2013. Vol.4, No.7, 569-571
Published Online July 2013 in SciRes (
Copyright © 2013 SciRes. 569
Six Categories of Illnesses
Paul Valent
Liaison Psychiatrist (retd.) Monash Medical Centre , Melbourne, Australia
Email: p.valent@bigpond.n
Received April 15th, 2013; revised May 17th, 2013; accepted June 16th, 2013
Copyright © 2013 Paul Valent. This is an open access article distributed under the Creative Commons Attribu-
tion License, which permits unrestricted use, distribution, and reproduction in any me di um, provided the or iginal
work is properly cited.
Studies show that between 40% and 60% of patients attending emergency departments have medically
unexplained physical symptoms (MUPS) that are determined by psychosocial factors. However, there ex-
ists no clear categorization of these factors and the symptoms that they produce. This paper delineate s six
categories of illnesses that help to overcome this deficit. The categories of illnesses are 1) Typical physi-
cal illnesses; 2) Typical psychiatric illnesses; 3) Psychophysiological symptoms; 4) Symptoms associated
with reliving traumas; 5) “Cherished” or hysterical symptoms; 6) Symptoms that identify with illnesses of
others. Clinical examples of each category are provided.
Keywords: Medically Unexplained Physical Symptoms; MUPS; Psychophysiological; Psychosomatic;
Somatization; Hysteria
An example of the conflict between philosophy and fact can
be seen in treatment of patients in emergency departments. The
philosophy goes back to the Cartesian dichotomy of mind and
body. Doctors see themselves as treating the body. The rest is
not their concern. The fact is that doctors’ patients are an
amalgam of body, mind, and society and the sources of their
physical symptoms are frequently a result of psychosocial fac-
The result of the dichotomy between fact and philosophy is
that between 40% and 60% of patients attending emergency
departments finish with medically unexplained physical symp-
toms (MUPS) (Stephenson & Price, 2006).
Apart from the misery this causes patients, the situation is
very costly (Abbas, Campbell, Han et al., 2010). Instead of
their problems being dealt with, patients are sent on merry-go-
rounds of ever-more expensive tests and referrals in efforts to
fit their symptoms into Procrustean beds of medical illnesses.
Doctors are reluctant to seek out psychosocial factors under-
lying physical symptoms. They feel untrained to deal with the
Pandora’s box of emotion and chaos they believe they may
unleash. But there is also no theoretical framework that can
help them to apportion symptoms to heuristically treatable
Vague warnings that stress can cause illness, and diagnoses
such as hypochondriasis, dissociation, factitious disorder and
malingering (Stephenson & Price, 2006) do not help to distin-
guish symptoms from “genuine” physical disorders.
The following approach is the result of our team’s experience
in the emergency department at Monash Medical Centre over
more than 20 years. Earlier versions of this approach have been
described elsewhere (Valent, 1979, 1998).
The approach recognises six categories of illness. Each is
recognisable and leads to pragmatic interventions.
Six Categories of Illness
Typical Somatic Illnesses
These illnesses provide the least difficulty as they are text-
book medical cases. Examples are acute appendicitis, urinary
tract infection, and myocardial in farct.
And yet even here it is worth looking at psychosocial factors.
Case 1: A child had her first attack of asthma during a pa-
rental quarrel where the father threatened to leave home. Sub-
sequent attacks recurred during similar quarrels. In adulthood
the patient was prone to asthma attacks when threatened with
separation from loved ones. The attacks incidentally inclined
people not to leave her.
Case 2: A young woman presented with polyneuritis (Guil-
lain-Barre syndrome). This developed within days of a fire that
destroyed the family home and business. She believed that it
was her fault and that she nearly caused the death of her sister.
She believed that she had forfeited any love for the rest of her
life. (For a full description of this case see Valent (2009).
Illnesses with a Psychiatric “Signature”
Some physical symptoms are part and parcel of major psy-
chiatric illnesses. Sleep disturbance, anorexia, constipation,
tiredness, exhaustion are classical accompaniments of major
depression. Bizarre symptoms such as ants crawling under the
skin, sense that one’s scalp is lifting, foreign agents regulating
physiological functions all have a schizophrenic signature.
Case 3: A woman presented with extreme tiredness after the
death of her husband. She also lost all interest and looked de-
pressed. When she grieved her husband her tiredness lifted
along with her depression.
Case 4: A schizophrenic man suffered a constant level of
nausea that he attributed to the neighbours poisoning him with
Psychophysiological Symptoms
Because the sympathetic and parasympathetic nervous sys-
tems and stress hormones reach and influence every organ of
the body, their arousal in stress can result in a very wide range
of symptoms that include potential arousal and dampening of
every bodily system. Musculo-skeletal tension symptoms in-
clude headache, neck ache, chest pain, and back ache. Digestive
system symptoms include loss of appetite, weight loss, weight
gain, nausea, constipation, diarrhoea, etc. Cardiovascular symp-
toms include palpitations, shortness of breath, chest pains, high
blood pressure. Urino-genital system symptoms include bladder
pressure, frequency, dysmenorrhea, painful intercourse.
Psychophysiological symptoms can mimic at least in part
most physical disorde rs.
Case 5: A woman who attended her GP with recurrent head,
neck, and back pains was found to suffer from tension that re-
sulted from bracing against her husband’s violent outbursts.
Case 6: The first time a patient developed migraine was
when she witnessed Nazis vandalise her grandmother’s shop in
Vienna on Krystallnacht. She felt a fury toward those who
made her grandmother collapse in the street. However she was
impotent to vent her rage. Throughout her life migraines re-
curred at times when she had to bottle up her anger.
Reliving Traumatic Situations
Dissociated aspects of traumatic situations may be relived as
physical symptoms.
Case 7: A combat veteran kept returning to hospital with
chest pain which he was convinced was sign of a heart attack.
The pain did not conform to heart disease and all tests were
normal. On closer questioning the pain was a wrenching of the
heart, as if it incurred a wound, or as if it was broken. It was the
exact pain he felt when his buddy died in his arms. Grieving
relieved the physical pain.
Case 8: A woman experienced severe physical pain each
time her husband penetrated her. The pain was a replica of the
pain she suffered when an uncle penetrated her as a child.
Identification wit h Ill ne ss es of Others
Patients often identify with symptoms and illnesses of those
they love, especially of those who had died. This is a result of
empathy, guilt, and not having let go. Symptoms often arise
during the loved person’s terminal illness, after bereavement, at
anniversaries, and when attaining the age of the loved person
(such as a parent of the same sex).
The symptoms are often unusual because they reflect pa-
tients’ concepts of what others suffered, and such concepts may
be anatomically untenable.
Case 9: A month after her husband’s death of a heart attack,
a woman presented with a sharp stabbing pain over her left
nipple. She believe d that she was having a hea rt attack like her
Case 10: A 12-year-old girl was brought to hospital after she
carelessly rode in front of an oncoming car. Two years earlier
her sister, then 12 was killed on her bike in a collision with a
car. The younger sister blamed herself for her sister’s death and
had fantasies of joining her in heaven.
“Cherished” Illnesses; Hysteria
It goes against the medical grain to consider that suffering
may be cherished. Patients who cherish their symptoms arouse
frustration because they do not comply with treatment, their
symptoms migrate, and they adopt fashionable diagnoses that
are difficult to diagnose and treat.
Once suspicion is aroused, diagnoses only thinly veil anger.
Diagnoses include “secondary (financial) gain”, “hysteric”,
factitious disorder, Munchausen’s syndrome, and malingering.
In reality, apart from the few cases of malingering, cherished
illnesses obey classical rules of hysteria. The symptoms are
produced through unconscious processes; they symbolise a
major stress or trauma ; whose consequences the symptoms help
to resolve this being primary gain; and they are secondarily
used for other gains (secondary gains). The classical example
was the World War One soldier whose paralysis of the right
arm necessitated his withdrawal from combat.
Case 11: A previously somewhat pampered inductee was
bullied by his army colleagues who teased him as not having
“guts” or “stomach” for the army. After a mild punch to his
stomach he developed severe abdominal cramps that did not
respond to treatment. Eventually he was “honourably” dis-
Case 12: A previously hard working man developed back
pain after lifting a heavy object. His disability was beyond any
objective pathology. The man’s wife withdrew from sex after
her doctor advised her that she would die if she had another
child. The man, however, suspected that his wife had a lover
while he was at work. Staying at home enabled him to keep a
watchful eye over her. Secondarily, his disability evoked con-
cern from his wife, as well as worker’s compensation.
The six categories of illnesses present a heuristically useful
way of conceptualising illnesses. Rather than consigning symp-
toms that do not meet typical somatic criteria to a waste-basket
of therapeutic nihilism, a checklist of illness categories may
find that the symptoms fit precisely into one of the non-somatic
Considering the frequency of MUPS, this has clinical impli-
cations for approaches to all patients. Such approaches have
been called holistic, and biopsychosocial. I prefer to call for a
wholist approach (Valent, 1998a) that includes both biopsy-
chosocial and whole. In addition to biological, psychological,
and social interactions, the approach concerns itself also with
moral dilemmas and existential meanings. They were very rele-
vant in the abov e cases.
Pragmatically, a somatic approach like “Tell me about the
pain”, is replaced with an open-minded question such as “Of all
the things that worry you what worries you the most?”.
All histories should include questions such as “Have you
been under stress or experienced trauma recently/when the
symptoms started?”, “Apart from these symptoms do you have
any others/any other worries/frustrations/conflicts?”, “Have you
been depressed/anxious/experienced other strange symptoms?”,
“Have you known anyone else who suffered these symptoms?”,
“If you could have any desire fulfilled, what would it be?”.
When patients reveal the emotions and contexts of their wor-
ries, it is not so much that a Pandora’s box opens with ever-
more problems, but rather that a box under pressure opens akin
to the release of an abscess.
The categories enable making positive psychosocial diagno-
ses. Further, diagnoses are confirmed when symptoms recur
Copyright © 2013 SciRes.
Copyright © 2013 SciRes. 571
when stresses return or when they are reproduced in fantasy.
They resolve when the stre sses are resolved.
An interesting test is over breathing for half a minute. This
often reproduces psychophysiological and other psychosocial
symptoms. Re-breathing in a paper bag diminishes them.
Of course categories, diagnoses, and treatments are not al-
ways simple. Categories themselves may be difficult to ascer-
tain, and they can be multiple and overlap. Further, presence of
a non-somatic category does not mean that a somatic one does
not exist as well.
Six categories of illnesses provide a step toward a heuristic
conceptualisation of what are otherwise medically unexplained
physical symptoms.
An advantage of the non-somatic categories is that they con-
nect with the initial disruptive conditions, their consequences,
and the existential meanings the symptoms symbolise. Treat-
ment can repair the disruptions, resolve the symptoms, and
provide new meanings.
Though symptoms may not always be easily classified, di-
agnosed, and treated, the expanded categories do provide ex-
tended tools for diagnosing physical symptoms without classi-
cal medical explanations.
Abbass, A., Campbell, S., Hann, S. G., Lenzer, I., Tarzwell, R., &
Maxwell, R. (2010). Cost savings of treatment of medically unex-
plained symptoms using Intensive Short-Term Dynamic Psycho-
therapy (ISTDP) by a hospital emergency department. Archives of
Medical Psychology, 7, 34-43.
Stephenson, D. T., & Price, J. R. (2006). Medically unexplained physi-
cal symptoms in emer gen cy medi cine. Emergency Medicine Journal,
23, 595-600. doi:10.1136/emj.2005.032854
Valent, P. (1979). Psychosomatic aspects of illness. Patient Manage-
ment, 8, 21-28.
Valent, P. (1998). Traum a and fulfilment therap y; A wholist framework.
Philadelphia, PA: Brunner/Mazel.
Valent, P. (1998a). From survival to fulfilment; A framework for the
life-trauma dialectic. Philadelphia, PA: B runner/Mazel.
Valent, P. (2009). In two minds; Tales of a psychotherapist. Sydney:
University of New South Wal es Press.