotionally sensitive people-poets, painters, artistic people generally-who got tuberculosis. The 20th century has been no better. When I was in graduate school in the late '50s, we took for granted that asthma was a direct outcome of unresolved Oedipal conflict, and until the '90s everyone I knew accepted as fact that ulcers came from stress and working too hard, being too competitive. 
 
Plague, tuberculosis and many ulcers are caused by bacteria; asthma starts with allergy and creates physical alteration of the airways; gout is a metabolic problem. The fact is that no illness affecting a diverse population has ever turned out to be primarily or predominantly mental. It is hard, though, to get this point across.
 
I work in a large mental health clinic and often see people with CFS or CFS-related problems. Getting them appropriate medical help is difficult. Recently, for instance, I saw a 17-year-old who had been on home instruction for a year because of dizziness, weakness, fatigue and visual problems. She'd had an extensive workup at a university medical center without getting any diagnosis at all. Everybody said she was a mystery. So I got her. Maybe she was depressed! Yet her symptoms fit the pattern so often seen in CFIDS, and she also had obvious orthostatic problems (sitting or standing made her symptoms worse). I gave her a "poor man's" tilt table test, 10 minutes of quiet standing. At the end her hands and feet were purple, her heart was going too fast, her dizziness, pain and visual problems had increased, and she could no longer stand up without support. I sent this information to her primary-care doctor. He phoned me and said he could find nothing wrong with her! My client's mother then went in to see him,
Then went again, and again. Finally he consented to refer her to a cardiologist for tilt table testing. After a positive test, the cardiologist put her on some medication and she's now a lot better.
 
The primary-care doctor produced no apologies-of course!
 
In my business we have a diagnostic manual, the DSM, that lists all the mental disorders and their criteria. It's put out by a psychiatric association. I'm going to write this group proposing that hysterical medicine is an overlooked mental illness, afflicting many physicians and some members of the general population, characterized by irrational beliefs in imaginary illness causes, deficits in good manners, and inhibition of the apology reflex. 
 
What do you think? If they turn me down, will they apologize?

Frank Albrecht has several family members afflicted with CFIDS and maintains a web site for parents of sick and worn out kids at www.bluecrab.org/health/sickids/sickids.htm.  He is a therapist and coordinator of special projects at Regional Mid-Shore Mental Health Services in Easton, Maryland.