They can’t find anything wrong! Seven keys to understanding, treating, and healing stress illness describes the approach and techniques developed by physician David D Clarke, MD, in treating more than 7000 patients with “stress illness.” For more than 20 years, Dr Clarke has taken referrals of patients with “medically unexplained” symptoms, who have generally already seen multiple health professionals bent on finding a biomedical explanation. Patients with medically unexplained symptoms have always existed, but with greater and greater advances in diagnostic technology they have become increasingly marginalized. The better we get at identifying the underlying mechanisms of disease, the more skeptical we are of patients for whom we “can’t find anything wrong.” Dr Clarke describes medically unexplained symptoms as a “blind spot in the health care system,” but it might be more accurate to say that very few physicians have the knowledge, attitudes, and skills to successfully manage such patients.

Reminiscent of the work of John Sarno, MD, with patients suffering from chronic low back pain,1 Dr Clarke provides example after example of patients with medically unexplained symptoms that vanish or become bearable after the connection to stress becomes clear and the patients are able to work directly with their stress. Dr Clarke divides stress into five overlapping categories that are easily understood and accepted by patients: childhood stress, traumatic stress, stress occurring now, stress from depression, and stress from an anxiety disorder. Even better, in story after story he walks the reader through his elegant approach to introducing patients to the notion that stress may be causing their symptoms. This approach is simple yet profound, incorporating unconditional positive regard, active listening, and a gentle curiosity as patients share with him parts of their lives they have been struggling to escape.

A number of questions arise reading this book. First, to what degree are Dr Clarke’s successes replicable by other practitioners? I have tried to apply his techniques with some success; in particular, I have found his approach to discussing stress with patients quite fruitful. I have had the best results in patients with irritable bowel syndrome, but I cannot report any spectacular “cures.” One observation I made in applying his techniques is that they were harder to introduce after I had undertaken an exhaustive search for medical explanations for a symptom.

Second, are the techniques that Dr Clarke describes useful for patients whose symptoms are medically explained but chronic in nature? The high rates of depression, anxiety disorders,2 child abuse,3 intimate partner violence,4 and post-traumatic stress disorder5 in patients with chronic pain, and the high rates of symptoms in patients with these histories,6 suggest that the stress illness approach to stress might be helpful to this patient population as well.

In conclusion, I highly recommend this book. Through storytelling and real life examples, Dr Clarke effectively captures the wisdom and respect inherent in his approach to patients. It is a potential classic because it offers a refreshingly practical approach to problems that have been tying doctors and patients in knots since medicine became a science. In the tradition of Kitchen Table Wisdom7 and other great books that teach through storytelling, Dr Clarke’s book speaks equally well to patients and clinicians alike.

References

1. Sarno JR. Healing back pain. New York: Warner Books; 1991.

2. McWilliams LA, Cox BJ, Enns MW. Mood and anxiety disorders associated with chronic pain: an examination in a nationally representative sample. Pain 2003 Nov;106(1-2):127-33.

3. Davis DA, Luecken LJ, Zautra AJ. Are reports of childhood abuse related to the experience of chronic pain in adulthood? A meta-analytic review of the literature. Clin J Pain 2005 Sep-Oct;21(5):398-405.

4. Campbell JC. Health consequences of intimate partner violence. Lancet 2002 Apr 13;359(9314):1331-6.

5. Sharp TJ. The prevalence of post-traumatic stress disorder in chronic pain patients. Curr Pain Headache Rep 2004 Apr;8(2):111-5.

6. Nicolaidis C, Curry M, McFarland B, Gerrity M. Violence, mental health, and physical symptoms in an academic internal medicine practice. J Gen Intern Med 2004 Aug;19(8):819-27.

7. Remen RN. Kitchen table wisdom: stories that heal. New York: Riverhead Books; 1996.

 

 

 

 

 

 

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