There is a tendency to talk about physical symptoms as either medical or psychological.
Either something is “really wrong,” or it is stress.
I don't think this is a particularly useful way to think about the relationship between the mind and the body.
Of course there are biological realities. I don't believe that everything is psychosomatic. If you have physical symptoms, they deserve appropriate medical evaluation. Psychoanalytic therapy isn't a substitute for medical care, and finding psychological meaning in a symptom doesn't mean that there isn't also something happening biologically.
But sometimes there is another question worth asking:
What Else Was Happening When Your Body Began To Struggle?
The body isn't separate from emotional life
We accept the relationship between psychological experience and the body in some circumstances without thinking very much about it.
A child has stomachaches every morning before school.
Someone gets diarrhea before an important presentation.
Your heart pounds when you're frightened.
You lose your appetite after a breakup.
You can't sleep before an important decision.
Nobody needs to decide whether these experiences are “physical” or “psychological.” They are both.
But when physical symptoms become persistent, we can become much more invested in separating the two.
This is understandable. If your body hurts, you want to know why. You want to find the problem and fix it.
And sometimes medicine provides a clear answer.
Sometimes it doesn't.
A person may have abdominal pain, bowel problems, headaches, fatigue, muscle tension, or other symptoms and go through one medical evaluation after another. Tests may be normal. Or doctors may find something real—IBS, psoriasis, migraine, or another condition—but the severity of the symptoms seems to fluctuate in ways that medicine alone doesn't entirely explain.
At that point, I think curiosity about emotional life can become useful.
Not because the symptoms aren't real.
Because the mind and body were never separate in the first place.
Stress Doesn’t Make a Physical Illness Imaginary
Emotional stress produces physiological stress.
That doesn't mean that stress “causes” every medical condition. It means that the state of the organism matters.
We know, for example, that the digestive system is particularly responsive to stress. We see this quite clearly in children, who sometimes develop stomachaches during periods of anxiety or conflict long before they have the words to explain what is troubling them.
We also know that stress can affect the course or severity of some inflammatory and immune-mediated illnesses. Psoriasis is a good example: psoriasis is a real biological disease, but stress can be one of the factors associated with flares in some people.
The psychologically interesting question isn't whether the psoriasis, stomach pain, or bowel symptoms are “real.”
Of course they're real.
Sometimes the Body Becomes the Thing We Can Think About
There is another dimension of physical symptoms that interests me as a psychoanalytic therapist.
When the body is in pain, it demands our attention.
It can become very difficult to think about anything else.
Why does my stomach hurt?
Why am I so tired?
Is this getting worse?
What if the doctor missed something?
What should I eat?
Should I see another specialist?
These can all be completely reasonable questions.
But sometimes focusing on the body also becomes easier than focusing on something else.
That doesn't mean a person is consciously avoiding an emotional problem. Usually it doesn't feel like a choice at all.
It may simply be emotionally easier to experience my stomach hurts than:
I'm furious with my husband.
Or:
I feel trapped in my job.
I am terrified that my mother is going to die.
I have spent my whole life taking care of everyone else, and I don't want to do it anymore.
I don't know why I feel so unhappy when my life looks perfectly good.
The physical symptom may be completely real while also occupying a complicated place in someone's emotional life.
Psychotherapy allows us to become curious about that complexity.
Where Do We Go From Here?
Psychoanalytic therapy isn't about imposing a psychological explanation onto every physical problem. It is about becoming curious when there may be more to understand.
Sometimes that means noticing connections that weren't previously visible.
Perhaps symptoms become worse every time you visit your family.
Perhaps your body becomes particularly activated when you feel dependent on another person.
Perhaps physical symptoms appear during periods when you are functioning extremely well and don't consciously feel stressed at all.
That last situation is particularly interesting.
People don't always experience stress as feeling stressed.
Someone can be highly productive, organized, successful, and outwardly calm while carrying an enormous amount of emotional strain. Sometimes the body is registering something that the person has become very good at not registering psychologically.
“It’s Just Stress” Isn’t a Satisfying Answer
Many patients with persistent physical symptoms have had the frustrating experience of being told that their symptoms are “just stress” or “just anxiety.”
I don't think that's particularly helpful.
It can feel dismissive because it implies that if medicine can't find an adequate explanation, the symptom somehow becomes less real.
Psychoanalytic thinking asks a different question.
Rather than saying, Nothing is medically wrong, therefore this must be psychological, we can ask:
What Role, if Any, Is Emotional Life Playing in What Is Happening to This Particular Person’s Body?
That is an individual question.
Two people can have the same diagnosis and very different psychological lives. Two people can experience the same amount of external stress and respond to it very differently.
The goal isn't to discover the psychological cause of every symptom.
It is to understand this particular person more completely.
Therapy May Not Make the Physical Condition Disappear
I think it's important to be realistic about this.
If someone has a biological illness, psychotherapy may not eliminate it.
Sometimes psychotherapy can help, for example, in cases of autoimmune disorders. Sometimes it can’t.
But eliminating a disease isn't the only possible measure of improvement.
If emotional stress is contributing to the severity or frequency of symptoms, understanding and changing some of that emotional stress may help reduce one source of strain on the body.
And even when a physical condition itself doesn't substantially change, a person's relationship to the condition can.
It is possible to become less consumed by monitoring the body. It may become easier to distinguish between a physical sensation and the frightening thoughts that immediately follow it. It may become possible to understand why certain circumstances reliably make symptoms harder to tolerate.
And sometimes a person discovers that while she has spent enormous amounts of time trying to understand what is happening in her body, there are other parts of her experience that have received almost no attention.
That is where psychoanalytic therapy can become useful.
A useful question may be:
What is happening in my body—and what else is happening in me?
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If you've been through one evaluation after another and the question keeps surfacing — what is happening in my body, and what else is happening in me? — there may be more worth understanding. Not instead of medical care, but alongside it. Psychoanalytic therapy in Washington, DC offers space to stay curious about the connection between your body and your emotional life, without settling for "it's just stress." You can start therapy with Nina Van Sant, LICSW, by following these simple steps:
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Other Services Offered with Nina Van San, LICSW
Psychoanalysis isn’t the only service that I offer. I’m also happy to offer postpartum therapy, therapy for teens, and older adults at different developmental stages. I also provide support for expats and international professionals managing cultural adjustment, relocation stress, and major life changes. You can visit my blog or about page for more support today!