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Soul Sickness: A Frequently Missed Diagnosis
Charles R. Perakis, DO
“Soul sickness,” or demoralization, is characterized by feelings of hopelessness and helplessness and a perceived sense of incompetence. This condition typically involves vague, unexplained physical symptoms. Soul sickness can be efficiently diagnosed by asking patients a series of questions about their personal lives. Patients with this condition require a restoration of their morale and hope. Physicians can assist patients in regaining hope by encouraging them to focus on new, adaptive behaviors. As osteopathic physicians, we can use our skills in osteopathic manipulative treatment to manage the demoralization-related physical symptoms of patients.
J Am Osteopath Assoc. 2010;110(6):347-349
Vague, unexplained physical symptoms (eg, body pains, dizziness, fatigue, headaches, insomnia) Hopelessness Helplessness Sense of incompetence Sense of not meeting expectations of others Inability to deal with internal stress (eg, from emotional, physical, or sexual abuse) or external stress (eg, from insufficient coping skills for dealing with daily problems) Attitude of “checking out” of life
oul sickness” is a diagnosis that one will not find described in medical textbooks. Nevertheless, I encounter this condition many times a day among patients in the family practice where I work. In my experience, patients with what I refer to as soul sickness typically have vague, unexplained symptoms, such as body pains, dizziness, fatigue, headaches, and insomnia (Figure). They may have been diagnosed as having such conditions as chronic fatigue syndrome, chronic Lyme disease, chronic pain syndrome, fibromyalgia, migraine headache, multiple chemical sensitivity syndrome, or any of a host of emerging new diagnoses. I have found that the origin of soul sickness is a patient’s inability to deal with internal or external stress. The internal stress may be borne of emotional, physical, or sexual abuse. The external stress may arise from insufficient coping skills for dealing with the problems and suffering that life brings almost everyone. Rather than transcending the suffering, patients with soul sickness have “checked out” of life. They no longer feel that they are competent to live productive lives and to meet the expectations of people close to them.
Figure. Characteristics of soul sickness, as recognized by the author.
“Soul Sickness” in the Literature
The psychiatric literature has recognized the presence of soul sickness for decades—but under other names. Gruenberg1 describes cases of “social breakdown syndrome,” in which patients manifest progressive chronic psychiatric deterioration. According to Gruenberg,1 some patients manifest this deterioration chiefly by modifications in their personal and social behaviors, and evaluations of “inner psychic connections underlying symptom formation can be complemented by investigating how social functioning breaks down” in patients. Gruenberg1 notes that social breakdown syndrome “occurs when certain reactions to the patient interact and resonate with some of [the patient’s] efforts to do what he [or she] feels will be acceptable.” Evidence indicates that the use of mental health services can interrupt this deteriorating process.1 Engel2 refers to “the giving-up—given-up complex” as a temporary failure of mental coping mechanisms. Frank3 defines the cardinal features of demoralization, the common denominator of all maladies addressed by psychotherapy, as feelings of helplessness, hopelessness, diminished self-esteem, meaninglessness, a perceived sense of incompetence, and a persistent inability to cope. Clark and Kissane4 argue for the addition of demoralization to psychiatric nomenclature. Kihlstrom and Kihlstrom5 describe the process of somatization, in which physical symptoms of unknown etiologic origin can result from psychosocial stresses.
From the University of New England College of Osteopathic Medicine in Biddeford, Maine. Financial Disclosures: None reported. Address correspondence to Charles R. Perakis, DO, Maine-Dartmouth Family Medicine Residency, 15 E Chestnut St, Augusta, ME 04330-5736. E-mail: email@example.com Submitted February 9, 2010; accepted February 25, 2010.
Perakis • Special Communication
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socially accepted standards and values) ▫ formation of warm. the physician can serve as a catalyst for action by initiating the conversation with patients.3 Physicians can help patients reframe their assumptions. Rather. We can guide patients toward behavioral techniques that allow them to soothe themselves. Buchholz10 wrote a wonderful description of using hope as a kind of pharmaceutical agent in a 1990 article titled “HOPE. We can lead patients toward a recognition of the value of managing their ailments properly and effectively. play. This field of psychology is based on the value of helping people lead meaningful and fulfilling lives. Besides being ineffective and inefficient. Soul sickness can be efficiently diagnosed by asking patients the following questions and by considering their answers: With whom do you live? What do you do for work? If you don’t work. and love. Perhaps they can be encouraged to make new connections with the healing powers of nature.SPECIAL COMMUNICATION Diagnosis Confusion Physicians—working in a healthcare system that does not provide reimbursement for taking comprehensive medical histories of patients—frequently choose to order blood tests or imaging to help define unexplained problems and to rule out serious conditions that would require immediate medical intervention.” In many cases. such as by incorporating healthy alternative lifestyle choices in diet and activities. Unfortunately. Hope is central to this behavioral form of healing.7 Although patients must find their own meanings to their lives in order to transcend such suffering.” One approach to this idea would be to place pharmaceutical-type advertisements on television to promote the medical benefits of the agent of hope—perhaps as public service announcements. Many patients do not have textbook diseases that are responsible for their physical symptoms. direction. what type of disability do you have? What brings meaning to your life? What is a typical day like in your life? What do you do for fun? Whom would you depend on in a crisis? These questions can help the physician open the door to a conversation that illuminates the true nature of the patient’s lifestyle. and helpless.11 Other behaviors or attitudes that the practice of positive psychology encourages in patients include the following12: ▫ cheerfulness. patients make certain assumptions that cripple them. Examples of ways in which physicians can encourage such adaptive behaviors in patients include the following9: We can introduce patients to new coping skills. The physician should understand the biopsychosocial factors of soul sickness and how to uncover this condition during diagnosis. interest in life. behaviors guided by one’s own internal. feeling sense of continued development) ▫ sense of purpose. Hope needs to be engendered in patients to restore their morale.6 biopsychosocial considerations are crucial in the clinical approach that physicians take with patients. such tests and images designed to reduce physician uncertainty often raise additional uncertainties rather than provide answers about patients’ conditions. Volunteering can also help patients better understand the value of give-andtake in their personal relationships. of cultivating the unique strengths within individuals. seeking challenges. The positive psychology movement emphasizes factors that encourage the flourishing of mental health. such as through camping. We can help patients achieve small victories that strengthen their beliefs about themselves. and molding personal environment to suit needs ▫ autonomy (ie. adaptive behaviors rather than on their old. encouraging them to focus on new. and these predicaments can become manifested as physical symptoms and psychological suffering. Physicians can assist patients in regaining hope by 348 • JAOA • Vol 110 • No 6 • June 2010 . hiking. they face “predicaments” as a result of certain situations in their lives. peacefulness ▫ overall satisfaction with life ▫ positive attitude about oneself ▫ personal growth (eg. and of enhancing positive experiences of work. Such diagnostic tests may also lead the patient to believe that the physician is concerned about the presence of certain disease states—resulting in further stress for the patient. Perhaps they can be guided to volunteer for activities that allow them to give to others while reaping the resulting psychological benefits for themselves. including the healthy use of leisure time. such as believing that they are rejected. this approach is also costly and creates the potential for iatrogenesis. Such activities can improve a patient’s relationships with other people by promoting reciprocity. alienated. Perhaps they might rediscover a hobby or other activity that brought them pleasure in the past.8 Restoring Morale and Hope Patients with soul sickness require a restoration of their morale. trusting personal relationships with others Perakis • Special Communication Making the Diagnosis of Soul Sickness What is the alternative to this approach? As noted by Engel. Physicians can begin this restoration by letting patients know that someone is listening to them and that someone wants to understand their “story. and meaning in life ▫ selecting. have you worked in the past? If you are disabled. problematic behaviors. or stargazing. managing.
123(12):1481-1489.org/pubs/journals/features/ccp-733539. Engel GL.36(1):90-94. the physician can arrive at a clear diagnosis. Conclusion Soul sickness is a frequent presentation in physicians’ offices.73(3):539-548. 5. 12. 1979.263(17):2357-2358. Keyes13 notes that any effort to improve our healthcare system must focus on increasing the number of individuals who are psychologically healthy. http://www. The clinical application of the biopsychosocial model. we can use our unique skills in osteopathic manipulative treatment to manage the physical symptoms of patients that result from demoralization. University of Pennsylvania Positive Psychology Center Web site. and valued by. and predicaments. Most patients with this condition present with frequent vague symptoms that remain medically unexplained. 2005. Treating patients in a holistic manner is most likely to lead to a greater number of patients who are flourishing rather than languishing. Instilling hope into forensic treatment: the antidote to despair and desperation. Am Fam Physician. Hillbrand M.apa.SPECIAL COMMUNICATION ▫ acknowledgment and acceptance of human differences ▫ belief that people and society have potential and can evolve and grow positively ▫ view of one’s own daily activities as useful to. Am J Psychiatry.pdf. 1990. patient’s story and by asking pertinent questions. 14.edu/. 1967. Ann Fam Med.org/cgi/content/full/36/1/90. References 1. 11. Am J Psychiatry. 1971.69(2):293-300. Feeney J. J Consult Clin Psychol. 15. Demoralization: its phenomenology and importance. Cullom S. By carefully listening to the Perakis • Special Communication JAOA • Vol 110 • No 6 • June 2010 • 349 . Talbott GD.ppc. others ▫ interest in society and social life. After soul sickness is recognized. Somatization as illness behavior. Positive psychology. Egnew TR. illnesses. 13. 3. 2010. Keyes CL. 1980.org/cgi/content/full/3/3/255. 1993.sas. Lancet.annfammed.2(8150):1008-1010. Am Psychol. and these presentations can be addressed with osteopathic manipulative treatment.15 Having conversations with our patients as we treat them is another important aspect of the holistic. Psychotherapy: the restoration of morale. Kihlstrom JF. 1974. A life setting conducive to illness: the giving-up—given-up complex. For example. Buchholz WM. 2.”14 As osteopathic physicians. The components of sickness: diseases.jaapl. Mental illness and/or mental health? Investigating axioms of the complete state model of health. Accessed May 12. Keyes CLM. 2010. though it may not be recognized by this name. Such a focus would likely drive down the need for—as well as the costs of—healthcare in general. J Med Educ. 8. Young JL. Osteopathic manipulation and tension-type headaches. HOPE (generic). Accessed May 12. stress. The meaning of healing: transcending suffering. 9. 6. JAMA. a community Another factor related to treating patients with soul sickness is the importance of mental health as it relates to the healthcare system as a whole in the United States. 7. Taylor DC. Accessed May 12.48(6):10231024. Frank JD. Headaches and back pain are common presentations in the clinical setting that may be related to demoralization. and deriving comfort and support from. J Am Acad Psychiatry Law. Applying Unique Osteopathic Medical Skills Many patients with soul sickness would benefit from the “laying on of hands.17(4):240-243. 2005. Clarke DM.36(6):733-742. finding them meaningful and somewhat intelligible ▫ sense of belonging to. 2010. Ann Intern Med. http://www. Promoting and protecting mental health as flourishing: a complementary strategy for improving national mental health.131(3):271-274 4. Accessed May 23.46(4):374-376. the physician can assist the patient in finding appropriate coping mechanisms and lifestyle changes to take the patient from a languishing life to a flourishing life.upenn. Baird RE. Cantor Kihlstrom L. Engel GL. http://www. Gruenberg EM.3(3):255-262.62(2):95-108. The laying on of hands: a doctor’s plea for the young men of medicine. osteopathic approach to medicine. Deedman R. or other psychological struggles. Aust N Z J Psychiatry. Kissane DW. Adv Mind Body Med. 2002. 2010 10.137(5):535-544. The social breakdown syndrome—some origins. 2008. Am J Psychiatry. 1968. Simning P. 2007. 2001. Kellogg J. http://www.
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