Letters to the Editor  |   October 2010
Soul Sickness: A Frequently Missed Diagnosis
Author Affiliations
  • Edward H. Tobe, DO
    Distinguished Fellow of the American Psychiatric Association; Clinical Associate Professor, University of Medicine and Dentistry of New Jersey-School of Osteopathic Medicine, Stratford
Article Information
Osteopathic Manipulative Treatment / Psychiatry
Letters to the Editor   |   October 2010
Soul Sickness: A Frequently Missed Diagnosis
The Journal of the American Osteopathic Association, October 2010, Vol. 110, 609. doi:
The Journal of the American Osteopathic Association, October 2010, Vol. 110, 609. doi:
To the Editor:  
I enjoyed reading the special communication article in the June issue titled “Soul Sickness: A Frequently Missed Diagnosis,” by Charles R. Perakis, DO.1 Dr Perakis1 emphasizes the importance of an attentive caring physician. “Doctor” in Latin means teacher, derived from docere, meaning to teach.2 Webster's New Twentieth Century Dictionary3 defines physician as “any person or thing that heals, relieves, or comforts.” Hope is vital for life, and the following statements expressed by Dr Perakis1 are appropriate: 

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.

However, the type of patient discussed by Dr Perakis1 has signs and symptoms of serious mood disorder, and I believe that the following description by Dr Perakis1 is misleading: 

“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.

Unipolar depression is one of the two most disabling medical conditions in the world, and it is associated with serious medical comorbidities and potential suicide.46 In addition, organic brain changes associated with mood disorder compromise many bodily functions, such as sleep, appetite, and cognition (eg, concentration, learning, memory).7,8 
Although Dr Perakis1 is well-meaning, he seems to downplay the need for a comprehensive diagnosis in such conditions: 

Unfortunately, such [diagnostic] tests and images designed to reduce physician uncertainty often raise additional uncertainties rather than provide answers about patients' conditions.

There is a need to perform a comprehensive differential diagnosis in order to maintain objectivity regarding the patient's disease process. The physician should not take the risk that the patient has an undiagnosed destructive disease. 
While a student at Kirksville College of Osteopathic Medicine-A.T. Still University in Missouri, I admired the clinical skill of the chairman of the osteopathic manipulative medicine department, Ira C. Rumney, DO, who humorously but wisely said, “DO means dig on.” 
Perakis CR. Soul sickness: a frequently missed diagnosis. J Am Osteopath Assoc. 2010;110(6):347-349. Accessed August 6, 2010.
Prakash R, Misra R, Misra R. Doctors as teachers [letter]. Psychiatr News. 2002;37(9):37. Accessed August 6, 2010.
McKechnie JL, ed. Webster's New Twentieth Century Dictionary, Unabridged. 2nd ed. New York City, NY: Simon & Schuster; 1983.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR. 4th ed, text rev. Arlington, VA: American Psychiatric Publishing;2000 .
American Psychiatric Association. American Psychiatric Association Practice Guidelines for the Treatment of Psychiatric Disorders, Compendium 2006. Arlington, VA: American Psychiatric Publishing;2006 .
Herrman H, Saxena S, Moodie R, eds. Promoting Mental Health: A Report of the World Health Organization, Department of Mental Health and Substance Abuse in Collaboration With the Victorian Health Promotion Foundation and the University of Melbourne. Geneva, Switzerland: World Health Organization Press; 2005. Accessed August 6, 2010.
Rajkowska G, Miguel-Hidalgo JJ, Wei J, et al. Morphometric evidence for neuronal and glial prefrontal cell pathology in major depression. Biol Psychiatry.. (1999). ;45(9):1085-1098.
McEwen BS. Glucocorticoids, depression, and mood disorders: structural remodeling in the brain [review]. Metabolism. 2005;54(5 suppl 1):20-23.