Anxiety—College Girl

Not feeling well for a weekend, getting through a really busy spell in your work, maybe just being exhausted and not getting a good night's sleep. Those are common reasons why people stop their regular daily exercise routine. It's not like they make a decision that the exercise they've been doing isn't a good idea, or even that they hadn't been enjoying it. But somehow the routine is broken. It's really hard to get started again. When you do restart, what came easily when you stopped is really difficult. It will take time to work up to your former level of fitness.

I got unusually tired and wasn't feeling well. My closest friend called and told me she had cancer.  Suddenly, the effort that was required to keep this up just didn't seem so important. A series of moving patient encounters, together with a surprising amount of encouragement from readers both locally and around the world combined to get me off my lazy behind. My 2-month sabbatical from this blog, I hope, is over.



Jessica came to my office by herself last week.  She was 18 now, and starting college.  She’s been seeing me since she was a girl, and though I knew we got along well enough, I never got the feeling that she was entirely comfortable.  This visit might be the first time I saw her without her mother.  She had always been thin, but my perceptive assistant noted to me that she had lost about 10 pounds since the last time she’d been in the office.

She said that she wanted me to take a look at something on the skin of her leg.  It had started as a bump a few weeks ago, about the size, she said, of a ‘mosquito bite.’  Maybe it was a little itchy at first, but she didn’t remember it being very annoying.  After some time, she wasn’t exactly sure how long, the bump went away and an area of the surrounding skin on her leg was red.  It wasn’t painful or bothersome.  Over the last couple of days, the redness has decreased and there was a very small amount of skin peeling.  When I asked, she said that it looked like it was getting better.  It didn’t hurt, itch, burn, bleed, ooze, or interfere with anything she did or wore.  I asked to see it.  A little above her knee was an area about the size of a quarter with some faint pinkness and a few skin flakes.  I asked if I could touch it, and found that it wasn’t warm, firm, soft, raised, or bumpy.  She said that it didn’t hurt when I touched or pressed on it.  There were no other such lesions on her.  I was not very worried about it, whatever it was originally—and told her so.  She should call right away, however, if it didn’t continue to improve a little every day. 

I will inject as an aside that I believe the rapport that a patient—even a little kid—has with her doctor can be really important.  It is very hard to establish that relationship with 6-minute visits.  There are lots of other impediments established by current care standards.  If you see a different doctor every time, if the doctor never seems interested in other symptoms you might be living with, if you’re made to feel like just another hot-stamped drop-shipped cog delivered through optimized just-in-time-supply-chain management into the inflexible assembly line of efficient health care designed to achieve least-common-denominator-acceptable outcomes for your particular diagnosis code in order to achieve maximal reimbursement from a 3rd-party-payer at whose toll-free-number you cannot ever reach a human, then you probably won’t really feel relaxed with your doctor.  My patients of all ages, I hope, know that’s not how I work.

So when I told her to call right away if it didn’t improve, my hand was not on the doorknob.  I didn’t even stand up to go.  I simply asked her, “What else hurts?”

“Nothing much,” she said thoughtfully.  “I mean, you know, except for the stomach aches.”  I resisted the urge to smack myself in the head.  Only gradually had I come to realize that bald as I am, a good smack might leave a red mark that could last an afternoon.  Somehow, it was not as satisfying to smack myself on, for example, the ankle.  I didn’t say or do anything except pay attention.  “Sometimes they’re really bad.”  With that her eyes filled with tears and so did mine.  The exam rooms are stocked with tissues, but only one box.  We shared.

She had been having abdominal pain for at least several months.  It was very worrisome for her.  She was afraid she had an ulcer caused by her anxiety.  Anxiety?  Forget the mosquito bite—what happened to the abdominal pain? 

About an hour later, I had learned that she had a couple of jobs that she couldn’t keep because of her anxiety about many, many things.  She had no problem with the academics of college but being in a classroom was a problem and if the classroom were filled with busy, social, chatting, comfortable peers it was an awful experience.   She had sought professional help for this, I was relieved to learn.  But the medication she was prescribed wasn’t helping her—and she was afraid of bringing this up.  I offered to make that call, but she declined for now.  She felt hopeless about the anxiety because the medication didn’t work.  She said that she was worried that her abdominal pain could be something serious.  Right after she said that, she said that it’s her fault because she probably has an ulcer that’s caused by her anxiety.

Here’s what I told her.  Neither the anxiety nor the abdominal pain were her fault.  This I backed up with a short neurophysiologic explanation of how the amygdala communicating with the prefrontal cortex can give the uncomfortable sensations associated with anxiety.  I told her that though it does indeed seem like she has an anxiety disorder, people with anxiety disorders can get just as sick as people without. 

I explained the curious history of peptic ulcer disease.  For more than 100 years, an entire field of medical knowledge was based on the belief that it was somehow caused by intense or anxious or angry or unstable personalities.  Idioms like Type-A Personality entered the daily lexicon largely based on this medical belief.  It was all crap.  Ulcers are usually caused by a bacterial infection in the stomach, which is typically successfully treated with antibiotics and Pepto-Bismol.  (Even happy little kids can get ulcers, by the way, though this is quite unusual.)

I told her that it would be a medical error to assume that her anxiety had been the cause of her symptoms.  It didn’t help, of course.  But I suggested an alternative way of looking at her pain.  Suppose there were some reasonable explanation for the pain and other symptoms that she described.  Maybe when the pain was bad, she would become worried about it and if it were something serious.  This, I pointed out explicitly, would be just how people without an anxiety disorder would think about it.  If the pain continued, a person would be increasingly worried.  As the worry increased, their senses would be focused on the pain, observing it carefully for changes.  With this concentration, continued pain would be sharply perceived and the worry would just continue in an accelerating spiral.  She had not looked at it that way.  Besides, I said, I would really like to relieve that pain if I could.  She deserved and needed the workup I would do for any young woman with chronic abdominal pain.

I informed her that though she might not have been helped by her treatment so far, there are many other treatments available.  None of them works with everybody, but all of them work with some people.  There’s at least a dozen medications she hasn’t tried.  Has she tried a workbook?  She said she had one but she didn’t want to do it because it might not help.  She had not seen that she was too anxious to try an anxiety treatment.  Maybe yoga, maybe hypnosis, I suggested.  She hadn’t thought of those.  I didn’t promise to make her better.  But I promised I would try and I wouldn’t give up.  I don’t know if that will be enough, but it’s all I had to offer.  Well, that and calling the shrink.  For now, I’m working on the stomach aches.

By complete coincidence I have had a series of patients with anxiety issues.  Maybe there were more of them out there than I knew about, and maybe I wasn’t asking enough or the right questions.  With teenagers, I screen everyone for depression.  I get the feeling that’s not enough.  I’ll write more about these young people.

The poster pictured above, stolen from the internet, is from a movie I have not seen.   It’s apparently being shown as a double feature with Libidoland, by the same filmmakers.  Not sure what to make of that.  The tag line for Anxiety Acres is:  “When Casey moved Kevin to the country, she hoped he’d find peace and quiet; instead he found new things to worry about: zombies, hitchhikers, and chocolate cake.”  Who doesn’t worry about zombies, hitchhikers, and chocolate cake?

Technorati Tags: anxiety,psychology,teenagers,abdominal pain

Mystery Cases, Mystery Medicine Part 1

Here’s how mystery cases typically present: Doctor, my kid has a fever. How’s he acting? Fine, playing as usual. But he has this fever.

If it were an adult patient, maybe it starts with: Doctor, I’ve been feeling a little tired recently. I just don’t have the energy I used to have.

Mystery cases don’t begin with a bizarre mixture of ankle pain, ringing in the ears, hair loss, and loss of feeling in the right thumb. And did I mention the canoe trip up the Ximim-Ximim River? The trip where you had to drink whatever water was at hand?

So mystery cases don’t start as mysteries, they just become mysteries over time. Usually.

This time is very different, and I will try to chronicle the case as it unfolds.

I received a call from a man who told me that his son had a stomach ache, and he wanted to come to see me.

The boy of 11 had severe abdominal pain for 8 months. Including last Spring, he’s missed a total of about 2 months of school. He has had some blood tests (don’t know what yet) and had an endoscopy (unclear as to which end, but I’d guess that somebody looked at his stomach with a TV camera to make sure he didn’t have an ulcer. If they got to an endoscopy, I have to assume they did some other imaging too, but I don’t know what. The father said that he was told everything is normal. He was advised to wait and see. He was recommended to me, but I’m not sure exactly by whom. Looked me up online, and got the impression that I wasn’t a ‘wait and see’ kind of doctor.

I am, in fact, often a ‘wait and see’ kind of doctor. But not when this kid’s in pain. This was going to take time, and if there were something that smart and perhaps more expert doctors than myself didn’t see or connect, it was not going to be obvious. I was booked solid, so I told him to meet me in the parking lot on Sunday, and I would open the building and open my office for him so we could have at least a couple of uninterrupted hours.

Here’s a mystery case from the first contact. It has already unfolded as a mystery. I think that might be tougher, actually. I’ll have to look through every test that was done and guess what other doctors were trying to look for or rule out. So there will be a lot of homework.

In this case, a father found me on his own. Sometimes I get referrals from other local doctors with difficult cases.

I am bothered most by a child in pain. Perhaps, as doctors are notorious for undertreating pain (especially in children and the elderly), this is really all about pain control somehow. Maybe it’s just that his previous doctors didn’t spend the time to get the whole story, thus missing some essential clue. I’m worried that I just won’t deliver a helpful answer, meaning one that will help the child.

Mystery cases only become mysteries when what you’re doing isn’t working, when what the patient’s disease is doing doesn’t fit with your expectations.

Sometimes, my job is to make a diagnosis. With a known diagnosis, so the theory goes, a known treatment can be applied for a known expected result. I say theory because there are plenty of diagnoses for which there are no effective treatments, so getting to the diagnosis is at best an academic exercise and at worst is costly and unpleasant. A good example is the common cold. There really aren’t good treatments for this basically benign disease. There are expensive exotic antiviral medications that might work if given early in the course of the disease, providing the cold is due, for example, to adenovirus and not rhinovirus. To determine this, one would have to have a nice sinus rinse (I don’t recommend it) at the first sign of a sniffle. This proud sample would have to be whisked off to a lab which has the capability of Polymerase Chain Reaction DNA amplification and analysis, and is willing to put aside the Ebola they’re working on so you can save half a box of tissues.

So I really look upon my job as making people better. Sometimes it’s through a diagnosis. Sometimes it’s just making them feel better.

Mystery cases, then, are more than just cases without a clear diagnosis. Every kid with a runny nose could be….

Maybe I should call this Dr. Wolffe’s First Law: Never ask your doctor, ‘What could it be?’ Yet that is one way I can approach a mystery case. As the doctor mixes in each new piece of information, many possibilities get ruled out and a few remain. Eventually, the doctor must make a decision. What’s possible? What’s likely? What fits best? Which diagnosis is the most important? Here’s an example. A kid is coughing, so much that he’s having a hard time getting a breath. Maybe it’s not asthma, and a steroid medicine won’t help him. In fact, he may have some other symptoms that don’t fit with asthma. But if it is asthma, and he doesn’t get the steroid medicine, he could be in the Intensive Care Unit in a matter of hours. If he gets the steroids, he could go to school tomorrow. It’s conceivable that I could choose to treat a diagnosis that is not the most likely, but is the most dangerous if I don’t treat it.

Tomorrow is Sunday, and I’m seeing this child and his family for the first time. The only thing I know for sure is that it is a mystery case.