Editorial: It’s All in Your Head

by Harry Goldhagen
First published November 13, 2002 in Medscape Infectious Diseases

A number of years ago, my editorial assistant at the time, whom I’ll call Nika, stopped by my desk to tell me something important. “I think I have chronic fatigue syndrome,” she said in her Russian-inflected English.

“What makes you think that?” I asked with some puzzlement, for she seemed as energetic and fit as usual.

“I don’t have any energy anymore. I feel tired all the time.”

I thought for a moment, and then asked, “Well, do you get enough sleep?”

“Oh, no,” she answered emphatically, “ever since he got his new job, my boyfriend keeps very late hours, and I hardly ever sleep enough.”

“Then I have both the diagnosis and treatment. . .”

One wishes all problems could be so simple. But often it’s not clear what’s going on. Take my Uncle Jerry, who recently passed away. About 40 years ago he lost his voice a few weeks after a respiratory infection, and it never really returned to what it was. He had to give up his job at an aerospace company because he could no longer communicate loudly or clearly enough to his large staff. At the time, no one had a clue what the problem was, so after numerous inconclusive tests, his physician suggested psychotherapy.

Of course, there was plenty to talk about — he had been a prisoner of war in Stalag Luft I, one of the camps “reserved for flyboys whose wings had been unceremoniously clipped” (as he described in his unpublished memoirs on his experiences during the war) after his plane was shot down and he parachuted to the ground during an ill-fated bombing mission in 1944. (According to my uncle, this prison served as the model for Stalag 17 and its later, sillier incarnation in Hogan’s Heroes.)

But psychotherapy didn’t improve his voice, and it took years for it to come around to relatively normal. Many years later, some physician realized that he probably had postviral vocal cord immobility, and I think someone took a look and demonstrated it. But for some reason, at the time that diagnosis wasn’t considered. No one knew what he had, so it was assumed to be “all in his head.”

In his book Phantoms in the Brain, Vilayanur S. Ramachandran of University of California at San Diego described a condition called anosognosia, in which a patient who has suffered a stroke in the right parietal cortex denies he is paralyzed on his left side despite all evidence.^[1] (Oddly enough, Ramachandran confirmed that pouring cold water into the left ear canal suppressed the denial, only to return a few hours later.) Oliver Sachs described a related case in his book, The Man Who Mistook His Wife for a Hat, in which a man kept falling out of bed after he tried to throw a “foreign leg” to the floor — even though the paralyzed leg was his own. He thought the leg had been placed in his bed as a gruesome practical joke by one of the young residents.

At last year’s ICAAC, we learned about an unusual relationship between group A beta-hemolytic streptococcal tonsillopharyngitis in children and obsessive-compulsive behavior.^[2] Murphy and Pichichero^[3] found that eradication of the organism with antibiotics led to prompt resolution of the obsessive behavior. And in the few who relapsed, the behavior returned, but once again resolved after effective therapy.

And to this day, it’s not clear whether the neurologic deficits that have persisted in some of those who survived the anthrax attacks are due to the long-term effects of the disease or the psychological sequelae of living through a bioterrorist event. Certainly, cognitive and neurologic deficits are a common finding even years after encephalitis.

In his recently published commentary in Emerging Infectious Diseases, Gerald N. Callahan^[4] beautifully describes the dichotomy we have created when dealing with diseases that affect the mind:

Callahan goes on to document various infectious diseases that make animals act “crazy,” and even includes diseases in humans such as neurologic syphilis. He also suggests that people infected with Borna disease virus have a higher incidence of bipolar disorder, schizophrenia, and depression.

What is the point of all this? I’m not simply touching on the fact that the mind and body are one, that you cannot separate one from the other when considering health and illness. Anyone who has treated patients with encephalitis, epilepsy, or brain tumors has experienced this at close range. And in clinical trials of acid-suppressive therapy for gastroesophageal disease, nearly 40% of patients receiving placebo experience relief, suggesting a very close relationship between the central nervous system and its gastric neurologic partner.

Rather, there is a bigger lesson here: Baldly stated, we don’t know everything. Sure, you agree with me now. What’s to argue with? It’s not a very deep concept. But wait until you’re talking with a patient whose condition seems odd, unusual, inexplicable — when it’s obvious to you that the problem is all in his head, that he’s malingering, looking for sympathy, or simply nuts.

Perhaps it is all in his head, but maybe not quite how you mean it. Just like infectious diseases know no boundaries (witness the recent cases of malaria in Virginia), bugs don’t always stop at the blood-brain barrier or the meninges — sometimes they cross the line and cause symptoms that are hard to recognize when we “razor medicine off at the neck,” as Callahan neatly describes it.

To quote Polonius (from Hamlet), “Though this be madness, yet there is a method in’t.” Or perhaps more to the point, Hamlet himself states, “There are more things in heaven and earth, Horatio, than are dreamt of in your philosophy.”

References

1. Horgan J. Mind over body. Sci Am. September 23, 1996. Full text.
2. Kaiser L. New approaches for preventing sneezing and coughing. Medscape Conference Coverage. 2002.
3. Murphy ML, Pichichero ME. Prospective identification and treatment of children with pediatric autoimmune neuropsychiatric disorder associated with group A streptococcal infection (PANDAS). Arch Pediatr Adolesc Med. 2002;156:356-361. Abstract.
4. Callahan GN. Madness. Emerg Infect Dis. 2002;8:998-1002. Abstract.