Skip to main content

Let's Talk About "All In Your Head"

If I had to vote for a phrase, just 4 short words, that cause more problems in our society than most others it would be these:

All in your head.


To hear these words as a person with medical symptoms brings about such a cascade of thoughts. Anything from "My doctor doesn't believe me" to "Are my symptoms really happening?" with corresponding emotions of anxiety, confusion, anger, even rage.

I spend a lot of time undoing the damage these 4 words can do in the patients I see. They've been told, either directly or indirectly, their disease is psychologically based. And that means it's really not that bad, that they should just get over it and move on. It's a running thread in most of the patients with any "functional" diagnosis I've seen, such as irritable bowel syndrome, but also appears in those with "organic" conditions - those diseases perceived as real like inflammatory bowel disease.

These 4 words are part of the fundamental understanding of disease-related stigma in all of the digestive diseases I've studied to date: IBD, IBS, EGIDs. And soon to be published, gastroparesis.

These 4 words often make it difficult to integrate psycho-gastroenterology services into the care of these patients for fear a referral to someone like me means their doctor doesn't believe them, doesn't take them seriously, thinks they're "crazy."  No matter how much research data there is identifying the link between the brain and the gut, the notion that symptoms are impacted by brain function skirts too close to all in your head.

Even though repeated studies demonstrate that brain-gut, behavioral interventions are twice as effective (at least) as medications for IBS they skirt too close to all in your head.

The aversion to these 4 words has pushed my colleagues in GI psychology to change our language. We don't call it "psychotherapy" even though it falls under that rather broad, umbrella term for what psychologists do. We call them brain-gut interventions. Wait, gut-brain interventions now.  I presume to put emphasis on the gut.

The Rome Foundation has changed its nomenclature of "Functional GI Disorders" to "Disorders of Gut Brain Axis."  While both are more technically accurate, and I agree 100% with the shift, I can't help but wonder how much of this is because all in your head is such an awful phrase and we're doing everything we can to avoid it? 

I have a chronic pain patient, not of GI origin, who came to a recent visit saying a medical provider said "we need to make sure this isn't all in your head" when planning her treatment. With context, the clinician was trying to talk about centrally mediated pain and how the brain can be sensitized to feel pain that maybe shouldn't be there.  But her choice of words was poor, and my patient immediately was sent reeling to those thoughts and feelings of being dismissed.

The thing is, and please don't yell at me for saying this, pain is all in our head. By definition, pain is processed in our brain. Which, last time I checked, is located in our skull, which sits atop our neck. The spinal cord does some things, too, but the ol' brain is key here.

Image Credit: Neurowiki
I took out my trusty brain model and showed her the parts of the brain involved in pain processing, many of which are "primitive" and not under our voluntary control.  But also how these pain centers are wired into our cortex, or the thinking part of the brain, which is under our control.  

I explained to her if we cut off the signals from the part of the body where her pain resides to her brain, she wouldn't feel the pain. It doesn't mean her body part isn't still damaged. But because the central processing center isn't getting the information, no pain. Like how a nerve block injection works.

This is why people with paralysis are at high risk of injury to their extremities because the signals to the pain processing centers of the brain are offline. 

My 5 minute lesson on brain anatomy helped her understand the phrase all in your head shouldn't mean a clinician thinks you're making things up. That it's a complicated relationship. Like Bennifer. Or Brangelina. 

Instead of embracing the role our brains play in our symptoms, the stigma of all in your head harms patients not just by making them feel completely invalidated, but because there will be a rejection of effective treatments that target the brain to treat pain or other symptoms in other parts of the body with legitimate dysfunction.

Unfortunately, most patients don't get the mini lesson in neuroanatomy I gave to mine. And the average person doesn't really understand how pain is processed, but they do know any implication physical symptoms are psychologically based is a bad thing.  Hell, I DO know how it all works yet when I'm a patient and I get any sense a doctor thinks my symptoms aren't real, I see red. So I get it. It feels like shit.

I don't have solutions to this right now. This is a long standing, deeply entrenched social issue. I'm sure I'll write more on this topic in the near future because it's a growing frustration of mine.  I want to make sure we do this right, that we help patients with our growing understanding of GI psychology and normalize the role of the brain in disease. And diffuse the immense power the words ALL IN YOUR HEAD continue to have.

--T2

Popular posts from this blog

So You Have IBD During a Pandemic

Hey! What's going on? Been pretty boring over here in Chicago. Ok I don't need to elaborate on what the hell is going on in the world. We are being bombarded with information - some accurate, a lot inaccurate - about this pandemic. It's very easy to become completely overwhelmed by it all. We've been forced, pretty damn quickly, to completely overhaul our way of life for the greater good. To reduce the strain on our healthcare system of the sick and dying. And us humans are generally bad with rapid, monumental change that we really don't have a lot of say in. Our little reptilian brains do what they're supposed to do (prime us for fight or flight or freeze) but our advanced "thinking" parts of our brain have to interject with all sorts of unhelpful thoughts, thereby sending some of us off the rails. Before we start, turn off the news. Seriously. In the days following 9-11 we found people who consumed more 24-hour news channel information were mor

Psychosocial aspects of having an ostomy

This past Saturday, Tiffany and I had the honor of speaking at the United Ostomy Associations of America's Regional Midwest conference. I was assigned the task of speaking to the patients, and Tiffany addressed the partners or caregivers. I wanted to share with you some of the highlights from my talk. I only had an hour for my session, and with about 100 people in the room, it was not nearly enough time. I love bullet points, so here you go: We are all different! Every ostomate is different and not one size fits all for the emotional/mental aspect either. Who had months to talk about an ostomy and weigh pros/cons? Who was this a more sudden decision for? Who had cancer? Who had IBD? Something else? Who had an ileostomy? colostomy? urostomy? Who has a temporary? Permanent? Multiple temporaries? What age where you when you got your ostomy? Under 20, 20s, 30s, 40s, 50s, 60+ Who was single when they got their ostomy? With a serious partner when they had it? Some find a stom

IBD & Medical Trauma

Medical trauma is such an under-recognized issue for the chronnically ill. It's a hard topic to talk about because it can seem like we are pointing fingers at healthcare workers. Maybe that's why there are only, now, 4 studies on the topic in patients with inflammatory bowel disease (IBD). If you are someone who treats people with IBD please know I am not here to demonize or criticize. I am both a patient and a GI psychologist. I know the medical system from both sides. I know how messed up and broken it is. But ignoring this or rationalizing it away as only affecting a few folks is wrong. So let's talk about it. Post-traumatic stress (PTS) is the term we use for medical trauma due to technicalities in the Diagnostic and Statistical Manual for Mental Disorders (DSM-5) for post-traumatic stress disorder (PTSD). PTS can be less severe that full on PTSD, or it can be full on PTSD. Regardless, the symptoms are identical: Feeling hypervigilant/on-edge (increased