David C. Ring
If disease is defined as a pathophysiological process, and illness as a human being’s experience of that process, then one can readily appreciate the psychological, sociological, and behavioral aspects of illness behavior. Contrast on the one hand the placebo effect, where the patient’s wellness is derived from the meaning they invest in a given treatment rather than that treatment’s efficacy or effectiveness, with secondary gain, where—mindfully (malingering) or mindlessly—the patient derives benefit from their illness. Also, consider the substantial variation in disability (what the patient perceives they cannot do) for a given degree of impairment (or objective decrease in physical function such as diminished motion or sensation). For instance, contrast examples of two patients with operatively repaired diaphyseal forearm fractures: The athlete whom you struggle to keep off the field until the fractures are healed and the patient who claims they cannot work even a year after injury with near normal objective function.
Some of the psychosocial aspects of illness—such as secondary gain—are intuitive and obvious to the surgeon, while others are not. Surgeons, as a rule, tend to see illness as mechanically based and physically correctable. Combine this with the current stigmatization associated with psychological illness and its treatment, along with our society’s tendency to dichotomize between the cognitive and physical aspects of illness (e.g., “It’s all in your head”), and it can be counterintuitive, unfamiliar, and even offensive to consider some of the less obvious psychosocial aspects of illness behavior. The majority of these illness concepts are most evident in the treatment of pain, particularly chronic pain.
Evidence is growing with respect to illness throughout the body, and chronic pain in particular, that psychological distress (depression/anxiety), ineffective coping skills (catastrophizing), and heightened illness concern (health anxiety/hypochondriasis) determine a patient’s complaints and disability as much as, if not more than, objective pathophysiological processes. But this is just putting fancy names to aspects of illness behavior that surgeons see every day.
The patient with a flat affect and disproportionate pain who complains that he or she sleeps poorly, is inactive, watches television all day, and is afraid to return to the job that injured him or her is likely experiencing elements of depression and anxiety.
Talk to the patient who gets a stiff swollen hand during recovery from a distal radius fracture and you will find that pain sends a very strong danger alarm to their mind that they cannot modulate and the sense of trouble is exacerbated by negative illness misconceptions such as “the pain means I’m causing damage,” “the pain will never go away,” and “I’ll never be able to do the things I enjoy” among other thoughts captured under the concept of pain catastrophizing.
Finally, consider the patient with vague, diffuse, disabling arm pain who does not feel the expected sense of relief and wellness when the examination and
diagnostic tests are reassuringly normal—they are convinced that something is seriously wrong with them, and your best efforts consistently fail to reassure them.
These patients tend to puzzle us. We feel uneasy with these patients. We feel inadequate, ignorant, and challenged. As result, the first patient (A) gets labeled as a malingerer, the second (B) is diagnosed with “chronic regional pain syndrome,” and the final patient (C) gets test after test until someone applies a diagnosis and—at worst—surgery is elected in a context where surgery can only do harm and any positive result may be due to the placebo effect.
It is probably best to trust feelings of uneasiness—no matter the combination of ignorance, limited technical skill, or difficulty in understanding a patient’s illness at their root. Our diagnoses and diagnostic tests are not as precise as we would like, and a large percentage of the surgeries that we do—particularly for pain—have not been adequately tested against simpler treatments or placebos. Perhaps the best reason to learn to trust uneasy feelings and look for their source is that depression, catastrophizing, and heightened illness concern, when recognized, are highly responsive to treatment. Given the substantial psychosocial influences on arm illness, one hopes that we will eventually treat arm illnesses in multidisciplinary teams that include behavioral medicine specialists as they do in many spine centers and chronic pain programs. Until that time the surgeon may not be able to provide or even suggest psychological treatments, but they can be honest about their puzzlement and unease, any disconnect between impairment and disability, disproportionate nonanatomical complaints, and what is healthy about the arm. All this should be done in a context that conveys empathy and legitimizes the patient’s illness, no matter the proportion that is biological and the portion that is psychosocial/behavioral. This will make it easier for other members of the patient’s health care team—their primary care doctor in particular—to help address the psychosocialbehavioral aspects of the illness.