Learning why men and women experience pain differently

It’s one of the more puzzling observations in medicine: The vast majority of chronic pain patients are women. Women suffer disproportionately from irritable bowel syndrome, fibromyalgia, headaches (especially migraines), pain caused by damage to the nervous system, osteoarthritis, jaw problems like TMJ, and much more. Women also report more acute pain than men after the same common surgeries.

In the lab, when researchers ask male and female volunteers to subject themselves to experimental pain — increasingly hot stimulation on the inner arm, immersion of the hand in very cold water, electrical jolts to the skin — women show lower pain thresholds (that is, they report pain at lower levels of stimulus intensity) and lower tolerance (they can’t bear intense pain as long).

Women are also better able to detect small gradations in pain stimuli. And they respond differently to certain opioid — painkilling — drugs. (It’s not clear whether men and women differ in sensitivity to cancer pain.)

But it’s only recently that researchers have begun to study the exact genetic, physiological, hormonal, and psycho-social factors that may underlie these sex differences. In part, that’s because pain researchers have been hampered by one — rather shocking — fact: Most basic pain research is still done in male mice and rats.

This has been “a catastrophe,” says McGill University pain geneticist Jeffrey Mogil, adding that the old rationale that menstrual cycles make females too difficult to study is bogus. Men and women, in fact, can be so different in the way their nervous systems process pain that someday there may be “pink pills for women, and blue pills for men,” he says. The lopsided research exists solely because of “inertia,” he adds.

Others agree, among them Dr. Roger B. Fillingim, lead author of an exhaustive 2009 review of sex and pain research published by the American Pain Society. In that paper, Fillingim, a pain researcher at the University of Florida, notes that while the National Institutes of Health now require routine inclusion of both sexes in human studies, much animal research “continues to eschew females.” Given that pain is mainly a female problem, he adds, this means research “that excludes females is incomplete at best and invalid at worst.”

Luckily, this shutout is not total, and of course, some human research does specifically address sex differences — with complex, and fascinating results.

Take hormones. Growing up, boys and girls show comparable patterns of pain until puberty, notes Dr. Navil Sethna, a pediatric anesthesiologist at Children’s Hospital Boston. “After puberty, certain types of pain are more common in girls, and even if the incidence is the same, reported pain severity is more intense in girls than boys, especially for headaches and abdominal pain,” says Sethna. This pattern persists through adulthood; the lifetime prevalence for migraines is 18 percent for women and 6 percent for men.

The same pattern holds for TMJ, temporomandibular joint disease — now called TMD — with no sex differences before puberty and significant differences afterward.

Not all studies agree, but many do show that after puberty, women experience striking fluctuations in their response to pain at different points in the menstrual cycle. This has been noted in irritable bowel syndrome, TMD, headache, and fibromyalgia. One explanation, some researchers say, is that estrogen protects against pain at high levels, and enhances it at low levels. (The male hormone testosterone seems to protect against pain.)

This theory fits with the observation that during pregnancy, when estrogen levels are high, women often get fewer migraines and TMD pain. And it fits with the observation that, after childbirth, when estrogen falls abruptly, the number of migraine attacks increases.

It may not be the absolute level of estrogen that is key, says Dr. Fernando Cervero, a pain researcher at McGill, but the fluctuations in hormonal levels during the menstrual cycle. (Estrogen levels climb in the first half of the cycle, then decline in the second half.) “It’s the change that produces the change” in perceptions of pain, he says.

What about that big hormonal change, menopause? That’s when estrogen falls abruptly. If the low estrogen-more pain theory is true, women should experience pain after menopause, but research results are all over the place.

Several studies have shown that women who combat low levels of estrogen by taking hormone replacement therapy actually have more back pain and more pain from TMD as well. Other studies detect no link between hormone replacement therapy and pain in older women. And still others show that when women taking hormone replacement therapy, their pain appears to go up and they may get more migraines.

Females “may have evolved sensory mechanisms that allow for greater acuity across sense organs” over the eons, says Dr. William Maixner, director of the Center for Neurosensory Disorders at the University of North Carolina, Chapel Hill. Females are more sensitive in general to changes in smell, temperature, visual cues, and other stimuli that may signal danger — traits that could have helped them in earlier times to protect the children they watched while the men were away. Experiencing pain in a more heightened way may be one more example of that sensitivity.

“The conditions that cause pain affect men and women differently in terms of prevalence and severity,” notes Dr. Daniel Carr, a professor of pain research at Tufts Medical Center. Some drugs also affect men and women differently. And then there’s “the whole social dimension and cultural dimension of being a woman versus being a man, which modifies” treatment choices. In other words, he says, “Whatever pain therapy one selects should have some flexibility to it.”

One thing is clear: In this culture, women are often encouraged to express pain, and men to hide it. But this doesn’t mean that friends, relatives — and doctors — react sympathetically to women’s expression of pain. In the clinic, this often translates to gender bias and under-treatment of pain, notes Fillingim.

Women, he says, should not put up with any doctor who says or implies that “you are just another whining woman.” But neither, he adds, should men stick with doctors who don’t respect them or believe their pain.

“There are doctors with a greater understanding of pain in general and a greater willingness to deal with it, and others who, if they can’t see it on an X-ray, don’t believe it’s real,” Fillingim adds. Bottom line? “Avoid that latter category.”

This is Judy Foreman’s last Health Sense column for a while. She is writing a book on chronic pain, provisionally titled “A Nation in Pain: Treating Our Biggest Health Problem.” She invites readers to send their personal stories of pain to:judyforeman@myhealthsense.com

Freezing human eggs is gaining in popularity, but declaring it a success would be premature

Doctors have been freezing sperm for 60 years and embryos (fertilized eggs) for 30. The first pregnancy from a frozen egg occurred in 1986.

But it’s been only in the past few years that fertility specialists have begun freezing eggs with any regularity — so short a time that two major professional groups, the American College of Obstetricians and Gynecologists and the American Society for Reproductive Medicine, still consider egg freezing experimental. They caution that a request to freeze eggs should be considered by an institutional review board before being granted.

Freezing eggs for non-medical reasons — a healthy woman choosing to harvest and preserve her eggs for conceiving a baby sometime in the future — is new enough that there are few reliable statistics on how successful the procedure is. “Success” in such cases means a take-home baby, not just an egg that is frozen without damage, or thawed safely, or even fertilized to yield a genetically normal, healthy embryo.

“So few women who have frozen eggs have come back to use them [that it’s impossible] to quote a clear pregnancy rate on it,” says Dr. Elizabeth Ginsburg, medical director of assisted reproductive technologies at Brigham and Women’s Hospital. There hasn’t been time to collect enough data, since women usually plan to freeze eggs for many months or years before retrieving them for conception.

But the idea is clearly catching on. Nationwide, roughly half of 282 US fertility centers surveyed offer egg freezing, according to researchers at the University of Southern California, who conducted the study and published findings last month in Fertility and Sterility, a journal of the American Society for Reproductive Medicine. There are about 400 fertility centers in the United States.

Egg freezing, not usually covered by insurance, can cost $10,000 or more per procedure. Beyond the initial expense, there are annual fees, often hundreds of dollars, to maintain the eggs.

At Boston IVF, a leading fertility cen ter in the United States and one of the oldest as well, typical fees are $6,000 for the harvesting and freezing of eggs, which does not cover the cost of hormones and medications, egg thawing, subsequent fertilization, or transfer of eggs to the uterus. The center has begun offering seminars on the process to young women, many of whom are just out of college or grad school and heading into the workforce.

A woman who decides on egg freezing is given hormones to stimulate egg production. At Boston IVF, egg retrieval is performed under general anesthesia, though other centers may use IV sedation plus pain-killing drugs.

Two-thirds of the clinics in the USC survey reported that they made the service available to women for elective reasons. Traditionally, egg freezing “has been used in women with cancer who face imminent loss of ovarian function. But recently, the technology has advanced to the point where it is worth using for women who want to preserve their oocytes for social reasons,” says Dr. Briana Rudick, a reproductive endocrinologist at the University of Southern California and the lead author of the survey.

There are no reliable numbers for how many women have chosen to have their eggs frozen so far. About 60 women have done so at Boston IVF, most of them as a hedge against their advancing age, says Dr. Kim Thornton, clinical director of the center’s egg-freezing program. So far, none has returned for the next step, she said.

Worldwide, more than 900 babies have been born from frozen eggs, according to a 2009 study conducted by researchers at the New York University Fertility Center, and published last year in Reproductive BioMedicine Online.

Of course, there are no guarantees that freezing eggs will preserve fertility, just as there are no guarantees — at any age — that a woman can get pregnant naturally. In both cases, the odds get worse as egg quality declines with age.

“Humans are the poorest of all mammalian species in terms of chromosomal integrity,” says Dr. Geoffrey Sher, founder of the Sher Institutes for Reproductive Medicine in Las Vegas. “With humans, even when they’re young, there’s only a 2 in 5 chance that an egg is normal. By the time a woman is 45, approximately 1 in 15 is normal.”

“Pregnancy rates at age 40 are pretty low even with fresh eggs,” says Ginsburg, at Brigham and Women’s. “You can chop that by two-thirds if it’s frozen eggs.”

Still, several advances are nudging the use of egg-freezing forward. One is “vitrification,” in which eggs are frozen within 15 minutes. Typically, eggs have been frozen slowly, over several hours, using programmable freezers that drop temperatures step by step. While many fertility clinics still use this method, ice crystals can form, making egg survival only about 60 percent, says Michael Tucker, scientific director at Georgia Reproductive Specialists in Atlanta. The claim with vitrification is that the egg survival rate may rise to 80 percent or even higher.

Testing the genetic viability of both eggs and embryos has also boosted interest in freezing. Several methods are available, including CGH, or comparative genomic hybridization, which checks eggs or embryos to be sure they have the correct number of chromosomes. Some embryos appear normal under the microscope but have the wrong number of chromosomes, meaning they are not viable, says Sher of Las Vegas.

Bottom line, a woman who wants to conceive a child at some point in the future should carefully consider the options — the risks, costs, and unknowns.

Regarding the use of egg freezing, Ginsburg advises not waiting too long. “If you want to have a child and it’s feasible socially, do it. . . . I get infertile patients, married for five years, who couldn’t imagine having a baby in [their] small apartment. That’s a bad reason to wait until age 35. It’s really sad, and I see it a lot.”

Restless legs syndrome keeps you going (even if you want to
stop).

The symptoms of restless legs syndrome sound so bizarre —
creepy-crawly feelings and an uncontrollable urge to move the legs, especially
at bedtime — that until recently, many people who experienced it simply weren’t
believed when they described it to others.

Betsy Dunn, an 85-year-old Cambridge businesswoman who has had
restless legs for nearly 30 years, remembers a doctor saying she must be
depressed. “I walked out and never went back,” she says. “All I needed him to
say was, ‘I don’t know what this is, but together we will find out.’ ”

In severe cases, like that of Donald Loveland, 75, a retired Duke
University computer scientist now living in Dennis, the urge to move the legs
overwhelms everything else, including pain. Right after back surgery, he
recalls, “it was actually painful to be up but I had to get up anyway.”

Ron Blum, 38, a Jamaica Plain e-mail marketer who first noticed
his symptoms as a 7-year-old, recalls that the minute he lay down and tried to
sleep, “my left leg felt like it had to go for a walk.” Though he never told
his parents, he’d get up and walk for hours in circles. It wasn’t until years
later that a friend heard about RLS. “He called me up and said, ‘Ron, I know
what you have. It has a name.’ ”

It also has growing recognition. RLS may affect some 12 million Americans, according to the National Institute of Neurological Disorders and Stroke, as reported on the
National Institutes of Health website (www.ninds.nih.gov/disorders).
The NIH supports research into the condition at major medical institutions
across the country, as well as within its own labs.

The NIH report notes that the number of RLS sufferers may be even
higher than estimated. Some people with the condition don’t seek medical
attention, believing that they will not be taken seriously, that their symptoms
are too mild, or that their condition is not treatable. Some physicians wrongly
attribute the symptoms to nervousness, insomnia, stress, arthritis, muscle
cramps, or aging.

“You can think of RLS today as where sleep apnea was 10 to 15
years ago,” says Dr. John Winkelman, a psychiatrist, RLS expert, and medical
director of Sleep Health Centers, which is affiliated with Brigham and Women’s
Hospital.

“We used to think of sleep apnea as a bunch of fat guys snoring,”
says Winkelman, who consults for drug companies that make RLS medications. “We
are also just beginning to recognize the potential negative medical
consequences of RLS.” A number of studies have hinted that the syndrome might
be associated with more serious conditions.

Not to mention the toll RLS takes on the quality of life.

“There were many, many nights when I would sleep for only two and
a half or three hours,” recalls Roberta Kittredge, a 65-year old retired
teacher in Hampton, N.H., who first got RLS when she was pregnant. (Some
studies suggest a link between RLS and high estrogen levels.) “Every night I
went to bed positive I would sleep, and two or three minutes later, I was out
of bed and walking the floor for hours and hours.”

There is currently no single diagnostic test for RLS.

“We know what’s wrong,” says Richard Allen, an associate
professor of neurology at Johns Hopkins University. “The neurobiology of RLS is
definitely clear.”

Levels of iron fall too low in parts of the brain, resulting in
reduced availability of dopamine, a neurotransmitter that carries information
between the body’s cells involved with movement that is also deficient in such
disorders as Parkinson’s disease. In addition, four genes have been linked to
RLS, which often appears in families.

The dopamine connection helps explain why RLS has such a distinct
circadian rhythm, says Allen, who also consults for companies that make RLS
drugs. Dopamine levels follow a clear 24-hour pattern, with levels lowest in
the evening. Moreover, presumably because both RLS and Parkinson’s involve low
dopamine, some of the dopamine-enhancing drugs used to treat Parkinson’s — like
Mirapex and Requip — also can reduce or eliminate RLS symptoms in some
patients. Side effects may include nausea and headache. Taking iron supplements
has been helpful in decreasing or halting RLS symptoms for some patients.

“I would probably be dead by now because of exhaustion,” says
retired Newton architect Paul Dudek, 70, whose life improved dramatically when
he was finally diagnosed and treated with medication.

Dopamine also plays an important role in erectile function, and
epidemiologist Xiang Gao of the Harvard School of Public Health has shown that
men with relatively severe RLS have nearly double the normal risk of erectile
dysfunction. (Xiang Gao has no ties to RLS drug companies.)

But dopamine isn’t the only neurotransmitter that plays into the
RLS picture. Histamine, for one, is a powerful brain stimulant, so drugs that
block histamine — antihistamines such as Benadryl — can significantly
exacerbate RLS symptoms.

One of the frustrations with RLS is that symptoms are usually
triggered just when a person needs to sit or lie still, such as on long plane
trips or when sitting in the audience at concerts and other presentations.
Symptoms tend to be most severe at night.

Once asleep, 80 percent of people with RLS also exhibit another
condition: periodic limb movement during sleep (PLMS), in which the legs jerk
as often as every 20 or 30 seconds. Researchers from the University of Montreal
and elsewhere have shown that each involuntary PLMS leg movement is associated
with a dramatic increase in blood pressure.

Studies suggest RLS might be associated with more serious medical
problems, such as increased risk of heart disease and stroke.

If a link between RLS and high blood pressure is confirmed, the impact
would be dramatic. “Hypertension is a powerful predictor of premature death,”
says Dr. David Rye, a neurologist at Emory University who studies the genetics
of RLS and PLMS and has the conditions himself. Rye also consults with
companies that make RLS drugs.

So far, though a number of researchers have noted associations
between RLS and other diseases, no one has established causality between RLS
and the other conditions. RLS is not an established risk factor for
cardiovascular disease in the way that cholesterol is, for example.

While understanding the condition is a complicated task, RLS
patient Kittredge can offer some hard-won advice to people who might be
suffering in silence and shame: “Find an educated doctor . . . who understands
RLS,” she says. “There is hope out there. I am living proof.”

 

A spate of recent studies reinforces the idea that what we think about our
medical care really can affect our health.

The new research into the power of placebos is giving scientists new
insights into how patients’ expectations their beliefs about whether an
inactive, sham treatment will work can have an actual, observable effect on
their well-being.

In one small study, volunteers with jaw pain were repeatedly injected with
what they were told was a pain drug but in reality was nothing but salt
water, yet PET scans showed that after every injection, their brains
produced endorphins natural, opiate-like painkillers.

The men’s beliefs about the treatment caused changes in the brains and
reduced their perception of pain, said Dr. Jon-Kar Zubieta, the study
leader and associate professor of psychiatry and radiology at the
University of Michigan Medical School.

The placebo effect can work in reverse, too, through its evil twin, the
“nocebo” effect. At least 25 percent of the time, when people take an
inactive placebo they report experiencing side effects like headache,
insomnia, and fatigue, said Dr. Arthur Barsky, a psychiatrist at Brigham
and Women’s Hospital. In other words, telling patients about potential side
effects can make it more likely that they’ll occur.

And last week, Harvard researchers reported that sham acupuncture provides
more pain relief than a sugar pill that comes with a promise of relief. The
conclusion to draw from the study, said researcher Ted Kaptchuk, is that
medical ritual “may be a critical component” of treatment.

The work on placebos will help researchers determine precisely what their
drugs are doing and what the contribution of the placebo effect is for
healing though it’s still unclear precisely how best to harness the placebo
effect to make patients feel better.

“The whole point of all this is, how do we capitalize on the placebo
response,” said Dr. Helen Mayberg, a professor of psychiatry and neurology
at Emory University School of Medicine.

The research shows that it’s not possible to “psych yourself” into making a
drug work. But not trusting your care whether it’s popping a pill handed to
you by a doctor or undergoing 30 minutes of treatment from an alternative
medicine practitioner is likely to undermine any benefits.

“This is not about the power of positive thinking, it’s about positive
expectations,” Mayberg said. “I can’t think myself well, but if you go in
with a new treatment and say, `This is not going to work,’ it probably
won’t help you.”

In general, from 30 to 60 percent of patients with everything from
arthritis to depression report an improvement in symptoms after receiving a
placebo. One-third of depressed people feel better after taking placebos,
while 50 to 60 percent of those taking antidepressants do, said Dr. Andrew
Leuchter, vice chairman of the department of psychiatry at the University
of California, Los Angeles.

“The placebo effect is the summation of all the things we do in treatment
that help people get better that are not part of a known specific
treatment,” he said.

“I define it that broadly because when we interact with someone in a
positive way, when we give them encouragement and support, and also when
they become part of the healthcare system no longer sitting at home ill,
but in a milieu where they are getting treatment we tap into positive
expectations.”

The effects of placebos wear off with time, but real drugs keep on working.

Because of this and medical ethics no one is suggesting that doctors
prescribe their patients sugar pills or sham treatments.

But combining real medicines with the “placebo effect” does more than
either can alone.

“The take-home message is that when you get an active drug, you get the
effect of the drug itself and the placebo effect,” said Michigan’s Zubieta.

The newest research, much of it based on brain imaging techniques, provides
direct evidence of how the placebo effect works. The research will help
scientists determine more precisely the contributions of the “placebo
response” to the effectiveness of medications.

Some other recent findings:

Columbia University researcher Tor Wager has used brain scans to map where
in the brain the placebo response occurs. It turns out that those areas
including the thalamus, the insula, and the anterior cingulate cortex are
also among the areas activated when a person is in pain.

The placebo effect can even kick in when there’s no placebo, according to
Dr. Fabrizio Benedetti, a professor at the University of Turin.

In one study, Benedetti hooked pain patients to a computerized injection
device. In some cases, the computer administered morphine without the
patients knowing it, and in others, a doctor gave the drug in full view.
The hidden therapy was much less effective than the open one, showing that
to get the most from a treatment, you have to know you’re getting it.

Similarly, Parkinson’s patients improved more when they were told doctors
were activating a stimulator in their brains than when the stimulator was
turned on without their knowing it, Benedetti showed.

In Alzheimer’s patients, however, the Italian team found the expectation of
pain relief did not reduce the perception of pain, suggesting that a mostly
healthy brain is required for the placebo effect to work.

Though all this makes for compelling research, it’s still unclear what it
means to patients and their doctors. “That’s the new frontier,” Harvard’s
Kaptchuk said.

What is clear is that having a reasonably positive attitude that a new
treatment will work can at least stack the odds in your favor, and not
focusing on all the possible side effects makes sense, too.

It’s also essential to pick a healthcare provider you trust so that his or
her words of encouragement about a treatment can boost the chance it will
work for you.

We’ve got e-commerce, e-banking, e-pharmacy and of course, e-mail. So why not e-therapy?

Actually, there are lots of reasons why not. But that’s not stopping the latest trend in electronic medicine – virtual therapists, some 150 to 200 of them, who offer assessments, generic advice and even ongoing individual psychotherapy online.

The mere idea of sending private thoughts into cyberspace to someone who may or may not be a qualified therapist, who probably isn’t licensed in the state where you live and who can’t see the tears in your eyes when you talk about your mother is enough to send mainstream therapists around the bend.

And the whole notion might indeed be silly except for two things. One: Some people actually prefer confiding in a computer. And two: There’s a huge unmet need for mental health services in America, and Net-based services might help meet it.

Consider depression. Roughly 18 million Americans suffer from it and only two thirds get treatment. Indeed, a recent Harris poll showed that among 60 million Americans who used the Net last year to search for health information, what they most wanted to know about was depression.

There are several ways computer technology can help, and the least controversial is by offering diagnosis and assessment. At www.mediconsult.com, for instance, you can take a 10-minute test to help interpret your moods. I took it, and it’s not bad – on a par with standard questionnaires in self-help books. In other words, it might help clarify whether you need treatment – but obviously can’t provide warm, supportive feedback.

Another online assessment tool is being developed by Healthcare Technology Systems (www.healthtechsys.com) and is already available by telephone (1-800-813-2364). I took this, too, and for some reason, found it more disconcerting to punch in answers on the phone pad than to click on a computer form.

Still, it’s not assessment that’s really controversial in virtual psychotherapy, it’s the idea of being analyzed by a therapist you can’t see. This drawback might change with the advent of video-audio transmission via the Net.

Many therapists draw a distinction between using e-mail occasionally to stay in touch with patients they already know and conducting therapy between strangers on the Net.

Dr. Russell Lim , a psychiatrist at UC/Davis in California, uses e-mail in the former way. “I’m a pragmatist,” he says, and is quite willing to try “whatever works in real life.”

He uses e-mail with a patient who lives far away and comes in every other week, just as some therapists use the telephone to stay in touch when necessary. “Without the Internet connection,” he says, “the point might be lost.”

Other therapists, like University of Chicago psychiatrist Dr. Robert Hsiung (www.dr-bob.org/tips) haven’t used the Net yet for individual counselling, but do run virtual self-groups. For instance, Hsiung puts patients with similar problems in touch with each other and is excited about the “potential to do something more directly clinical online.”

But when virtual contact is the only or the primary mode of therapy, numerous questions arise, including the issue of online confidentiality.

Hsiung, for instance, acknowledges that “e-mail isn’t totally secure or confidential. You hope people realize that, but maybe not.” E-mail is fine for innocuous things like re-scheduling an appoinment, he says, but patients should “think twice before sending out sensitive information.”

But the “biggest drawback to online versus real life [therapy] is you don’t get the nonverbal cues, which are a big part of communication,” acknowledges psychologist John Grohol, who runs the mental health section of drkoop.com.

That means the therapist can’t detect a telltale whiff of alcohol on a patient’s breath, or the dirty clothes and hair of someone who’s too depressed to bathe, adds Dr. Ronald Pies, a Tufts University psychiatrist.

And if the therapist and patient have never met, it could be downright dangerous to perform therapy online, warns Gerald Koocher , chief psychologist at Children’s Hospital in Boston.

“The difficulty is when you don’t know who you’re dealing with or what the reality of the situation is,” he says, which is particularly crucial for patients who may be suicidal.

“Do you know who they are and where they are? Do you know how to get emergency services to them? If someone is in your office, you can call the police. If you’re on the phone and you know where they live, you can call intervention for them. If they’re on the Net, you may not know who you’re talking to or where they are or what the nearest emergency facility is.”

Patients, of course, are equally “blind” as to who an Internet therapist really is. “Anybody can hang up a shingle on the Net,” says Pies, which raises the risk of both bad therapy and fraud.

Moreover, psychiatrists, psychologists and social workers are licensed state by state. If if you were harmed by online therapy offered by someone in another state, where would you file a complaint or sue for malpractice?

Even www.metanoia.org, a website that offers lists of online therapists and does some checking of credentials, admits on its site that “if something goes drastically wrong as a result of your interaction with a therapist online, at the present time, you probably have little or no legal recourse against the therapist.”

In fact, metanoia concedes that e-therapy is not really therapy, though it says “it can definitely be therapeutic.”

Despite the serious drawbacks, some believe cybertherapy is an idea whose time has come.

“I personally think this technology has the most potential to improve the rates of treatment and overall quality of treatment of any technology since antidepressants,” says Dr. Joshua Freeman , a psychiatrist at UCLA and medical director for mental health at mediconsult.com.

As it is now, he says, “the system is failing if it insists on providing a certain type of treatment that most people don’t get.”

Besides, a number of studies suggest that some people feel more comfortable – and are more honest – when they’re “interviewed” by a computer rather than a human, especially about sensitive issues.

A 1987 study by University of Wisconsin researchers, for instance, examined the scores of 150 psychiatric patients on diagnostic interviews given both face to face with a trained interviewer and on a computer. A significant majority “liked the computer interview better and found it less embarrassing,” the researchers concluded.

Other studies compiled by Dr. John Greist, CEO of Healthcare Technology Systems, suggest that people may feel more comfortable confessing problems with alcohol, drug or sexual function to a computer because they can think before they answer and don’t have to worry about keeping a professional waiting. People with “social phobia” may also prefer a computer.

So where will all this lead? Let’s hope not too far.

Okay, online self-diagnosis tests are fine. And in a pinch, an online shrink might be better than none, though it’s inappropriate if you’re seriously ill or suicidal.

But basically, therapy is a complex, subtle human endeavor that would lose something essential in cyberspace.

In other words, I side with psychologist Barry Schlosser, who runs a consulting firm in New Haven called Clarity Consulting Corp. E-therapy, he says, is not “ready for prime time.”<
SIDEBAR

THERE ARE MANY WEB SITES OFFERING INFORMATION ON MENTAL HEALTH PROBLEMS AND GUIDANCE IN FINDING A THERAPIST. SOME YOU MAY WANT TO VISIT ARE:

www.healthtechsys.com (for information oncomputerized mental healthassessments)

www.mediconsult.com (for mental health assessment – click on depression, then on “mind health tracker”)

www.drkoop.com (for information on depression and other mental health problems)

http://mentalhelp.net (for information on mental health problems)

It’s been years now, but I can still picture the articulate young woman with the mysterious disease who came to the Globe to see me.   She was armed with a stack of medical papers and spoke with the ease of a scientist about possible causes, symptoms, and tests. But what was most striking was how much her identity seemed to be wrapped up in her illness.

I still have no idea what she may have had. She was clearly suffering – and angry. Yet she seemed unable to take comfort in the fact that her doctors could find nothing seriously wrong. In fact, she seemed stuck in what doctors call “the sick role.”      That’s a shame.

Granted, stories abound about people who stick to their guns, resist the bland reassurances of busy doctors and keep fighting until they get the right diagnosis. More power to them!

In fact, that’s what happened to Dr. Martin P. Solomon, a popular Boston internist who works for Affiliated Physicians Group, based at Beth Israel Deaconess Medical Center.

Twenty years ago, Solomon was worried about a mole on his arm. He consulted dermatologists – “the three biggest guys in the city” – and all told him it was nothing. He insisted that it be removed. Sure enough, it was a melanoma, a potentially deadly cancer. “Had I waited, I wouldn’t be here,” he says.

But still, much of the time, contends Solomon in his new, self-published book, “Don’t Worry, Be Healthy – How to Avoid Obsessing About Your Health,” the American fixation on understanding every hiccup has become downright unhealthy.

“Worry displaces joy,” says Solomon, who certainly sees enough patients – 30 to 40 a day – to know. “People push joy out of the way, from fear or from fatigue.”

The bottom line is as simple as it can be hard to swallow: Get yourself checked out if you’re worried about something, and get a second opinion and more tests if you’re really worried. But once you’ve done all that and everything appears fine, get on with your life, including addressing the emotional issues – anxiety, depression or simply stress – that might be causing your troubles, or at least, hampering your ability to cope with them.

The “sick role” is a terrible trap, and oddly enough, people who really have a serious disease may be less likely to fall into it than people who have no documentable illness.

In one study, Dr. Arthur Barsky, a psychiatrist and director of psychosomatic research at Brigham and Women’s Hospital, interviewed people waiting for medical appointments in a clinic, simply asking them to describe themselves.

People who were not deemed by doctors to be hypochondriacs (defined as people who are not faking their symptoms but can’t be reassured when nothing is wrong) tended to talk about themselves as teachers, parents or to describe their hobbies, even if they had cancer. Those who were considered to be hypochondriacs saw themselves as patients.

In a review published in June in the Annals of Internal Medicine, Barsky and Dr. Jonathan F. Borus, chairman of the department of psychiatry at the Brigham, note that it’s normal for healthy people to report physical complaints every few days.

“Significant fatigue” is a problem for more than 20 percent of healthy adults, and musculoskeletal problems, for 30 percent, they note. Indeed, 86 to 95 percent of the general population has at least one symptom such as a headache, dizziness or heart palpitations in any two- to four-week period.

In many cases, Barsky and Borus say, it’s the belief that one is sick that causes distress. In one study they reviewed, people who hadn’t known they had high blood pressure had a threefold increase in days of work lost once they were diagnosed.

In another, telling healthy volunteers they had tested positive for a disease caused them to recall symptoms characteristic of the disease and to think they had acted in ways that could have put them at risk. In yet another, Barsky and Borus note, people who signed informed-consent forms that specified certain gastrointestinal side effects of a treatment were more likely to experience those side effects than those whose forms did not specify those problems.

Sometimes, obsessing about bodily symptoms and conveying this distress to other people is an indirect way of asking for attention. But this can backfire because, to keep getting that attention, you have to stay in the “sick role.”

One way around that is to agree with your doctor that, even though there seems to be nothing wrong at the moment, you’ll come back in a specified number of weeks or months. That accomplishes two things: It allows a window for re-testing, in case you do have a serious disease. And it lets you let go of your need to be “sick” in order to see the doctor again.

Another solution is to tackle the emotional component of hypochondria head-on.

At the Brigham, Barsky is running a study sponsored by the National Institute of Mental Health to see whether six sessions of counselling using cognitive-behavioral techniques helps ease hypochondriacs’ distress. This approach aims at teaching people to spot what things – thoughts, situations, behaviors – make symptoms worse and which make them better.

At Harvard Vanguard Medical Associates, psychiatrist Dr. Steven Locke, chief of behavioral medicine, also runs a 6-week program. It’s geared toward people who have have stress-related symptoms like headaches, or diseases like asthma that are exacerbated by stress; those with chronic diseases like irritable bowel syndrome or cancer who have a hard time coping emotionally with their illnesses; and to those, like the woman who visited me at the Globe, who have persistent symptoms that defy medical explanation.

Dealing more directly with the emotional causes or consequences of illness can not only decrease distress, it can save a health care organization money. In one recent study at Kaiser Northwest in Albany, N.Y., people who participated in a mind-body program cost the system nearly $1,000 less a year than similar patients who were referred to the program but opted out.

But saving money is not the point. Finding contentment is, and that’s important whether you, or someone you love, has a serious disease or not – as Dr. Martin Solomon found out the hard way. For years, he took only two week’s vacation. “I always felt bad when I went away,” he says. “I felt I should be here seeing patients.”

Then, several years ago, his wife was diagnosed with lymphoma. So for their 25th anniversary, they took the trip to Italy they’d planned for their 30th. They bought a bigger house on Cape Cod to accomodate their grown daughters. He now takes six weeks a year off. “We’ve learned to enjoy walks on the beach. We do more things together,” he says.

“I don’t have to tell this to patients with cancer. They know it,” he adds. It’s the worried well who need to hear it.

ILL OR HEALTHY, DON’T ASSUME THE ‘SICK ROLE’

If you and your doctor have appropriately pursued the symptoms that distress you and there still seems to be no cause, take heart. At a minimum, you should know you’re in good company – an estimated 35 to 50 percent of visits to primary care doctors are for problems for which no physical cause can be found.

But that doesn’t mean you’re not suffering, and it doesn’t mean you are powerless, either. Here are some suggestions:

Don’t assume the “sick role.” This means not thinking of yourself as a patient, but instead defining yourself by who you really are – a parent, spouse, worker, friend, gardener, whatever.

If you do have genuine restrictions on what you can do because of pain, disability or fatigue, make realistic concessions to those limits, but focus on what you still can do.

If your doctor does the appropriate tests and does give you reassurance, try not to reject it. If you get angry when the doctor says you’re fine, look deeper into your feelings. Ditto if you find yourself substituting a new worry as soon as you let go of an old one.

Ask yourself what factors other than disease might be contributing to your symptoms. Do you hate your job? Are you fighting with your spouse? Are your kids acting out? Are you fretting about money? If so, the answer may be to focus on the problem that really needs attention, not your aching back.