Stress Illness and Surprises

In presenting my lecture last month in four US states and two European countries, one story always got a big reaction.  A woman of about 60 years of age had unexplained chest pains (requiring narcotics) for nearly two years that were linked to finding a letter from her emotionally abusive mother.  She found the letter in the family Bible just after her mother’s funeral.  Among other things the letter had a list of “10 Reasons Why I Hate You.”  The woman’s chest pains faded rapidly after we uncovered this connection and she wrote her mother an emotional and cathartic reply.

It is a surprising story in several ways.  Audiences don’t expect the final letter from a mother to be hateful.  They don’t expect to hear a story like this in the segment of my talk that discusses post-traumatic stress disorder.  They aren’t accustomed to hearing about a significant physical illness caused by a letter.  For me, what should be most surprising is that the health care system doesn’t consider possibilities like this in evaluating unexplained symptoms.  These issues are routine if you look for them.

There are more surprises suggested by this case.  We spend over $2.5 trillion dollars on health care in the US, much of it on well-reimbursed technology like the diagnostic tests used for my patient before I met her. The public often is unaware that reimbursement for talking to people is at far lower rates.  My patient’s diagnosis was found following one routine question: “Have you had any traumatic, terrifying or horrifying experiences in your life, especially around the time your symptoms began?”

The final surprise is that even some researchers in this field are pessimistic about successful treatment of medically unexplained symptoms (MUS).  One leading group wrote a research paper (1) describing their approach to MUS which included the statement “Patients are told not to plan on cure.”  For most people with MUS, we can do much better than that.

1. Smith RC et al.  Treating Patients with Medically Unexplained Symptoms in Primary Care.  J Gen Intern Med 18: 478-489, 2003.

Tags: , ,