Irresolution, the Basis of Psychosomatic Illness

Prof. [Dr. of Med.] Charles McWilliams ©2015

Life Begins with Oxygen and Ends with Carbon Dioxide

Life begins and ends with a breath. In fact, respiration or breathing is at the core of all our metabolic processes as we inhale oxygen and exhale carbon dioxide through our lungs.

The Calvin cycle is the principal mechanism that leads to the conversion of carbon dioxide into sugars by plants, algae, photosynthetic bacteria, and certain other bacteria that use chemicals as an energy source instead of light. The plants then "fix" or capture the carbon dioxide and are able to convert it into simple sugars like glucose through the biochemical process known as photosynthesis. Plants store and use this sugar to grow and to reproduce. Thus, by their very nature as makers of their own food, plants remove carbon dioxide from the atmosphere. When plants are eaten by animals, their carbon is passed on to those animals.

Respiration is the next evolutionary step in the cycle, and unlike photosynthesis, it occurs in plants, animals, and even decomposers. Although we usually think only of breathing oxygen when we hear the word "respiration," it has a broader meaning that involves oxygen too at the cellular level where disease begins and ends. To a biologist, respiration is the process in which oxygen is used to break down organic compounds into carbon dioxide (CO2) and water (H2O). For an animal then, respiration is both taking in oxygen (and releasing carbon dioxide) and oxidizing its food (or burning it with oxygen) in order to release the energy the food contains. In both cases, carbon is returned to the atmosphere as carbon dioxide. Carbon atoms that started out as components of atmospheric carbon dioxide gas have passed through the body of living organisms and been returned to the atmosphere, ready to be recycled again. Any interruption in this process leads to disease.

A Doctor's Dilemma: La Maladie Du Petit Papier

Roughly translated ``la maladie du petit papier'' means ``the illness of the list.'' Sir Edward Waine, a physician in Glasgow, Scotland, first described this medical issue after observing a patient take a long list of questions out of his pocket at the end of the medical consultation. It is unclear why this phenomenon is described in French but the axiom implies that when the patient presents the “little piece of paper,” with a litany of complaints, the patient status almost certainly is going to contain psychosomatic elements. Among the most difficult and frustrating of complaints from patients for physicians are those with multiple complaints involving many organ systems who, despite seeing numerous physicians, fail to obtain a satisfactory diagnosis, explanation or relief from their symptoms. We all have witnessed this on countless occasions.

Traditional medical wisdom holds that patients who relate their complaints to their physicians from prepared lists are, ipso facto, emotionally ill. List writing, therefore, is called la maladie du petit papier, the illness of the little piece of paper, occasionally written maladie du morceau du papier. Osler's aphorism 309 states, "A patient with a written list of symptoms — neurasthenia." DeGowin and DeGowin in their venerable textbook on bediside diagnosis which I recommend to all my students states that note writing is "almost a sure sign of psychoneurosis. The patient with organic disease does not require references to written notes to give the essence of his disease…”

After numerous physicians have been seen and multiple diagnostic tests have been done, which have excluded organic disorders, such patients are often dismissed as having nothing wrong with them or having various forms of neurosis, anxiety, depression, hypochondriasis or hysteria, despite the persistence of symptoms that may be disabling in their work and other aspects of everyday living. Unfortunately, this scenario continues to be a common occurrence and is the frequent setting in which the hyperventilation syndrome is not recognized, months or years after its onset. This is misdiagnosis at the outset. La maladie du petit papier cinches the diagnosis.

Stress Response, First Stage of Disease, the Misdiagnosis

Stress and anxiety is often associated with a hyperadrenergic state that is provokes hyperventilatory breathing responses in humans called hyperventilation syndrome. The "Adrenergic" is a physiological state of excitation from adrenalin or from something with effects like adrenalin. Hyperadrenergic is a state with abnormally elevated amount of excitation or anxiety. A person would feel nervous, shaky, agitated, have low appetite, and maybe feel a little nauseous. Once hyperventilation is initiated, persisting stresses of everyday living or the stresses of new bothersome symptoms from hyperventilation create the potential for a self- perpetuating cycle of chronic hyperventilation.

Hypocapnea, reduced carbon dioxide in the blood results from hyperventilation, and respiratory alkalosis develops rapidly upon onset of hyperventilation and can easily be maintained indefinitely, by nearly imperceptible hyperventilation episodes, such as by taking an occasional deep breath while maintaining a normal respiratory rate. Without knowing this, physicians fail to observe the subtle, chronic forms of hyperventilation and upon considering the diagnosis, inappropriately reject the patient’s symptoms because they fail to understand the full scope of human respiration.

The hyperventilation syndrome may be associated with a myriad of symptoms, affecting both men and women equally. Some of the most frequent complaints for which medical attention is sought after are lightheadedness or dizziness, headache, dyspnea (shortness of breath), and non-anginal chest pain. Substantial weakness, exercise intolerance, fatigue and peripheral or perioral numbness and tingling, occurring in isolation or in concert with other hyperventilatory symptoms, are almost always present to some degree. Many patients have multiple other symptoms on their roster of complaints. When symptoms are taken by the doctor in isolation or in group, the syndrome of hyperventilation syndrome is rarely considered and psychotropic medications immediately prescribed.

The dizziness of hyperventilation syndrome may be described as lightheadedness or an unsteady, giddy feeling, similar to transient drunkenness or vertigo. Breathlessness is another common medical complaint and is usually described as the inability to inhale a satisfying deep breath, as if starving for air. It is often manifested by periodic, thoracic deep breaths, such as sighing and yawning. Although the hyperventilation syndrome rarely is associated with an obvious increase in respiratory rate, astute observers usually will note an increase in thoracic respiratory efforts with probing questions. Paradoxically, whereas many people take deep breaths in an effort to relax, they may be provoking the very state they wish to avoid, i.e. hypocapnia - a state in which the level of carbon dioxide in the blood is lower than normal. The dyspnea of the syndrome may arise from constricted respiratory muscles, overworked from chronically tense, excessive respiratory efforts. Palpation along the intercostal muscles will reveal numerous spots that are excruciatingly tender. Since this type of functional dyspnea rarely occurs in the absence of other related symptoms, it is important that other manifestations of the hyperventilation syndrome be sought in all cases of otherwise unexplained dyspnea.

It is critical to recognize that the presence of the HV syndrome does not exclude the presence of an organic disease. In fact, reaction to the symptoms of an organic disease may be a prime factor provoking hyperventilation. Further, what begins as hyperventilation syndrome, actually ends with organic pathology including cancer!

A diagnostic Nijmegen Questionnaire provides an accurate diagnosis of Hyperventilation without triggering symptoms. It has been used extensively in many scientific studies.

The standard diagnostic technique is to have the patient breathe rapidly for two minutes. This will trigger the symptoms and convince the patient that over breathing is responsible for their symptoms. This test can only be performed at a time when the patient is not already experiencing symptoms, and can be risky in people who have occult vascular disease or epilepsy.