Mystery of the Mind

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In his last lecture, “Mystery of the Mind”, famed neurosurgeon Wilder Penfield said that the mind was dependant on the brain and could only be understood metaphysically (therefore outside the scientific realm). Yet the mind and conflicts therein do unquestionably influence bodily physiology. Conversely physical diseases can influence mental health. The DSM classification of mental disorders has an Axis III to list physical ailments that can underpin Axis I, the major psychiatric afflictions.

This is how it works. A young male patient I recall seeing came in with classic acute schizophrenia. A physical exam revealed track marks on the arms. Urine and blood screens revealed amphetamines.  The latter can induces symptoms that are identical to schizophrenia especially if used IV. This is intriguing as speed use turns over dopamine metabolism thought to be a factor in psychosis.

A 30-year-old aboriginal man I saw presented with confusion and seizures. It turns out that in a psychotic state thinking he was “impure” he  drank litres of water to the point of water intoxication which lowered his sodium enough to induce neurological symptoms.

A 60-year-old man presents with severe depression and nagging abdominal pain. You order a scan and find a pancreatic cancer, which can in a way not clearly understood present early on as depression.

For conditions inside the central nervous system we note that a brain tumour can be associated with  depression, confusion or headache. Multiple sclerosis with depression and weakness of a limb. It would be a clinical error therefore to not investigate symptoms IF the physician has a high index of suspicion. The majority of depressed folk do not a have major physical identifiable cause. How much screening one does depends on careful history. 80% of what is wrong with the human mind- body can be determined by the lost art of careful listening. The rest through the physical and lab findings.

Looking at the flip side there has been a long-standing tradition of viewing certain disorders as having psychosomatic causation-the mind influencing the body. This has included: peptic ulcer, rheumatoid arthritis, irritable bowel, fibromyalgia, or ulcerative colitis. For the latter unproven theorizing had led at one time to a “colitis personality” characterized by obsessive compulsive features or immaturity, passivity and dependency.

Of course association doesn’t imply causation. Having a chronic miserable bowel illness can make you compulsive and dependant. And peptic ulcer disease has a bacterial aetiology- Helicobacter Pylori-treatable with antibiotics. Back in the day repressed hostility and anxiety were relevant and do indeed generate stomach acid, and this is why treatment  may involve pump inhibitors like Losec.

Stress management or more in-depth psychotherapy can be helpful as well for many of these “psychosomatic” disorders and reduce relapse frequency. Indeed stress of any sort can induce exacerbation of most chronic illnesses. They do that in part  by increasing cortisol which reduces the efficiency of the immune system or by causing a lack of synchronization in the autonomic nervous system. Consider irritable bowel syndrome. I was taught that the bowels were mirror of the mind. Certainly episodes of pre interview or final exam diarrhea support this.

So it is no surprise that  depression and anxiety figure prominently in contributing to symptoms of IBS. Hormonal fluxes and possible infectious agents may also be involved.

Having a terminal illness leads to classic grief reactions beginning with disbelief and denial progressing to depression and acceptance.

In all of the above case scenarios psychiatric intervention can prove valuable in sorting out the mind-body interface.

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