Thursday, January 25, 2007

Psychosomatic Illness

I can't easily forget a patient we saw earlier this week. Loudly denying that she was depressed, she exhibited multiple signs of psychosomatic illness: irritable bowel syndrome, fibromyalgia, and, most recently, "facial droop" and "trouble walking". On exam, she had what is known as "astasia-abasia", or hysterical gait. She would wobble all over the place, yet JUST manage to catch herself before she fell. Her Romberg sign, or ability to stand with her eyes closed without falling, was negative, so her actual balance was unimpaired. The rest of her neuro exam was similarly normal. She continued to deny depression, despite her recent cruel divorce, her lost job, her difficulty concentrating, her recent weight gain, and her generally unkempt appearance. In fact, she even informed us that "I quit seeing my family doctor because he kept saying I was depressed!"

I felt really bad for her, yet what could we do? She was already taking an SSRI "for pain", and she clearly wasn't interested in any further psychiatric workup. The power of her denial was impressive, and sadly, was contributing to her condition. If she could only have been willing to admit that there was a possibility that her stressful situation was making her feel ill, she would have stood a chance of some relief of her symptoms.

I would like to point out that this patient is not simply faking her symptoms (not consciously). It would likely take lengthy psychotherapy and possibly antidepressants to relieve her symptoms, even after she came to believe that her mind was causing them. Rather, her mind was turning her anxiety onto her body, against her will. It is my understanding that this is the reason conversion disorders are more commonly found in lower SES groups--these are groups that are probably less likely to discuss anxiety or depression, and are less likely to realize that the mind could play such tricks. (This is simply my simplistic explanation; feel free to disagree with me.)


Since I am rather anal-retentive/OCD (I'm a med student, duh), I picked up a copy of "First Aid for the Match" today, after meeting with the urology course director. I also scheduled a meeting with the school's residency advisor for tomorrow, in order to discuss away rotations and writing a CV. Why the rush? In order to obtain an away rotation over the summer, I have to apply by March. Before then, I have to get a CV written and fill out all kinds of crazy applications. The urology director recommended that I try to do two away rotations in order to increase my exposure to local urology programs (and get letters? Please?), so that's a lot of forms to fill out between now and then. I also need help scheduling my third year, so that's why I need to meet with the residency guy.

I, too, have irritable bowel syndrome (hence my obsession with fiber). Every time I start thinking about applying for residency, my stomach cramps up. I'm perfectly aware of the cause of my discomfort (my anxiety over trying to match into a competitive residency oh my god what if I don't get in or I don't get in near my husband!!!!!) Thus, in order to try to decrease my discomfort, I bought the "First Aid" book, and whenever I feel too stressed, I pick it up and read through sections on writing CV's, etc. If I can ACT, I can decrease my stress (theoretically).

I see many similarities between myself and this patient. I felt sorry for her, and the way the team dismissed her as hysterical (although you can only do so much for someone who refuses help). I just try to remain aware of my propensity for somatization, and acknowledge my depression, so hopefully I don't end up wobbling down a hospital hallway in front of a team of medical students and residents who all know there's "nothing really wrong with me."

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