Special Communication  |   June 2010
Soul Sickness: A Frequently Missed Diagnosis
Author Notes
  • From the University of New England College of Osteopathic Medicine in Biddeford, Maine. 
  • Address correspondence to Charles R. Perakis, DO, Maine-Dartmouth Family Medicine Residency, 15 E Chestnut St, Augusta, ME 04330-5736. E-mail: 
Article Information
Neuromusculoskeletal Disorders / Osteopathic Manipulative Treatment / Pain Management/Palliative Care / Psychiatry / Headache
Special Communication   |   June 2010
Soul Sickness: A Frequently Missed Diagnosis
The Journal of the American Osteopathic Association, June 2010, Vol. 110, 347-349. doi:10.7556/jaoa.2010.110.6.347
The Journal of the American Osteopathic Association, June 2010, Vol. 110, 347-349. doi:10.7556/jaoa.2010.110.6.347

“Soul sickness,” or demoralization, is characterized by feelings of hopelessness and helplessness and a perceived sense of incompetence. This condition typically involves vague, unexplained physical symptoms. Soul sickness can be efficiently diagnosed by asking patients a series of questions about their personal lives. Patients with this condition require a restoration of their morale and hope. Physicians can assist patients in regaining hope by encouraging them to focus on new, adaptive behaviors. As osteopathic physicians, we can use our skills in osteopathic manipulative treatment to manage the demoralization-related physical symptoms of patients.

Soul sickness” is a diagnosis that one will not find described in medical textbooks. Nevertheless, I encounter this condition many times a day among patients in the family practice where I work. In my experience, patients with what I refer to as soul sickness typically have vague, unexplained symptoms, such as body pains, dizziness, fatigue, headaches, and insomnia (Figure). They may have been diagnosed as having such conditions as chronic fatigue syndrome, chronic Lyme disease, chronic pain syndrome, fibromyalgia, migraine headache, multiple chemical sensitivity syndrome, or any of a host of emerging new diagnoses. 
I have found that the origin of soul sickness is a patient's inability to deal with internal or external stress. The internal stress may be borne of emotional, physical, or sexual abuse. The external stress may arise from insufficient coping skills for dealing with the problems and suffering that life brings almost everyone. Rather than transcending the suffering, patients with soul sickness have “checked out” of life. They no longer feel that they are competent to live productive lives and to meet the expectations of people close to them. 
Characteristics of soul sickness, as recognized by the author.
Characteristics of soul sickness, as recognized by the author.
“Soul Sickness” in the Literature
The psychiatric literature has recognized the presence of soul sickness for decades—but under other names. Gruenberg1 describes cases of “social breakdown syndrome,” in which patients manifest progressive chronic psychiatric deterioration. According to Gruenberg,1 some patients manifest this deterioration chiefly by modifications in their personal and social behaviors, and evaluations of “inner psychic connections underlying symptom formation can be complemented by investigating how social functioning breaks down” in patients. Gruenberg1 notes that social breakdown syndrome “occurs when certain reactions to the patient interact and resonate with some of [the patient's] efforts to do what he [or she] feels will be acceptable.” Evidence indicates that the use of mental health services can interrupt this deteriorating process.1 
Engel2 refers to “the giving-up—given-up complex” as a temporary failure of mental coping mechanisms. Frank3 defines the cardinal features of demoralization, the common denominator of all maladies addressed by psychotherapy, as feelings of helplessness, hopelessness, diminished self-esteem, meaninglessness, a perceived sense of incompetence, and a persistent inability to cope. Clark and Kissane4 argue for the addition of demoralization to psychiatric nomenclature. Kihlstrom and Kihlstrom5 describe the process of somatization, in which physical symptoms of unknown etiologic origin can result from psychosocial stresses. 
Diagnosis Confusion
Physicians—working in a healthcare system that does not provide reimbursement for taking comprehensive medical histories of patients—frequently choose to order blood tests or imaging to help define unexplained problems and to rule out serious conditions that would require immediate medical intervention. Unfortunately, such tests and images designed to reduce physician uncertainty often raise additional uncertainties rather than provide answers about patients' conditions. 
Such diagnostic tests may also lead the patient to believe that the physician is concerned about the presence of certain disease states—resulting in further stress for the patient. Besides being ineffective and inefficient, this approach is also costly and creates the potential for iatrogenesis. 
Making the Diagnosis of Soul Sickness
What is the alternative to this approach? As noted by Engel,6 biopsychosocial considerations are crucial in the clinical approach that physicians take with patients. The physician should understand the biopsychosocial factors of soul sickness and how to uncover this condition during diagnosis. Soul sickness can be efficiently diagnosed by asking patients the following questions and by considering their answers: 
  • With whom do you live?
  • What do you do for work? If you don't work, have you worked in the past? If you are disabled, what type of disability do you have?
  • What brings meaning to your life?
  • What is a typical day like in your life?
  • What do you do for fun?
  • Whom would you depend on in a crisis?
These questions can help the physician open the door to a conversation that illuminates the true nature of the patient's lifestyle. Many patients do not have textbook diseases that are responsible for their physical symptoms. Rather, they face “predicaments” as a result of certain situations in their lives, and these predicaments can become manifested as physical symptoms and psychological suffering.7 Although patients must find their own meanings to their lives in order to transcend such suffering, the physician can serve as a catalyst for action by initiating the conversation with patients.8 
Restoring Morale and Hope
Patients with soul sickness require a restoration of their morale. Physicians can begin this restoration by letting patients know that someone is listening to them and that someone wants to understand their “story.” In many cases, patients make certain assumptions that cripple them, such as believing that they are rejected, alienated, and helpless.3 Physicians can help patients reframe their assumptions. 
Hope needs to be engendered in patients to restore their morale. Physicians can assist patients in regaining hope by encouraging them to focus on new, adaptive behaviors rather than on their old, problematic behaviors. Examples of ways in which physicians can encourage such adaptive behaviors in patients include the following9: 
  • We can introduce patients to new coping skills, including the healthy use of leisure time. Perhaps they can be encouraged to make new connections with the healing powers of nature, such as through camping, hiking, or stargazing.
  • We can guide patients toward behavioral techniques that allow them to soothe themselves. Perhaps they might rediscover a hobby or other activity that brought them pleasure in the past.
  • We can lead patients toward a recognition of the value of managing their ailments properly and effectively, such as by incorporating healthy alternative lifestyle choices in diet and activities.
  • We can help patients achieve small victories that strengthen their beliefs about themselves. Perhaps they can be guided to volunteer for activities that allow them to give to others while reaping the resulting psychological benefits for themselves. Such activities can improve a patient's relationships with other people by promoting reciprocity. Volunteering can also help patients better understand the value of give-and-take in their personal relationships.
Hope is central to this behavioral form of healing. Buchholz10 wrote a wonderful description of using hope as a kind of pharmaceutical agent in a 1990 article titled “HOPE.” One approach to this idea would be to place pharmaceutical-type advertisements on television to promote the medical benefits of the agent of hope—perhaps as public service announcements. 
The positive psychology movement emphasizes factors that encourage the flourishing of mental health. This field of psychology is based on the value of helping people lead meaningful and fulfilling lives, of cultivating the unique strengths within individuals, and of enhancing positive experiences of work, play, and love.11 Other behaviors or attitudes that the practice of positive psychology encourages in patients include the following12: 
  • cheerfulness, interest in life, peacefulness
  • overall satisfaction with life
  • positive attitude about oneself
  • personal growth (eg, seeking challenges, feeling sense of continued development)
  • sense of purpose, direction, and meaning in life
  • selecting, managing, and molding personal environment to suit needs
  • autonomy (ie, behaviors guided by one's own internal, socially accepted standards and values)
  • formation of warm, trusting personal relationships with others
  • acknowledgment and acceptance of human differences
  • belief that people and society have potential and can evolve and grow positively
  • view of one's own daily activities as useful to, and valued by, others
  • interest in society and social life, finding them meaningful and somewhat intelligible
  • sense of belonging to, and deriving comfort and support from, a community
Another factor related to treating patients with soul sickness is the importance of mental health as it relates to the healthcare system as a whole in the United States. For example, Keyes13 notes that any effort to improve our healthcare system must focus on increasing the number of individuals who are psychologically healthy. Such a focus would likely drive down the need for—as well as the costs of—healthcare in general. 
Applying Unique Osteopathic Medical Skills
Many patients with soul sickness would benefit from the “laying on of hands.”14 As osteopathic physicians, we can use our unique skills in osteopathic manipulative treatment to manage the physical symptoms of patients that result from demoralization. Headaches and back pain are common presentations in the clinical setting that may be related to demoralization, stress, or other psychological struggles, and these presentations can be addressed with osteopathic manipulative treatment.15 
Having conversations with our patients as we treat them is another important aspect of the holistic, osteopathic approach to medicine. Treating patients in a holistic manner is most likely to lead to a greater number of patients who are flourishing rather than languishing. 
Soul sickness is a frequent presentation in physicians' offices, though it may not be recognized by this name. Most patients with this condition present with frequent vague symptoms that remain medically unexplained. By carefully listening to the patient's story and by asking pertinent questions, the physician can arrive at a clear diagnosis. After soul sickness is recognized, the physician can assist the patient in finding appropriate coping mechanisms and lifestyle changes to take the patient from a languishing life to a flourishing life. 
 Financial Disclosures: None reported.
Gruenberg EM. The social breakdown syndrome—some origins. Am J Psychiatry. 1967;123(12):1481-1489.
Engel GL. A life setting conducive to illness: the giving-up—given-up complex. Ann Intern Med. 1968;69(2):293-300.
Frank JD. Psychotherapy: the restoration of morale. Am J Psychiatry. 1974;131(3):271-274
Clarke DM, Kissane DW. Demoralization: its phenomenology and importance. Aust N Z J Psychiatry. 2002;36(6):733-742.
Kihlstrom JF, Cantor Kihlstrom L. Somatization as illness behavior. Adv Mind Body Med. 2001;17(4):240-243.
Engel GL. The clinical application of the biopsychosocial model. Am J Psychiatry. 1980;137(5):535-544.
Taylor DC. The components of sickness: diseases, illnesses, and predicaments. Lancet. 1979;2(8150):1008-1010.
Egnew TR. The meaning of healing: transcending suffering. Ann Fam Med. 2005;3(3):255-262. Accessed May 12, 2010.
Hillbrand M, Young JL. Instilling hope into forensic treatment: the antidote to despair and desperation. J Am Acad Psychiatry Law. 2008;36(1):90-94. Accessed May 12, 2010
Buchholz WM. HOPE (generic). JAMA. 1990;263(17):2357-2358.
Positive psychology. University of Pennsylvania Positive Psychology Center Web site. Accessed May 12, 2010.
Keyes CLM. Mental illness and/or mental health? Investigating axioms of the complete state model of health. J Consult Clin Psychol. 2005;73(3):539-548. Accessed May 23, 2010.
Keyes CL. Promoting and protecting mental health as flourishing: a complementary strategy for improving national mental health. Am Psychol. 2007;62(2):95-108.
Talbott GD. The laying on of hands: a doctor's plea for the young men of medicine. J Med Educ. 1971;46(4):374-376.
Baird RE, Cullom S, Deedman R, Feeney J, Kellogg J, Simning P. Osteopathic manipulation and tension-type headaches. Am Fam Physician. 1993;48(6):1023-1024.
Characteristics of soul sickness, as recognized by the author.
Characteristics of soul sickness, as recognized by the author.