Abstract
Physical symptoms caused by psychosocial stress are responsible for most primary care office visits. Stress capable of producing illness may be in the patient’s life at the moment or may result from past trauma, depression, or childhood stress. Here is one patient’s story. For more information about stressrelated illness, please log on to www.stressillness.com.
Emma was the sort of patient who drove her doctors to despair. She had been suffering from bowel problems for nearly eight decades. Just looking at her massive medical record was discouraging.
She was 87 years old with loosely curled, pearl-white hair. She answered questions thoughtfully and in great detail. Her eyes searched your face to see if you had the solution to her abdominal cramps and alternating diarrhea and constipation. These symptoms were not severe, and sometimes they even went away—but never for more than a week or two. No diagnostic test had ever revealed an abnormality. No treatment had ever worked for very long.
All appropriate studies had been done at least once: lower-GI series, sigmoidoscopy, upper-GI series, small-bowel series, ultrasound, CAT scan of the abdomen, colonoscopy, gastroduodenoscopy and numerous blood tests. Her chart also showed a number of different trials of medication: antispasmodic agents, antidepressants, and one prescription for a tranquilizer.
Was there a source of stress in her life? “Since my husband died, I get lonely at times,” she replied when asked. But he had passed away more than ten years before. For the most part, her days now were pleasant and productive. She wasn’t depressed or anxious.
Her symptoms had begun when she was a child. Had she experienced any difficulties during that time in her life? She had grown up on a farm in a valley in the Rocky Mountains. Her parents loved each other and their five children. There was no abuse, no alcoholism, and no pressure. In many ways, it was a storybook place. Emma was the oldest daughter. When she was six years old, a sister was born. With the large number of other children and the work of the farm, the mother relied on Emma to care for the baby. Emma took to this task as she would to a favorite doll. She held, fed, dressed, changed, played with, sang to, and slept with her sister. They were inseparable.
Two and a half years later fever developed in the infant. Medical resources in rural areas in 1918 were not abundant. By the time appendicitis was diagnosed, it was too late—the child died.
Emma went into shock. The emotional self-expression usual for a young girl temporarily shut down. At the funeral service, an uncle made a remark that remained with her the rest of her life. He pointed out that she was the only person in the church who wasn’t crying. His tone implied that she must not care about her sister’s death. Her guilt, already intense, went off the scale. While she related this story, her eyes watered. Her rapidly flowing speech slowed to a trickle, and her lively face softened. She looked away from me toward the landscape painting on the exam room wall.
Not surprisingly, her sister’s death affected her entire life. Within two months, she began caring for a newborn on a neighboring farm. Sometimes, though, she couldn’t make the walk to the neighbors because during that time, her stomach first began bothering her. The pains persisted during high school and college, where she supported herself by caring for children. Her career choice: pediatric nursing. She married and had several children of her own. She raised them, with great care, to adulthood. Through all these years, her symptoms persisted.
She stopped talking and looked again at the landscape painting. After awhile, she turned back. “You know, you’re the first doctor that ever asked me about my sister,” she said. “What do you think I should do?”
I recommended that she visit an elementary school at recess so that she could see the children on the playground. She was then to pick out a girl who reminded her of herself at age eight. Emma was then to ask herself what such a girl could do to save a two-year-old with a ruptured appendix in the days before antibiotics. Once she had done that, I suggested that she return home and write a letter to her infant sister, asking forgiveness. She thanked me quietly and has not been to a physician about her illness since.