“It’s All in Your Head”—Medicine’s Silent Epidemic | Neurology | JAMA Neurology | JAMA Network

Is it all in your head?  Of course, it is. Your brain is where you think and feel.  It is all biochemistry. It is also electrical.  Medicine is just beginning to understand the process, due to the relatively recent addition of specialized imaging.  It is now possible to see what is occurring in the brain by monitoring glucose uptake and locating the exact areas that "light up" when thinking, feeling, moving, or sensing our surroundings.

The irony of “it’s all in your head” is that although this phrase is often used inappropriately and dismissively, it is technically correct. The problem does indeed lie within the head. More specifically, it lies within the brain and its complex networks that we are just beginning to understand. Over the past 10 years, neuroimaging research studies have consistently identified brain abnormalities in patients with medically unexplained symptoms—yes, biologically based changes in the activity and connections of brain regions, such as the amygdala, prefrontal cortex, temporal-parietal junction, and other structures.1 These brain circuit abnormalities provide physiological explanations for once mysterious links between regions implicated in emotional processing and the generation of “physical” symptoms (eg, pain, fatigue, weakness). Jean-Martin Charcot, MD, a famous 19th-century French neurologist and early pioneer of this field, reportedly insisted that a “functional lesion” would be found when microscopes were sufficiently powerful.2 Well, our microscopes are getting better, and we are now starting to see evidence of the predicted functional or software disruptions in the brain.

We still do not fully understand what causes these software problems; however, recent research suggests a multifactorial etiology, including genetic predisposition, environmental risk factors (eg, childhood adverse events), and psychological stressors.

In the case of gastrointestinal disorders, we know that the GI system's neurologic system is equivalent to a second brain, in terms of weight and size.  Our head brain is connected directly to the gut-brain by the Vagus nerve

The Clinical Encounter

Based on such attitudes, a typical physician-patient interaction may proceed as follows: (1) the physician provides a rundown of normal investigations, (2) the patient is told they have no known medical diagnoses, (3) a brief awkward exchange occurs, and (4) little further explanation, guidance, resources, or facilitation of an appropriate referral process is given. Even if the infamous phrase is not explicitly stated, this sequence leaves the patient to infer for themselves that it must be all in their head. Unfortunately, they do not perceive this as, “I have a real dysfunction of networks in my brain,” but instead understandably conclude that “they think I’m crazy” or “faking it.”4 Sometimes, patients may hear the distant utterance of, “Maybe you should see a psychiatrist,” as they exit the office door, but in this context, such advice is rarely productive.

Many of these patients can be so offended by this encounter that they quickly seek multiple second opinions and subsequent rounds of pricey and unnecessary investigations. Depending on the jurisdiction and medical record system, the original physician may be completely unaware of these additional rounds of care. Mounting negative and invalidating clinical interactions can become a source of distress and cause medical trauma. At this point, patients often either fall through the cracks or stumble on a fringe medical specialist or alternative medicine practitioner who may offer the “physical” diagnosis they’ve been yearning for. This could include a growing list of unsubstantiated metabolic deficiencies, infectious disorders, or autoimmune hypersensitivities. Anecdotally, the most common current example seems to be the diagnosis of chronic Lyme disease by unvalidated assays.5 Let me be clear that many of these practitioners are well-intentioned and can offer holistic approaches that medicine could learn a lot from. However, there appears to be a subset that takes advantage of these patients’ desire for “physical” diagnosis and exploit their vulnerabilities.

For the patient, receiving such a concrete, “organic” diagnosis often quells mounting anxiety, which in itself could be partially therapeutic. However, now wedded to their given diagnosis with no knowledge of their actual software problem, patients do not see a need to address underlying factors that may be contributing to their disorder nor do they receive the multidisciplinary care that they may so badly need. The saddest part of this epidemic is that if addressed early, these symptoms may be reversible; however, with delays to proper diagnosis and management, prognosis worsens considerably.

Functional Neurological Disorder (FND) : a patient's guide

Included below are several helpful video programs of patients with FND.

Unfortunately, physicians trained in another era often used the term "conversion disorder" as a wastebasket term for a disorder that could not be measured with laboratory testing.  Modern neuroscience and diagnostic imaging and soon biological markers will help make a diagnosis.

“It’s All in Your Head”—Medicine’s Silent Epidemic | Neurology | JAMA Neurology | JAMA Network: This Viewpoint discusses the harm of dismissing patients with medically unexplained symptoms and how to better support this population.