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Doctors often turn to psychology when trying to understand patients and their problems, especially when no underlying physical pathology can be found. They focus on depression and anxiety as causes of symptoms and propose therapies such as counselling and cognitive behaviour therapy as possible solutions. The symptom itself is rarely questioned. But is the symptom so unproblematic? Why does one person experience headaches and sore throats whereas another has migraines and tonsillitis? Why does retirement exacerbate symptoms but a busy job make them disappear? And why do some patients bring their headaches to the doctor whereas others manage their migraines at home? An understanding of how symptoms arise and how only some are given the status of a problem can create a broader psychological perspective in which to understand patients' health and illness.
In this issue Mercer et al and Nazareth et al describe “lacking interest in sex” as the problem reported most often.1,2 In their anxiety not to feed into the medicalisation of sexual dysfunction they emphasise the role of psychological factors in exacerbating lowered libido and describe possible psychological solutions. This approach draws on the tradition of clinical psychology, with its focus on the identification management of psychological problems. Lack of sexual interest, for example, may relate to depression and anxiety, and such affective states may be implicated in both the cause and the treatment of the problem. But this analysis accepts the symptom as presented. The symptom is considered simply an indicator of an underlying (psychological) problem, which is divorced from the idiosyncratic patient. This approach cannot explain why symptoms vary so much between individuals and even in the same person as her or his lifestyle and social situation changes.
The alternative is to regard the symptom not as a simple sensation but as a perception that places the patient's experience within a broader perspective that includes not only mood but also cognition. Research on the perception of symptoms highlights what some of these cognitions might be.3-5
Before patients can perceive that they have a symptom such as “lacking interest in sex” the salience of their experience needs to be raised above a threshold of recognition. Many elderly people (and people of all ages in fact) would not routinely monitor their level of sexual interest and do not think, “I am aware of my level of sexual interest.” If sexual interest is of no relevance, then, however low, it will not be detected. Once detected, the symptom then needs to be labelled as normal or a problem—“my level of sexual interest should be higher.”
For a patient to detect and label a symptom a range of cognitions are required. Many have been described and manipulated by much psychological research. For example, cognitions include attention, value, social and peer norms, self identity, and an analysis of cost and benefit. These are reflected in thoughts such as “I am aware of my libido,” “The media tell me that every one is having sex therefore having a libido is important,” “Everyone in the media seems to be having sex all the time so I must have a problem,” “My friends are having more sex than me,” “I am a sexual being,” “There is no point wanting sex as I can't get it,” and “I would rather sleep than have sex.” Central to all these cognitions is patients' appraisal of the symptom in the context of their own and others' life experience. This appraisal may, firstly, raise the salience of the experience to create a symptom, and, secondly, result in the symptom being labelled a problem. Even a questionnaire or interview about sexual interest could raise the salience of the problem. However, the role of cognitions does not stop here. When a symptom has both been experienced and been labelled a problem, appraisal also influences whether or not a patient seeks help. To visit the doctor for “lacking interest in sex” the patient has to believe that the problem is of relevance to medicine, that a doctor is the appropriate person to see, that he or she would be prepared to do what the doctor suggests, and finally that he or she actually wants the problem removed. Some patients may both perceive the symptom and decide that it is a problem but also decide that this problem works for them.
Symptoms are brought to doctors in their consulting rooms and described by patients in research studies. Doctors have a duty to rule out an organic cause that can be treated by a medical solution. When this has been achieved they sometimes turn to narrowly defined psychology to broaden their understanding of the patient. But the symptom itself remains unexplored. The very generation of a symptom and the translation of the patient's perception into a problem are also open to psychological influence.
An understanding of the range of cognitions that create, exacerbate, and label symptoms could provide doctors with a richer forum for understanding the variability in the way patients present and the complexities of their experience. Despite the findings of the two papers, there is unlikely to be any need to get alarmed about the high levels of lack of sexual interest reported. Symptoms are not that simple.