Is it all in your head?

According to Dr. David Sobel, a primary care physician with Kaiser Permanente and author of the highly respected Mind-Body Health Newsletter, only 16 percent of people who visit their physician for common maladies like nausea, headache and stomach upset are diagnosed with a physical, organic cause. The rest are classified as having a somatic disorder, the expression of bodily symptoms when you're under psychological distress -- or, as Sobel puts it, "the body speaking its mind."

And when the body speaks, it curses. You can wash out its mouth with soap, but it simply doesn't respond to direct commands. You didn't will the rash onto your body when your spouse left you; you can't will it away. This is perhaps the most frustrating part about the mind-body connection, and what Sobel sees as the danger of simplifying the relationship. "It's not true that if you simply think better thoughts your pain will go away," he says. "It's far more complex than that. There is lots of evidence that a positive state of mind increases the chance for healing, but it doesn't guarantee it."

Psychophysiological treatment doesn't necessarily involve learning how to think good thoughts. It's more about learning how to control largely involuntary processes like heart rate, blood pressure and muscle tension. The preferred method is biofeedback, in which patients are hooked up to devices that pick up electrical signals from the muscles, triggering a flashing light every time they tense up. To relax tense muscles, the patients have to slow down the flashing light. By associating sensations from the muscle with actual levels of tension, they learn to undo detrimental physiological effects.

Not only can our minds make our bodies sick, our bodies are more than willing to return the favor. Doebbeling, at the University of Iowa, believes the mind and the body are so intertwined that it's hard to tell which one has the wheel of the car. The only certainty is that whoever's in control has one hell of a back-seat driver.

Take a patient who comes in with symptoms of depression. Does she have a psychiatric disorder with medical symptoms or a medical disorder with psychiatric symptoms? Doebbeling doesn't know until she does a medical work-up. The classic symptoms of depression are fatigue, an inability to concentrate for very long, sleeping too much or too little and constant rumination. But guess what? Those are the same symptoms of hypothyroidism. "Thyroid hormones serve a homeostatic function," says Doebbeling, "regulating body temperature, energy levels, alertness and cognition."

In other words, your body is just as apt to make you depressed as your mind -- and not just because you don't like what you see in the mirror.

Doebbeling approaches psychophysiology like a snake handler, respectful of the beast's existence but fearful of its ability to mislead. "I support psychophysiology," she says. "It's contributed a lot to our understanding of pain. But I think there's a tendency to relabel unpalatable conditions. It's a lot more socially acceptable to say you have chronic fatigue syndrome than major depression."

Doebbeling sees three pegs in the mind-body connection: mental health, physical health and psychosocial health (which includes everything we do as social beings with our job, family and friends). Each influences the other. For example, a female patient came to Doebbeling complaining of a mysterious stomach ailment. After an expensive battery of tests proved there was nothing medically wrong with the woman, Doebbeling found a "psychosocial" explanation: Her husband was beating her.

Somatic disorders like Pussy's backache or the battered woman's stomach disorder are forcing the medical industry to pay more attention to the mind-body connection. "Twenty percent of the patients are eating up 80 percent of the medical costs," says Gervitz, who predicts "mind-body specialists" will eventually be ubiquitous in physician offices and -- surprise! -- covered by HMOs. "Managed care is getting eaten alive by the expensive tests that are being run on patients with somatic disorders," he says.

There aren't any records of people dying from somatic disorders, but there's plenty of evidence that they die from asinine treatments. "Death from hepatic failures in IBS sufferers isn't that rare," says Doebbeling. "The pain and discomfort can be so unbearable that some ... gravitate to dangerous treatments like massive vitamin dosages that overwhelm their livers."

Gervitz reports that the medical community has become much more open to psychophysiological research and treatment. "I was always condescended to by physicians," he said. "It was always, 'Sure, give me your card, I'll call you.' Now it's, 'Here, have a seat -- can I get you some coffee?'"

The medical community is just beginning to understand how our thoughts, feelings and behaviors affect us physically. There are more and more challenges to Western medicine's insistence on treating physical health separately from mental health. In the future people will no longer ask, "Is it all in my head?" because the answer is, No, it isn't all in your head. It just starts there.

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