"I believe that the psychological component of disease is underappreciated and largely neglected here in the U.S. Though there are some gray areas that are not yet completely understood, the mind plays a large role in the development of many medical conditions, including pain syndromes," says Roy Stern Seidenberg, M.D., assistant clinical professor of dermatology, New York University School of Medicine, New York, and director of Central Park Dermatology, Manhattan, N.Y.
"Most physicians would agree that stress can exacerbate physical symptoms, but not actually initiate them. However, one does not have to look further than the placebo effect regularly seen in clinical trials and everyday medical practice. Watching a young man with tattoos pass out from a simple skin biopsy is witness to the power the mind has over the body," says Dr. Seidenberg, who also teaches at the Manhattan VA Hospital.European countries are very much attuned to the potential of the mind-body connection. In Paris, for example, a clinic led by psychoanalysts (L'Institut de Psychosomatique Pierre Marty) is a tertiary referral center for patients deemed to have psychosomatic illnesses. Germany has residency programs with board certification in psychosomatic medicine. In contrast, the concepts of psychosomatic medicine are often not taught in medical schools in the United States, and thus the root of patients' symptoms is overlooked. This may be due in part to profound differences in healthcare, medical-legal issues and societal beliefs.
In his lecture "Psychosomatic Dermatology," given at the 2010 Annual Meeting of the American Academy of Dermatology, Dr. Seidenberg highlighted the case of a patient who had psychosomatic illnesses that she attributed to a simple cosmetic procedure.
"I start with this particular case," Dr. Seidenberg said during his lecture, "so plastic surgeons and dermatologists realize that these concepts are important for their cosmetic patients as well as medical patients." In another well-known case, a famous dermatologist was sued by his patient after she developed chronic muscle pain, fever and hives for up to a year after a Botox (onabotulinumtoxinA, Allergan) treatment (February 2003, Los Angeles County Superior Court; Irena Medavoy v. Arnold Klein, M.D. and Allergan, Inc.).
THE MIND–BODY CONNECTION Psychosomatic medicine is based on the concept that the unconscious mind and the body are interconnected. Psychosomatic disorders are thought to be created by the unconscious as a defense mechanism to prevent undesirable emotions from coming to consciousness.
Oftentimes, these disorders first appear through a false trigger — the unconscious will initiate a psychosomatic disorder at the occurrence of a particular event, thus providing circumstantial evidence for the conscious mind. Ubiquitous across all specialties in medicine, psychosomatic disorders can encompass everything from migraines, carpal tunnel syndrome, allergies and back pain to many other conditions and diseases (both cutaneous and internal). Dr. Seidenberg says he learned these concepts from his mentor, John E. Sarno, M.D., who has used the concept of "cognitive cure" to heal tens of thousands of patients with chronic pain syndromes and/or medical diseases. "The unconscious mind can initiate real physical changes, causing real physical disease, which can be verified on clinical and microscopic examinations, such as adult acne, eczema or urticaria. Psoriasis or alopecia areata can often first appear in patients soon after a psychological trauma such as a death in the family," Dr. Seidenberg says.
POSSIBLE SOLUTIONS The two main parts of treating psychosomatic pain after a cosmetic procedure are careful patient selection, and teaching and implementing the following cognitive treatment.
When seeing cosmetic patients, Dr. Seidenberg says he first tries to determine whether the patient has any history of psychosomatic conditions. "I get a sense of my patients' 'psychosomatic signal' even before I see them by inquiring about the presence of other psychosomatic disorders on my patient intake form," he says.
Should a patient reveal a fair amount of psychosomatic-related illnesses upon first presentation (chronic fatigue, carpal tunnel syndrome, chronic back pain, fibromyalgia, irritable bowel syndrome and migraines), Dr. Seidenberg exercises caution because of the increased likelihood of psychosomatic-related complaints. According to Dr. Seidenberg, such patients seem more likely to have pain after a cosmetic or surgical procedure, and he notes that other factors — such as cultural or genetic — may also be playing a role.
"If a patient has had some of these conditions, I would put off a cosmetic procedure, or at least until I got to know them better," he says. "I realize, of course, that if a physician doesn't believe in psychosomatic medicine, then she/he won't consider the above conditions to be psychosomatic."
According to Dr. Seidenberg, establishing whether the patient is open to the connection of mind and body is the first step of treatment. This can be ascertained by taking a thorough history that includes specific questioning presented on an intake form (for example, "How do you rate the connection between the mind and the body?"). The next step is educating the patient in this regard and offering guidance.
"I often hand out a 'prescription' with a list of Dr. Sarno's books. Ironically, I've cured more back pain than psoriasis (this way)," he says, adding that the books can help with teaching patients how to reflect and address deep-seated, or sometimes obvious, unresolved issues. If improvement reaches a roadblock, psychotherapy can be very enlightening.
Addressing the root cause of physical pain and other conditions generated from the mind may appear to be a daunting task. Simply turning to pharmacology to treat pain and other disorders, however, is a temporary solution at best and masks the true etiology of disease.
Dr. Seidenberg offers two psychosomatic pearls: "It's important that the patient knows that their physician believes their pain or symptoms are real. Also, the patient needs to understand that they don't have to get rid of 'stress,' which is impractical; they just have to understand the mind-body connection," he says.
Dr. Seidenberg reports no relevant financial interests.