Medically unexplained, mindfully explained
On empathy towards psychosomatic illness
Dr Raviteja Innamuri
Consultant Psychiatrist, Ananda Mind Care
Previously Assistant Professor of Psychiatry, CMC Vellore
It was a typical Monday morning. The OPD was brimming with patients. Doctors arrived slowly pretending to stretch off the laziness of the free Sunday evening, even if they didn’t have one. The automated machines announced the numbers one after another, streamlining the patients physically while their problems remain cluttered.
A 32 year old coal miner was brought to the CMC by his wife. His eyes carried visible distress and his suffering, palpable. His wife began by landing a huge pile of investigation reports and expressed her agony of the failed medical system – which couldn’t see the pain of her husband. Why did they refer us to a psychiatrist now? Does he look ‘mad’? Why don’t you admit that even you doctors at CMC can’t find out what the problem is instead of calling us crazy!!
I offered her a seat beside her husband and acknowledged her distress. I began to go through the pile of papers and remarked, “So, he has palpitations – could be a heart problem, headaches – brain problem, indigestion – stomach problem, body pains – muscle and bone problems. Hmm, as his entire body is affected, this looks like a really big problem.” I could visibly see from their expression that his problems had not even been acknowledged for a long time now. They eagerly looked on for me to continue. “But you see, if the problem is this big, affecting almost every part of the body, any simple test should have been able to pick up this dangerous disease, isn’t it.”. “But all the tests are normal!”, they exclaimed while the hope on their faces began to ooze out slowly, but I continued with my explanation.
“It is very clear that your husband has had a very rough time since the last 10 years beginning with the untimely death of his parents due to unknown health problems and later significant pressure at work that resulted in a lot of stress. Much like a rubber band stretched beyond its usual limit, the human body/mind also may lose its capacity to return to normal after repeated and prolonged stress”.
She stayed silent, trying to understand but still looking perplexed. “Okay, but why the pain? I accept that his mind is in pain but why is his body suffering?”, with a piercing look. I suddenly remembered what my professor said to me before my final MD exams – it’s easy to answer predictable questions with scribbles on those lifeless blank sheets of paper, what’s actually difficult is answering the difficult questions from your patients after graduation. I think he meant exactly these kinds of questions. I maintained my composure and replied in a calm voice. “The mind and the body share a close relationship. The distress of one can be expressed by another. Each of us experience this when we are tensed in our minds before an exam or an interview but our body shows- racing heart, butterflies in the stomach, sweating and wanting to pee!! “
She spoke for her husband again. “So, I get it. He was in a lot of stress and he began to experience pain symptoms around the same time. He was also worried if something would happen suddenly to him like his parents. But why this much pain? Pain that doesn’t allow him to function normally?!”
I was glad I was beginning to make sense. “I understand. Can you notice the volume of my voice right now as I speak to you, but what would happen if I spoke the same into a mike? Everybody across the street will also be able to hear me. Similarly, it’s true that because of the anxiety he developed gastritis etc. but it looks like because of the state of his mind, these problems are being amplified and experienced like the body was speaking through a troubled mind/brain. While his pain is true, his suffering could not be explained by the general physician and that’s why the referral to us – the soul surgeons aka psychiatrists.” As I saw them sigh a relief, knowing fully well that my words have made a difference, I bend down in satisfaction to write my plan of management.
With the rut of daily routine, the constant barrage of problems that we face, many of us thicken our skin to cope better. But I keep reminding myself what Dr Robert Twycross told me during our discussion on empathy and suffering at Oxford – “Remember doctor, let your shoulders broaden but do not allow your skin to thicken.” Because when we do allow our skin to thicken, we stop feeling the pain of our fellow human beings. And when we do, we lose the first reason to become healers.” All it takes is only a few words to make a difference, because, words can, what medicine can’t.