How patients' emotions can unlock a diagnosis

Even major physical ailments can be the result of severe stress. Patients often need empathy as much as MRIs.

By Patricia L. Elliott, MD
General Practitioner/Rapidan, VA

Louise went to her ob/gyn for a yearly check-up at a time when she was under a lot of stress from an abusive marriage. For years, she'd kept all her feelings inside, just to survive. When her physician spoke kindly to her, it was as though someone had given her permission to let down her guard and cry.

Unprepared for this sudden burst of emotion, the ob/gyn carried on stoically, delivering his medical counsel in the same tone he'd take with a perfectly calm patient. It was as if Louise's tears simply didn't exist.

The sad thing is, this doctor's behavior isn't uncommon. If there's one complaint I hear far too frequently from patients, it's that we doctors don't convey genuine concern for them in a way that can reassure and comfort.

There are a number of reasons we avoid emotional intimacy with patients. We rationalize our failure to express concern as a need to maintain a professional distance. We think it's not really our place to become so involved. We feel awkward. Some of us may want to help but simply don't know how. Others are just too absorbed in the rigors of everyday practice to notice that patients need our succor.

But with all the talk today of holistic medicine and the influence of the mind on well-being, can anyone really consider a show of feelings a sign of weakness? Or, worse, inappropriate? I have come to believe that if a physician—no matter what her specialty or noble intent—doesn't treat the whole person, she is simply not doing an adequate job.

Consider:

Mary comes into your office obviously agitated. You don't know it, but she has just found out that her mother is critically ill. You know only that she's here to have you examine her shoulder. As you begin, she asks if she can talk about something that has her very upset.

"Of course," you say sympathetically. "Make an appointment with my secretary. Now let's have you slide off your blouse so I can see that shoulder."

How likely is it that Mary will schedule that follow-up visit? Chances are, she'll find someone who's willing to back the sympathetic tone with a little sincere action. It would have taken only a few minutes to inquire about what had happened and to say you're genuinely sorry. What's more, you'd have earned bonus points by recommending measures to protect her shoulder while caring for her mother.

Chronic emotional upsets need to be addressed, too. Consider Joan, who comes in complaining of ongoing severe throat pain that has lasted for two years. It's probably due to her prolonged personal stress, she acknowledges, but she admits that lately she's begun to worry about a more serious cause.

"Well, at least we know it isn't cancer," you say, "because you've had it too long. In fact, I can't find anything wrong. Come back if anything changes."

Later, she calls to complain. Why didn't you inquire further about the stress she was under? And what about its connection with her pain and possible treatment? Rather than giving me sympathy, she continues, you seemed condescending once you discovered that there was nothing physically wrong.

Often, a doctor's first reaction to a complaint like Joan's is, "How can I get into a 15-minute discussion about your feelings? I'm lucky to get through all my patients by a reasonable hour."

That excuse may be valid. But, in general, a brief acknowledgement of the patient's problem takes only a few seconds. Just looking Joan in the eye and offering a sincere comment can mean a lot. "You're feeling pretty overwhelmed, aren't you?" is all you usually have to say. A brief but genuine moment of empathy frequently is all a patient really wants.

Those few extra minutes a day will go a long way toward cultivating patient loyalty. I believe the highest compliment a patient can pay is, "I came back because I can talk with you."

This philosophy toward patient care didn't come naturally to me. I've worked on it since the night my teenage daughter asked me why I sounded so cross while talking with patients on the phone at home. My reply: I was tired, it was late, we were in the middle of dinner, the baby was sleepy, the other kids needed me, etc., etc. But, I realized then, none of these were the patients' problems.

Maybe you've run through the entire differential diagnosis and come up dry. Should you send the patient home with a reassuring "it's just your nerves" or "it's only a muscle spasm"?

I'd encourage you not to. Just because the usual patient history hasn't proven productive, don't despair of finding an answer to a puzzling diagnosis. Remember that emotional disruptions can cause very real physical problems. Muscle tension, high blood pressure, hypocapnia, and hyperacidity caused by anxieties are just as real as any other bodily change, and they can have very real implications.

Take Carrie, for example. She came into my office several months ago complaining of multiple eye problems—itching, aching, blurring. Several local ophthalmologists had told her that there was nothing wrong with her eye, that "some people have a problem like that." This was little comfort to Carrie, who continued to suffer the frustrating symptoms.

By interviewing her more thoroughly, I discovered that she did indeed have a big problem: She was very anxious and depressed. Unfortunately, she had stopped taking her prescribed antidepressants and anxiolytics a long time ago. I encouraged her to resume them, and she gradually got better. Today, she no longer has psychosomatic eye problems and is beginning to socialize again. This diagnosis, I believe, was as important to Carrie's health as uncovering allergic blepharitis or Sjögren's disease would have been.

Here's another example. Let's say you're talking with Sara, a pleasant young patient in her 20s who presents with what she describes as "another terrible, pounding headache." She thinks she may have migraines.

A headache work up and a CT scan yield no physical etiology. You're able to determine that Sara's headaches definitely aren't migraines and, in fact, are not organic. Should your final step, then, be reassurance and treatment?

No. Most headaches are caused by stress; it's important to dig for the root of it. Often, a general inquiry like, "So what's going on with you right now?" or "How's life treating you these days?" can open a floodgate of pent-up frustration.

Depending on your degree of familiarity with Sara and her level of trust in you, you may want to inquire more directly: "Have you been having any particularly stressful problems lately?" This line of inquiry needn't take long, and it can often save you and the patient countless hours of fruitless diagnostic measures.

Remember, patients frequently don't connect their pain with strong feelings. You need to explain that feelings are not just thoughts—they are primarily physical and only secondarily an awareness. Discussing them in a productive way can often help dissipate their negative effects on the body.

Because we are conditioned by society to ignore or repress our feelings—whether frustration with work, fear of confronting an authority figure, or hurt over an argument with a friend or loved one—we often don't understand their manifestations. And not understanding the real physical pain they can cause often compounds a patient's stress level.

If a person is clear about why he is afraid—he's in the path of a runaway bus—then he won't be too worried about the physical feelings he's having. He will be responding to the immediate threat. On the other hand, when the cause of physical feelings isn't obvious to the patient—as it might not be for a woman with great fear of and anger at an abusive husband—those feelings may be overwhelming.

Unfortunately, feelings are pretty much an all-or-nothing response; a minimal worry or affront often elicits a maximal reaction. While this sort of mechanism may have been useful for survival in less civilized times, it's often overkill today, particularly when a person doesn't even realize that she is having stress. Such unacknowledged or unresolved tension can simmer and cause distressing physical problems for years.

A physical feeling that is not understood can be very frightening to a patient. People with undiagnosed symptoms will often assume the worst. Whether they have a sore throat or a lower abdominal disorder, I find that some patients rush to the worst-case scenario.

So it is exceptionally important that we fully explain the more benign possibilities after ruling out serious illnesses. For instance, if a patient's hip hurts, and she knows that it's simply because she twisted it or has osteoarthritis, she may not feel any less pain, but at least she won't find it frightening.

I had a recent case in which a patient went racing to the emergency room because of central chest pain and facial numbness. Lisa had called that day for an appointment, but before coming to the office she became so panicked that she raced over to the hospital. The staff there established that she wasn't having a heart or lung problem, told her that she simply had chest wall pain, and sent her home with an analgesic.

Lisa, though, wasn't convinced. She came flying over to my office, still not understanding her symptoms. After some discussion, we determined that she had pulled the pectoralis muscle at its sternal attachment, making it a little sore when she took a deep breath. Because she hadn't known why she had the pain, she'd gotten into the habit of taking deep breaths to monitor it. Pretty soon she was hyperventilating, and her face became numb as the chest discomfort increased.

Lisa wasn't going to get well until the source of her pain was uncovered.

Emotions are very powerful factors in our physical well-being—factors that we physicians occasionally underestimate. For instance, when Janice presents with a right subacromial bursitis attributable to no specific injury, we may learn that her condition is being exacerbated by her anxiety over caring for an elderly and difficult mother. It takes only a minute to elicit the problem and acknowledge to Janice that, "That must be tough. Let's figure out how you can rest your arm more."

The key is to be attuned to what patients aren't saying, as well as what they are. And to respect individuality. Remember, each of your patients has a unique experience base—and thus will react to different circumstances very differently. Perhaps the best thing you can do for each patient is to understand how the stress factors in his particular life are affecting his health, and, after covering all the bases physically, to offer a healing dose of compassion.

 

Patricia Elliott. How patients' emotions can unlock a diagnosis. Medical Economics 2001;6:120.