Six Categories of Illnesses

doi:10.4236/psych.2013.47082

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Psychology

2013. Vol.4, No.7, 569-571

Published Online July 2013 in SciRes (http://www.scirp.org/journal/psych) http://dx.doi.org/10.4236/psych.2013.47082

Six Categories of Illnesses

Paul Valent

Liaison Psychiatrist (retd.) Monash Medical Centre , Melbourne, Australia

Email: [email protected] et.au

Received April 15th, 2013; revised May 17th, 2013; accepted June 16th, 2013

tion License, which permits unrestricted use, distribution, and reproduction in any me di um, provided the or iginal

work is properly cited.

Studies show that between 40% and 60% of patients attending emergency departments have medically

unexplained physical symptoms (MUPS) that are determined by psychosocial factors. However, there ex-

ists no clear categorization of these factors and the symptoms that they produce. This paper delineate s six

categories of illnesses that help to overcome this deficit. The categories of illnesses are 1) Typical physi-

cal illnesses; 2) Typical psychiatric illnesses; 3) Psychophysiological symptoms; 4) Symptoms associated

with reliving traumas; 5) “Cherished” or hysterical symptoms; 6) Symptoms that identify with illnesses of

others. Clinical examples of each category are provided.

Keywords: Medically Unexplained Physical Symptoms; MUPS; Psychophysiological; Psychosomatic;

Somatization; Hysteria

Introduction

An example of the conflict between philosophy and fact can

be seen in treatment of patients in emergency departments. The

philosophy goes back to the Cartesian dichotomy of mind and

body. Doctors see themselves as treating the body. The rest is

not their concern. The fact is that doctors’ patients are an

amalgam of body, mind, and society and the sources of their

physical symptoms are frequently a result of psychosocial fac-

tors.

The result of the dichotomy between fact and philosophy is

that between 40% and 60% of patients attending emergency

departments finish with medically unexplained physical symp-

toms (MUPS) (Stephenson & Price, 2006).

Apart from the misery this causes patients, the situation is

very costly (Abbas, Campbell, Han et al., 2010). Instead of

their problems being dealt with, patients are sent on merry-go-

rounds of ever-more expensive tests and referrals in efforts to

fit their symptoms into Procrustean beds of medical illnesses.

Doctors are reluctant to seek out psychosocial factors under-

lying physical symptoms. They feel untrained to deal with the

Pandora’s box of emotion and chaos they believe they may

unleash. But there is also no theoretical framework that can

help them to apportion symptoms to heuristically treatable

categories.

Vague warnings that stress can cause illness, and diagnoses

such as hypochondriasis, dissociation, factitious disorder and

malingering (Stephenson & Price, 2006) do not help to distin-

guish symptoms from “genuine” physical disorders.

The following approach is the result of our team’s experience

in the emergency department at Monash Medical Centre over

more than 20 years. Earlier versions of this approach have been

described elsewhere (Valent, 1979, 1998).

The approach recognises six categories of illness. Each is

recognisable and leads to pragmatic interventions.

Six Categories of Illness

Typical Somatic Illnesses

These illnesses provide the least difficulty as they are text-

book medical cases. Examples are acute appendicitis, urinary

tract infection, and myocardial in farct.

And yet even here it is worth looking at psychosocial factors.

Case 1: A child had her first attack of asthma during a pa-

rental quarrel where the father threatened to leave home. Sub-

sequent attacks recurred during similar quarrels. In adulthood

the patient was prone to asthma attacks when threatened with

separation from loved ones. The attacks incidentally inclined

people not to leave her.

Case 2: A young woman presented with polyneuritis (Guil-

lain-Barre syndrome). This developed within days of a fire that

destroyed the family home and business. She believed that it

was her fault and that she nearly caused the death of her sister.

She believed that she had forfeited any love for the rest of her

life. (For a full description of this case see Valent (2009).

Illnesses with a Psychiatric “Signature”

Some physical symptoms are part and parcel of major psy-

chiatric illnesses. Sleep disturbance, anorexia, constipation,

tiredness, exhaustion are classical accompaniments of major

depression. Bizarre symptoms such as ants crawling under the

skin, sense that one’s scalp is lifting, foreign agents regulating

physiological functions all have a schizophrenic signature.

Case 3: A woman presented with extreme tiredness after the

death of her husband. She also lost all interest and looked de-

pressed. When she grieved her husband her tiredness lifted

along with her depression.

Case 4: A schizophrenic man suffered a constant level of

nausea that he attributed to the neighbours poisoning him with

asbestos.

P. VALENT

Psychophysiological Symptoms

Because the sympathetic and parasympathetic nervous sys-

tems and stress hormones reach and influence every organ of

the body, their arousal in stress can result in a very wide range

of symptoms that include potential arousal and dampening of

every bodily system. Musculo-skeletal tension symptoms in-

clude headache, neck ache, chest pain, and back ache. Digestive

system symptoms include loss of appetite, weight loss, weight

gain, nausea, constipation, diarrhoea, etc. Cardiovascular symp-

toms include palpitations, shortness of breath, chest pains, high

blood pressure. Urino-genital system symptoms include bladder

pressure, frequency, dysmenorrhea, painful intercourse.

Psychophysiological symptoms can mimic at least in part

most physical disorde rs.

Case 5: A woman who attended her GP with recurrent head,

neck, and back pains was found to suffer from tension that re-

sulted from bracing against her husband’s violent outbursts.

Case 6: The first time a patient developed migraine was

when she witnessed Nazis vandalise her grandmother’s shop in

Vienna on Krystallnacht. She felt a fury toward those who

made her grandmother collapse in the street. However she was

impotent to vent her rage. Throughout her life migraines re-

curred at times when she had to bottle up her anger.

Reliving Traumatic Situations

Dissociated aspects of traumatic situations may be relived as

physical symptoms.

Case 7: A combat veteran kept returning to hospital with

chest pain which he was convinced was sign of a heart attack.

The pain did not conform to heart disease and all tests were

normal. On closer questioning the pain was a wrenching of the

heart, as if it incurred a wound, or as if it was broken. It was the

exact pain he felt when his buddy died in his arms. Grieving

relieved the physical pain.

Case 8: A woman experienced severe physical pain each

time her husband penetrated her. The pain was a replica of the

pain she suffered when an uncle penetrated her as a child.

Identification wit h Ill ne ss es of Others

Patients often identify with symptoms and illnesses of those

they love, especially of those who had died. This is a result of

empathy, guilt, and not having let go. Symptoms often arise

during the loved person’s terminal illness, after bereavement, at

anniversaries, and when attaining the age of the loved person

(such as a parent of the same sex).

The symptoms are often unusual because they reflect pa-

tients’ concepts of what others suffered, and such concepts may

be anatomically untenable.

Case 9: A month after her husband’s death of a heart attack,

a woman presented with a sharp stabbing pain over her left

nipple. She believe d that she was having a hea rt attack like her

husband.

Case 10: A 12-year-old girl was brought to hospital after she

carelessly rode in front of an oncoming car. Two years earlier

her sister, then 12 was killed on her bike in a collision with a

car. The younger sister blamed herself for her sister’s death and

had fantasies of joining her in heaven.

“Cherished” Illnesses; Hysteria

It goes against the medical grain to consider that suffering

may be cherished. Patients who cherish their symptoms arouse

frustration because they do not comply with treatment, their

symptoms migrate, and they adopt fashionable diagnoses that

are difficult to diagnose and treat.

Once suspicion is aroused, diagnoses only thinly veil anger.

Diagnoses include “secondary (financial) gain”, “hysteric”,

factitious disorder, Munchausen’s syndrome, and malingering.

In reality, apart from the few cases of malingering, cherished

illnesses obey classical rules of hysteria. The symptoms are

produced through unconscious processes; they symbolise a

major stress or trauma ; whose consequences the symptoms help

to resolve this being primary gain; and they are secondarily

used for other gains (secondary gains). The classical example

was the World War One soldier whose paralysis of the right

arm necessitated his withdrawal from combat.

Case 11: A previously somewhat pampered inductee was

bullied by his army colleagues who teased him as not having

“guts” or “stomach” for the army. After a mild punch to his

stomach he developed severe abdominal cramps that did not

respond to treatment. Eventually he was “honourably” dis-

charged.

Case 12: A previously hard working man developed back

pain after lifting a heavy object. His disability was beyond any

objective pathology. The man’s wife withdrew from sex after

her doctor advised her that she would die if she had another

child. The man, however, suspected that his wife had a lover

while he was at work. Staying at home enabled him to keep a

watchful eye over her. Secondarily, his disability evoked con-

cern from his wife, as well as worker’s compensation.

Discussion

The six categories of illnesses present a heuristically useful

way of conceptualising illnesses. Rather than consigning symp-

toms that do not meet typical somatic criteria to a waste-basket

of therapeutic nihilism, a checklist of illness categories may

find that the symptoms fit precisely into one of the non-somatic

categories.

Considering the frequency of MUPS, this has clinical impli-

cations for approaches to all patients. Such approaches have

been called holistic, and biopsychosocial. I prefer to call for a

wholist approach (Valent, 1998a) that includes both biopsy-

chosocial and whole. In addition to biological, psychological,

and social interactions, the approach concerns itself also with

moral dilemmas and existential meanings. They were very rele-

vant in the abov e cases.

Pragmatically, a somatic approach like “Tell me about the

pain”, is replaced with an open-minded question such as “Of all

the things that worry you what worries you the most?”.

All histories should include questions such as “Have you

been under stress or experienced trauma recently/when the

symptoms started?”, “Apart from these symptoms do you have

any others/any other worries/frustrations/conflicts?”, “Have you

been depressed/anxious/experienced other strange symptoms?”,

“Have you known anyone else who suffered these symptoms?”,

“If you could have any desire fulfilled, what would it be?”.

When patients reveal the emotions and contexts of their wor-

ries, it is not so much that a Pandora’s box opens with ever-

more problems, but rather that a box under pressure opens akin

to the release of an abscess.

The categories enable making positive psychosocial diagno-

ses. Further, diagnoses are confirmed when symptoms recur

570

P. VALENT

when stresses return or when they are reproduced in fantasy.

They resolve when the stre sses are resolved.

An interesting test is over breathing for half a minute. This

often reproduces psychophysiological and other psychosocial

symptoms. Re-breathing in a paper bag diminishes them.

Of course categories, diagnoses, and treatments are not al-

ways simple. Categories themselves may be difficult to ascer-

tain, and they can be multiple and overlap. Further, presence of

a non-somatic category does not mean that a somatic one does

not exist as well.

Conclusion

Six categories of illnesses provide a step toward a heuristic

conceptualisation of what are otherwise medically unexplained

physical symptoms.

An advantage of the non-somatic categories is that they con-

nect with the initial disruptive conditions, their consequences,

and the existential meanings the symptoms symbolise. Treat-

ment can repair the disruptions, resolve the symptoms, and

provide new meanings.

Though symptoms may not always be easily classified, di-

agnosed, and treated, the expanded categories do provide ex-

tended tools for diagnosing physical symptoms without classi-

cal medical explanations.

REFERENCES

Abbass, A., Campbell, S., Hann, S. G., Lenzer, I., Tarzwell, R., &

Maxwell, R. (2010). Cost savings of treatment of medically unex-

plained symptoms using Intensive Short-Term Dynamic Psycho-

therapy (ISTDP) by a hospital emergency department. Archives of

Medical Psychology, 7, 34-43.

Stephenson, D. T., & Price, J. R. (2006). Medically unexplained physi-

cal symptoms in emer gen cy medi cine. Emergency Medicine Journal,

23, 595-600. doi:10.1136/emj.2005.032854

Valent, P. (1979). Psychosomatic aspects of illness. Patient Manage-

ment, 8, 21-28.

Valent, P. (1998). Traum a and fulfilment therap y; A wholist framework.

Philadelphia, PA: Brunner/Mazel.

www.paulvalent.com/books/trauma-and-fulfillment-therapy/#more-7

Valent, P. (1998a). From survival to fulfilment; A framework for the

life-trauma dialectic. Philadelphia, PA: B runner/Mazel.

www.paulvalent.com/books/from-survival-to-fulfillment/#more-793

Valent, P. (2009). In two minds; Tales of a psychotherapist. Sydney:

University of New South Wal es Press.

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