We like to imagine a very specific relationship between our minds and our bodies. In this relationship our mind is in charge, always calling the shots. Our legs don’t decide between the soba and udon noodles; our brain does. We rarely consult our spleen about the necessity of a breakup or a job change. If there is an illness or injury to our physical self we are aware, and we take steps to have the arm set, the lump examined, or the rash salved. If we have a “mental problem,” we do the needful, from pills to therapy, in order to restore our trusted leader to the helm. There are minor leaks and border crossings, to be sure – we are bombarded with ads for Cymbalta telling us that “depression hurts,” and we know that a long or serious physical illness can cause depression. Mostly, though, we tend to believe that our mind and body are separate, and that our mind is our most trusted ally. It tells it like it is, that fine mind, and we depend on it to observe, assess and guide.
Over the years I have become convinced that the relationship we see as axiomatic is really far more complex. When I practiced Social Security Disability law, there were clear cases in which the client could not work because of a chronic heart condition, schizoaffective disorder or the effects of a closed head injury. We all agreed, the client, the doctors, my office and eventually the judge, about what was wrong, the mechanics of the problem, and that it prevented a person from working in any meaningful and predictable way.
It was my job to explain, and to prove to a judge that the medical evidence matched up with the client’s claims. That’s an easy task if you have records of several heart-related hospital stays and surgeries, letters from three cardiologists and a client who is short of breath and vaguely gray. It’s tougher, but possible when you have a client with a record of trouble in school, an adult inability to hold a job, an IQ of 87 and a treating therapist who has diagnosed severe depression. A judge wants “signs and symptoms,” charts and records, pills prescribed, specialists in agreement. There is, among other things, a great deal of money involved.
There were other cases, though, where I could not align my ducks so easily. The hardest of these involved clients with symptoms that were clearly crippling, but which seemed to have no grounding in objective, medical reality. A client might come in describing “constant pain” that required her to sleep sitting up in a recliner, and necessitate frequent ER visits. The person before me would be in obvious distress, and I would feel the usual compassion and urge to help. Then I would look at the medical records: normal blood tests, x-rays, EKGs, MRIs, CT scans, EMGs…nothing but “within normal limits” to be seen. Somewhere in the charts, at least once, I would see the fatal notation: “pain apprs psychogenic” or “psych referral.” Contact with the client’s treating physician would confirm that there was nothing physically wrong, and that the only possible explanation was that a problem in the mind was causing pain in the body. It was real pain, but its origins were “psycho” rather than “somatic.” This client’s trusted executive branch had abdicated, lied to her and made a terrible mess of her life.
In a perfect world, I could just have explained all of this to the client, told her that she would really only be successful with Social Security if she started seeing a mental health professional to treat (and document) her real issues, and felt gratified as she thanked me profusely. In the actual world, any suggestion that the pain originated in her psyche was inflammatory. If my client was relatively unsophisticated, the whole idea of “shrinks” was bizarre and repellant. No one in the family had ever seen a psychiatrist, and it wasn’t going to start with the person sitting across from me. If the client was more sophisticated I was told about how wrong it was to dismiss a person’s (especially a woman’s) pain as “hysterical.” I was told about how doctors had dismissed chronic fatigue and fibromyalgia as being psychosomatic until they had come to understand the relevant pathologies. I was a minion of the Evil Empire, dismissing and diminishing the very real, terrifying, perpetual pain of another human being just because it didn’t show up in test results.
What these clients didn’t know was that as a young woman, in the midst of my lawyer years, I had been through it myself. I had developed dizziness, a feeling that my head was always in motion, and that I was not quite present or lucid. I had seen my GP, a vague, pleasant woman, and she had prescribed nasal spray, antihistamines, and motion sickness medicine. I had a tilt table test, an MRI of the brain, and a battery of blood tests. I saw ENTs, neurologists and the inside of every medical office suite in town. Everything was “normal,” and yet I could not live with the constant jerking I felt in my head. When she took maternity leave, I reluctantly went to see my parents’ doctor; I had seen him in the past, and we were not a love match. I found him blunt, crude and sophomoric. When I told him about my problems, he told me it was probably anxiety, and offered to prescribe medication. I told him it was not anxiety – I knew this because I did not have shortness of breath, panic attacks or any of the symptoms that I knew were associated with anxiety. I secretly suspected that he was calling me “hysterical,” because I was a woman with symptoms he couldn’t understand. He raised his hands in surrender; I put my suit back on and left.
Within a month I couldn’t swallow. There was something in my throat – maybe a bit of plastic wrapper. I tried to move it with chunks of bread, I drank spoons full of olive oil, I gargled and I cried. It would not budge. I returned to the hated doctor, reluctantly, and told him about the swallowing. I was still dizzy, and now I couldn’t swallow. “Dysphagia” he said. “Probably caused by anxiety.” I knew this had to be wrong, knew that there was a Thing in my Throat. I wanted a cure, I was miserable, I was falling apart in the midst of trying to establish a law practice, dating, and generally beginning my adult life. He made a deal with me: I would try taking anxiety medication for a month, and if I didn’t get better after that, he would shift gears. I dragged my sad, sick self to CVS and left with Xanax and Celexa. In two days, the “thing” in my throat disappeared and my head felt normal for the first time in a year. My fine, trusted mind had misread or ignored every cry for help, and my body, that dullard foot soldier had picked up the slack and sent for backup. Also, the raving sexist pig doctor had been entirely correct.
In my practice, I was usually able to convince most clients at least to visit a psychiatrist or psychologist; often I told them my own story. It may not have been the most arms-length, professional choice, but I was never that kind of lawyer. In some cases the notion of seeing a “shrink” was just too frightening, and the client and I parted ways. I believed their pain was real, but with no objective medical support, we were all wasting our time.
In my personal life, I have learned that medicine is as much art as science, and that a diagnosis of somatization is often valid. It takes patience and trust to sort out causes and choose the best treatment, and it is sometimes painful to look hard at the ways in which our conscious minds betray us. The fact that a doctor sees a psychological origin for physical issues may mean that he or she is dismissing us. Most often, though, it means that she is trying to relieve suffering, trying the next approach after the obvious ideas have been proven wrong. They are not magicians, just humans with experience, useful tools and a desire to see us healthy.
I have a doctor that I love, these days, and I absolutely trust her. I have replaced Xanax with meditation, yoga and exercise, but I still watch my body closely for signs that all is not well in the north. The fact that pain, or dizziness or a lump in the throat can originate in the mind, bypass conscious thought and wreak havoc in our bodies should teach us to question the supremacy of the brain, to trust messages from the body, and to recognize that soma and psyche are not separate but intimately entwined, and in constant, passionate conversation throughout our lives.