EXISTENTIAL MEDICINE

Case Studies in Existential Medicine  

 

The following pseudonymous case stories are drawn from Dr. Brian Broom’s book Meaning-full Disease – how personal experience and meanings can cause and maintain physical illness.

 

Arthritis

Natalie is a forty-five year-old business woman. She was referred by her general practitioner because of a two year history of crippling arthritis (technically called ‘sero-negative rheumatoid arthritis’) affecting the hands, wrists, knees, and ankles. She had seen rheumatologists in two cities, and had received a wide range of the medical therapies available. She had developed life-threatening bone marrow problems as a complication of gold treatment. During the first consultation with me I confirmed the very typical appearances of rheumatoid arthritis in her joints. She was requiring constant steroid treatment to keep active. She was alarmed at the side-effects of drug treatments and wanted a second opinion and an alternative approach, if there was one.

I had nothing in the way of medications to offer her, so I turned to an exploration of her ‘story.’ Natalie revealed that she was adopted but knew little about her biological parents. She discovered her adoption through neighbors and relatives, and the only direct communication about it during her childhood and since was once when her mother screamed out “you are bloody adopted.” Natalie’s comment was “that we don’t talk about things that really matter.” The other main theme, which had become much more apparent over the recent two to three years, was a need to be separate and free and have her own personal domain, and a feeling that the ‘shared domain’ takes over. She felt stuck in relationships with old friends, and that she somehow had to live out patterns that were no longer relevant. It reached something of a crisis at Christmas which she felt obliged to spend with these friends, though she was bored, and wanted to move onto something freer, something more true to her interests and reality. It is noteworthy that her arthritis originally began between Christmas and New Year. The same issues of stuck-ness were revealed in many aspects of her relationship with her partner, George. She had taken a job at another town so that she could both hold on to the relationship and spend time out of it. But the problem remained unresolved because every new context quickly became a ‘rut’ as well. She said she was frustrated with her rheumatoid principally “because it stops me.”

While my approach is always to start from the patient’s story and try and discern the patterns that emerge I did have some rudimentary preconceptions of what kind of story might be behind this sort of physical disorder. I remembered that the psychoanalyst Joyce McDougall spoke of the manifestations of rheumatoid arthritis as a reflection of unresolved conflicts around dependence and independence. I had reviewed several previous patients where this seemed to be the case, and from the material emerging in my initial session with Natalie I felt justified in exploring her story further.

Because she came from a considerable distance I saw her only thirteen times over a period of eighteen months. The pervasive themes of those sessions are clearly captured in her own language.  On freedom and constraint: “it’s keeping me in a bind like my parents were,” “I can’t get moving,” “I can’t go out temporarily, or I will go back and be captured by the comfort zone,” “comfort…is deathly…a lack of life…closed to new directions,” “I want to loosen up.” On feeling tied to her partner: “I am responsible for his happiness,” “it’s hard to take freedom,” “George still wants me,” “I feel tethered, enslaved.” On who she is: “I don’t belong anywhere,” “I don’t know who I am, or what I want,” “I lose me in relationship,” I was quite strong in asserting me as a child, but I’ve stopped asserting me,” “I’ve got pathetic in the last five years.” On her geography: “I hate being in (her town), it cripples me.”

Ten months after the sessions started she had moved permanently to another town, separating from her husband with whom she was maintaining a good friendship. By fourteen months her joint symptoms were greatly improved. She regularly rated her joint-related problem statement “I have stiff painful swollen joints” on a 0-8 scale. This scale measures whether the “problem upsets me and/or interferes with my normal activities.” The scale is as follows: 0=does not, 2=slightly/sometimes, 4=definitely/often, 6=markedly/often, 8=very severely/continuously. At the beginning of therapy she rated the state of her joints as grade 6. At fourteen months she rated herself at grade 3. At eighteen months we stopped the sessions because she felt in reasonable health, though not entirely free of symptoms, and she certainly felt much freer in her life, with new healthy horizons. At the last session she promised to write to me sometime to let me know how things turned out long-term.

Six years later I received the promised letter. She was doing remarkably well: “I swim and bike regularly”…”I feel good”…”I hardly get sick”…”new health and happiness”…”direct result of my sessions with you”…”I think of the way you wouldn’t accept my bullshit i.e. the image of myself that I had chosen to construct which you saw as somehow not congruent with something truer or more real about myself” … “It was very difficult to leave George, but I knew I needed to, years before really”… “I love living on my own…(George and I) “have a good friendship,”…“I was really glad I talked to my Mum about being adopted about six years ago…as a result of seeing you….”

Psoriasis

Emily, in her early 30’s had suffered from very severe psoriasis, a disfiguring skin condition, for seventeen years, and covering most parts of her body. It had been unresponsive to all types of orthodox medical approach including potent immunosuppressive drugs. Her illness began when she was rejected by her first boy-friend for one of her close peers. As the session progressed I began to see the beginnings and the fluctuations of her illness in terms of the vicissitudes of intimate relationship, and referred her to a mindbody-oriented psychotherapist I work with. Initially she was reluctant and skeptical but by the fourth session became very engaged in the work. Within less than ten sessions with the psychotherapist her psoriasis remitted. I received a letter of thanks from her saying how delighted she was with her improvement. She claimed that not once in the seventeen years had she had a remission anything like this. I got to see her seven or eight sessions into her psychotherapy when she returned to me for a medical certificate, and at that point the only residues of her psoriasis were some hardly perceptible oval dusky pigmented patches on one flank.

I asked her, and, later, her therapist to conceptualize what had happened. They both agreed it had to do with boundaries, with taking on board other peoples’ feelings, of getting ‘too involved.’ Any stirring up of such issues led to an almost immediate onset of burning and itchiness in her skin lesions. There were additional important questions of whether she was ‘attractive’ or not; whether she was ‘supersensitive’ or, conversely, whether ‘nothing offends me’; or whether she was ‘free’ or ‘forced into a mould’.

A year later I came across her in a café in the city center. She bounced up to me baring her right elbow to show a small area of psoriasis four centimeters in diameter which had flared during a recent stressful academic event, but otherwise her skin had remained clear.

Uterine bleeding

Margaret, age 44, was referred for depression triggered when she was embraced by her church minister who was clearly sexually aroused.  When aged 15 her twin brother, sexually assaulted her, beginning with a demand that she expose her breasts, and going on to forceful vaginal penetration. She was left bleeding and traumatized. During therapy we uncovered almost unutterable feelings in relation to this trauma, and collaterally she developed excessive bleeding from the uterus. She was thoroughly investigated by a gynecologist, and eventually had a hysterectomy. Within a few weeks she started to show blood in her urine. Despite further investigation by a urologist the source of this bleeding was never found, and she continued to periodically show blood in the urine, especially at times when she felt badly treated by powerful males (in her work-place).  But this was not the end of the phenomena. She then developed bleeding from both her breasts. Again she was thoroughly investigated by a surgeon, and nothing sinister was found.  Margaret and I realized from early on that the bleeding from the breasts commenced at the time we were exploring her feelings towards her brother who raped her, though we both felt everything should be done to exclude cancer of the breasts.

Headaches

Mary first develops headaches at age thirteen when her father dies. The headaches persist for six months. At age seventeen when a boy breaks off a relationship with her she develops the same type of headache, again lasting for six months. At twenty-one she falls pregnant, and the father of the child abandons her. The headaches resume and persist for the next twelve years, triggered from day to day and week to week by issues of relationship with males.  The point of Mary’s story is that her headaches appear to be triggered by important males leaving or betraying her. The symptom seems to be specifically connected with this theme, which builds in intensity over time. Mary did not want to hear this, and was angry with the suggestion that her headaches might be related to unresolved feelings. For her it implied her headaches were not ‘real,’ that they were imaginary, and ‘all in the head’ (sic). She broke off further contact with me.

Facial rash

George has suffered a very severe rash on his face for forty years. He has had repeated treatments with steroid drugs and has developed marked side effects from these. The rash began soon after a bitter family argument involving other family members who (in his view) cheated him out of inheriting the family farm. He retaliated by buying the farm next door and, thus, the injustice “was constantly in my face” (his exact words). The rash cleared whenever he took time away from the farm. The point of George’s story is that both his words and his body (his face) seem to be telling us about his anger or bitterness at being the victim of injustice or scheming.  George quickly accepted this conceptualization. It seemed to be a relief to have an explanation that made sense.

Allergy

A 35 year old scientist and university teacher has been in New Zealand for some years. As a child and teenager he had suffered severe allergic symptoms of the eyes and nose, which had been cured by allergy ‘shots’ or immunotherapy. Soon after arriving in New Zealand he fell prey to ‘any bugs that came along.’ He consults me because each year, starting late autumn or early winter he develops a very irritating drip from the back of his nose into his throat, requiring constant throat clearing. It usually cleared towards the end of the winter, though in 2003 it continued right through the summer. Though he and his doctor had wondered whether his allergies had returned, the new symptoms were quite different. Allergy skin testing revealed that his original allergies had indeed disappeared. I said I believed the symptoms were not due to allergy. He asked me what were the alternatives? I told him some stories of patients whose sinus problems had originated in relevant personal meanings. He became thoughtful, and said that the way his job was constructed he felt chronically frustrated at not being able to get onto his research work and the writing of papers. What’s more, this feeling reached its peak each year about the start of winter as his student responsibilities reached a peak. It subsided again to towards the end of the year. I agreed that was interesting, but it did not explain why his symptoms continued through the summer of 2003. He flushed and looked a little anxious, and said ‘Ah, I know what that was…an unusual thing…I had to go on a prolonged field trip which competed with my other plans.’ He left saying ‘Thank you, for a most interesting session.’

Skin thickening

Eunice, a 71 year old woman, had an 18 month history of generalized thickening of the skin, and tissues under the skin, causing uncomfortable splinting of the chest, and tightness of the arms and upper legs. This thickening was very obvious. Despite her age it was impossible to pinch her skin into folds.  Despite intensive investigation a firm diagnosis had not been made. I will not emphasise the medical detail but though the appearances were not classical she was told she had “connective tissue disease” and was accordingly treated with steroids and other potent drugs.

I was asked to see her for a second opinion. I began by enquiring about the onset of her skin thickening. She startled me by saying that it began when she fell over in the local garden nursery, sustaining injuries to her face and legs. I was inclined to brush this information off, and get on with the important (sic) material. But something made me hesitate, and I enquired further. She described the fall as “shattering.” Mystified as to the relevance of this I asked what effect this event had had on her. She replied: “ I went into my shell for a while.” I was immediately struck by the fact she was presenting to me with a thickened shell of skin and here she was using language to match. I invited further comment, and within the next 3 to 4 minutes she used the words “I went into my shell” 3 times. Moreover, she further volunteered in her description of being taken back to her home by a friendly gentleman: “I went inside the four walls of my house, and closed the door, and sat and sat and sat.” In the few weeks following the injury skin thickening developed first in the legs and then became more generalized.

I sat listening to this wondering what sense to make of it. I enquired about aspects of her life. She had enjoyed very good health throughout her life, but it seems that the accident compromised (“shattered”) her sense of herself as perennially invulnerable. Moreover the embarrassing injuries to her face induced social withdrawal. She had actually started to improve by the time I saw her and the possibility existed that this was a response to the drugs she had been on. I enquired of her as to what she felt was the cause of her improvement. She related it to a friend who had come to her and said that she should get active again. She said that she improved again as she started to “come out of my shell.” This “shell” theme was the metaphor she persisted with in both her language and her body.

I suggested to her that the thickening of the skin was a bodily (somatic) representation of what she was also expressing in using the term “shell.” She accepted this, though without much insight. I encouraged her to continue to be active and resume her previous social contacts, and suggested I follow her up regularly for support, encouragement, explanation, education, and revision of her home situation so that coping could be ensured for as long as possible. After the third visit she declined further sessions. One year later both she and her physician reported marked clinical improvement, and she was on no medication.

Nasal irritation

Katrina, a woman in her twenties has struggled with obesity since age thirteen. Finally she conquers it by having a gastric bypass operation, losing some 60 kilograms in weight.  At last the obesity is behind her. But the problems associated with her obesity appear in another form. She works as an acupuncturist. Since losing weight, and transcending her enormous weight problem, she has become more and more irritable with clients who seek her help for what she sees as relatively trivial bodily concerns. Compared to her struggle with obesity many of these clients have little to complain about. She no longer wants to tussle with ‘bodies’. As this irritability increases she develops chronic nose and sinus catarrh, congestion, and infections resistant to antibiotics. She ‘can hardly bear to face’ some of these clients. Her nose may settle for a while when away from clients, but as soon as she leans over these troublesome clients demanding solutions to their ‘trivial’ problems her nose starts to pour fluid. They get ‘up my nose’.

Puffy eyes

A woman aged thirty four who complained of eight years of nasal congestion, facial soreness, and puffy eyes all beginning when her mother was diagnosed with scleroderma, a very serious disease that causes both skin and internal organ damage. I could not find an allergic cause for her symptoms. Discussing her mother, the woman says: “I will always grieve”. Note the congruence between her physical symptoms and her words. Grieving shows physically as tears, congested nose, and puffy eyes.

Multiple symptoms

A woman aged 33 was referred for assessment of multiple symptoms including an odd ‘tingling’ sensation on both sides of her head, a worsening of her previously mild allergic nose and throat symptoms, and an aching at the back of her neck. She had seen three general practitioners, an Ear, Nose, and Throat specialist, and had had CT scans of the head and neck, and nothing had been found except for some minor allergic thickening of linings of her sinuses which could hardly explain her tingling or neck symptoms but was compatible with her worsened nose and throat symptoms. When asked what her tingling felt like she said “it’s like a cloud over my head.” She also said that the symptoms consistently disappeared when she did one of three things: when she lay down, or put her sun-glasses on, or donned her sun hat. These details mystified me. The timing of her symptoms was explored. They came on one month after returning from a holiday in the tropics, and about the time she stopped her anti-malarial medication (which she was inclined to blame for the problem). Still unsure where I was going I asked her about her life in general and her holiday and discovered that she worked in a boring, menial, but ‘safe’ job, felt chronically under-achieved, and that the holiday in the tropics represented a temporary escape into freedom, spontaneity, and exploration. Coming home reversed all that. Suddenly I realized that the lying down, the sun-glasses, and the sun hat symbolically represented freedom, spontaneity, and exploration. The cessation of the anti-malarial medication was the breaking of the final link with the holiday.  Home-life was stifling, and indeed a ‘cloud over my head.’

Arm rash

A 59 year old man was born with a paralytic condition of his legs. As an infant aged 5 he lost his mother suddenly, and he was subsequently reared by a close relative. He adapted well to life and indeed enjoyed a balanced, fruitful existence, and a happy marriage. There appeared to be few consequences emanating from this difficult start. Certainly his legs were a problem and, as he put it, ‘my wife was my legs and I was her voice.’ He acknowledged that he had got through his life ‘depending upon my strong arms.’ This was interesting because he presented to me with a history of several years of itchy band-like hives of the hands and forearms but on no other parts of the body. When I explored this further I discovered that the problem began in the context of the deaths of the close relative who had ‘mothered’ him and of one of his ‘sisters’ (one of the children in the adoptive family). This had been very upsetting for him. He felt ‘abandoned’ and ‘despair.’ It became clear that the deaths had awakened the issues of loss in childhood. But there was more. Over the years he had developed a personality style that required him to be strong, resilient, and emotionally non-disclosing. But, gradually, as he got older, and his wife was less strong, the equilibrium they had developed together was showing signs of disintegrating. They were not able to sustain their garden in the same way. They were not as able to be as available for their children as they had expected. So the losses of people important to her echoed the losses of childhood, and the erosion of the defensive resilience the couple had achieved together, combined to stir up a core issue of vulnerability. His arms, that were his strength and symbolized a compensatory resilience, developed a problematic rash that undermined his ability to use his arms, and therefore undermined his abilities and strength at a literal and a symbolic level.

Eye inflammation

A woman aged fifty complains of two years of chronic eye inflammation. She has been diagnosed with Sjogren’s syndrome, an inflammatory disease that mainly affects mucous membranes typically causing symptoms of irritable dry eyes, and dryness of the mouth and the vagina. Actually, despite the medical diagnosis, she did not have any clinical evidence of dry mouth or genitals. She complains of exhaustion related to wandering around the world following her diplomat husband. She appears to want to come back home and settle down in her own house. She says: “I am tired, I can hardly open my eyes”, and appears angry and frustrated. Her husband attended the consultation with her but would not allow further discussions. Here I suggest that the woman’s speech, the facts of her domestic circumstances, and her symptoms all tell the same story of tiredness, anger, irritability.

Tachycardia

A female aged thirty seven developed a heart rhythm disturbance, called a supraventricular tachycardia, while working in a stressful cardiology catheter laboratory. She then works for a urology specialist who treats her rather badly and she gets an inflammatory bladder condition called interstitial cystitis. She attends my clinic for nasal congestion and catarrh for which we can find no allergic cause. We talk about the possible connections between her various negative feelings towards her previous employers and her various symptoms over the years and the nasal symptoms subside.

Bladder infections

A woman aged fifty two complains of twenty years of bladder infections, bloody urine, vaginal discomfort, and excessive watering of the eyes. At age eight she endured sexual abuse. Her bladder problems had been continuous since her honeymoon twenty years before. In her speech she says: “I was such a go-er but I crash after sex; every now and again I give in to sex”; “I feel sickened”. The sexual abuse, the onset at the honeymoon, the bladder and genital symptoms, and the language, all suggest unresolved issues centering around the abuse.

Chronic diarrhoea

A woman aged twenty six complains of nearly three years of chronic diarrhoea and many medical investigations. It is clear that her husband works too hard, and that the symptoms began when they moved cities, and, more importantly, moved away from her father to whom she was very attached. She confessed that “I hate arguing” which might suggest that her strong feelings relating to the important men in her life were not being confronted adequately because of fear of conflict. I suggested these connections and a month later she returned for a follow-up consultation. Her symptoms had completely resolved after she told her husband “I am not going to be treated like shit any more.” I had not suggested any such interpretation nor had I used language like that with her at the first consultation.

Itchy welts

A woman aged fifty four complains of six years of itchy welts on the skin, and an inflammatory bowel condition called Crohn’s Disease both flaring each year in September. It turns out that she has a rigid workaholic husband, a lawyer, who has by-and-large refused regular intimate relations with her. She lives in constant hope that their relationship will improve. At Christmas time when the family are around and she sees more meaning to her existence her hopes rise, that this year ‘things will improve, and he will see sense’. But by September “my hopes begin to sag”, and “how else can I show what I feel”. She feels frustrated, angry, lonely, and afraid. Her symptoms break out again.

Severe tendonitis

A man aged fifty two who has suffered fifteen years of severe tendonitis, a condition involving visible swelling and redness around joints. Curiously enough, this inflammation only occurred in tendons around joints that had been actively exercised a few hours before onset of the symptoms.  There was a clear ‘story’. By background and nature he was an extremely active man, a person whose identity was pretty well captured by action in the wilderness. But then he got married which greatly limited his independence. He felt trapped and limited to domestic duties. Significantly, it was always after domestic physical activity rather than wilderness physical activity that the tendonitis would emerge.

Breathing difficulties and cold uticaria

Charlotte, 28 year old school teacher, was referred for a relatively rare but well-recognised skin condition called cold urticaria, which is characterized by itchy welts on any skin exposed to cold temperatures.  Cold urticaria is usually satisfactorily managed (as per the medical natural attitude) by cold avoidance, education regarding the risk of swimming and other cold exposure situations, and antihistamine drugs.

I was also asked to address a breathing problem as a separate issue. She was experiencing episodes of difficulty in breathing, which she recognized as being associated with anxiety. The breathing problem involved a feeling “that I am not getting out of the air that which I need.” It did not appear to be asthma or any other type of common respiratory condition, though phenomena such as ‘air hunger’ and tightness of the chest are common concomitants of anxiety.  The content of her anxiety always involved the possibility of something dreadful happening to her parents or brothers. The breathing problem would arise as she brooded on being separated from them, or losing one of them.

The story opened up wide when she said she had had these curious breathing problems as a child from about age six, and she emphasized that they only occurred during the winter months. She would often call her parents to her bedroom complaining she was not getting enough air. Physicians were consulted but nothing physical was found. Her mother believed that the problem began after surgery Charlotte had had when aged six. She was admitted with suspected appendicitis but a ‘growth’ on the ovary was found and removed. They were informed that the growth was a vestige of a twin that had died in utero.

I noted that Charlotte was born full-term in April, indicating conception in July the previous year. July is of course mid-winter in New   Zealand. I then started to wonder aloud with Charlotte about this apparent conjunction between the cold urticaria, the winter-time breathing problem starting at age six, the removal of the twin vestige at age six, the current persistent anxieties about separation, her July conception, and the possibility that her twin didn’t survive beyond the winter after conception. She was somewhat startled, but responded saying her life was dogged by July-ness. She met her husband in July, got engaged in July, then married in July, and was planning an overseas trip in July. She nearly died in a car accident in July (age 17), and her father had surgery for cancer in July (when she was age 18). Her favorite number was seven.

Leukoplakia

Teresa requests review because she wants to ‘live life more fully’. In her thirties she developed leukoplakia, a precancerous condition of the mouth. By the time she came to me she had had seven surgical interventions, including removal of carcinoma and one plastic reconstructions of the tongue and the floor of the mouth–the last requiring eighteen months rehabilitation as she learned to speak again. Early in the interview she proffered the interesting comment that “if only I could get rid of it(my emphasis) I would be able to live more fully from day to day”. Though she was obviously (!) referring to the leukoplakia and cancerous tendency I suspected the itwas not the cancer that had been removed 2 years before, with no evidence of recurrence. I noted the words but made no comment.

A review of her life-story was illuminating, and some key points will be emphasised. Apparently, after she was born, she and her mother were collected by father from the hospital. He dropped them off at home and went off to see his mistress. When Teresa was seven years old her father suicided, though she was not aware of the nature of his death. At age twelve she was crying in her bedroom. Mother found her, asked what was wrong, and Teresa replied that she was crying about ‘daddy”. Mother, who was now alcoholic, responded: “It’s your fault your father is dead–you would never sit on his knee.” The background to this cruel comment is not clear. Teresa did remember that as a child she often felt much more identified with her absent father than with her mother. At age sixteen she learned from relatives that her father died by suicide. At nineteen she entered a marriage that, over six years, repeated in some ways the traumas of childhood. At age thirty three she developed the leukoplakia of the mouth. It turns out that this was the age that her father committed suicide. Her father was an oral surgeon. I point this out to Teresa who has herself wondered, over the years, whether this is significant, though it had never been discussed with doctors. Returning in my mind to the it referred to above, I asked her what, apart from this cancerous tendency, she would most like to get rid of in her life. She seemed to understand what I was asking, but struggled initially, becoming very tearful, unable to find the right word. Eventually she said she most wanted to get rid of the shame.  To me it seemed likely that the shame and the leukoplakia were intimately connected in some way. Could one think up a better somatic metaphor than a precancerous condition of the mouth, for the shame of being responsible for the death of one’s oral surgeon father?

Teresa had some brief psychotherapy, which was unusually fast-moving and involved only nine sessions. The turning point in therapy occurred when she actually started to remember sitting on her father’s knee. She reported, after the session in which that occurred, a persistent “joy” which has continued, and seems to have expressed itself in a variety of interpersonal and social freedoms. A year later she reported no further problems and her surgeon expressed astonishment with the good state of her mouth.

Migraine, asthma and diarrhoea

John is forty-three years old and has suffered from severe ‘migraine’ from age eleven. It occurs about two monthly, and is unresponsive to all medications. He is rendered non-functional for three days, two of which he spends in bed. As an infant he had very severe eczema, and he has been assumed to be an ‘allergic person.’ He returned to New Zealand after twenty years of being settled in a foreign country with an excellent social network. The reasons for returning was his ‘closeness’ to his mother, and her deteriorating health. He developed quite severe asthma the day after he arrived back, and had had it most days in the six years since then. It gets much worse with exercise, and he has noticed it is triggered by ‘stress.’ Even more distressing was the development of violent diarrhoea, again beginning within days of returning to New   Zealand. It is much worse if he runs, and has therefore been labeled ‘runner’s diarrhoea.’ His headaches, asthma, and diarrhoea were much worse after his mother died in somewhat distressing circumstances. His hostile relationship with his father then became much more obvious. He has strong fears that his health might deteriorate like his mother’s did, and that he might meet the same fate. He has not established a good social network in New   Zealand. While he has strong feelings about many things he has no one to talk with about them; his partner ‘just doesn’t understand.’ He presents in the clinic as feeling quite strongly, but keeping tight control of the feelings. He has been sent to me to sort out his allergies. The history was not particularly suggestive of allergy, and allergy skin testing showed no evidence of allergy.

I framed his illness as follows. He was brought up in a caring healthy environment, enjoying a very close relationship with his mother. He establishes an excellent social context in a foreign country and enjoys good health except that every now and again he ‘explodes’ in the form of headaches, which I see as an outlet for pent-up feelings or needs in a person who has learned to contain them within himself. After twenty years overseas his primal links with his mother motivate a return to New Zealand. Several aspects would predict this might have been risky for him: he was rather too identified with his mother, and was returning to an old, overly close, pattern of relationship; he had a fundamentally hostile relationship with his father who was envious of John’s relationship with his mother; and John was leaving behind crucial well-established support networks. Within hours of arriving in New Zealand he lost control of his airway and his gut. He recognizes (though his clinicians do not) that when his feelings get stirred up (or he gets stressed) so does his asthma and his diarrhoea. His symptoms are understandably much worse as his mother gets very ill and dies. Running seems to make the asthma and diarrhoea worse, but is not the main or sole cause of the symptoms. It seems that vigorous physical exercise activates the nervous system in such a way as to make his lung and gut instability worse.

Multiple symptoms

Jonathan, aged 35, with a four year history of groin pain, sore throats, muscle spasm headaches, and fatigue, consulted me, asking very specifically for an ‘allergy’ approach to his symptoms. He had enjoyed good health for most of his life, and, until he became ill, there had been no necessity for any examination of his understandings of health and disease. Over the four years of the illness he had received many orthodox (specialist and non-specialist) and non-orthodox investigations and treatments, including antidepressants, acupuncture, removal of all his mercury dental fillings, and a variety of herbal remedies. He was a handsome, urbane, articulate, apparently confident person who crowded the consultation interaction with internet-based information, diagnostic labels, and working assumptions about his illness acquired in many previous consultations with other health professionals, most of which were predicated on the belief that his illness was purely physical. Nevertheless, he described himself as a ‘driven’ person, and it was easy to discern that he was a highly performing individual, very disdainful of weakness of any sort, and afraid of psychological concepts. The illness originally began at a time when he was struggling with a decision to return to New Zealand from Europe, and in the immediate context of two work redundancies, and very unstable social relations. Gentle enquiry around these aspects led to a sharp retort that ‘my symptoms are so physical that they cannot be related’ to such life events. Later in the session he hinted at some awareness of his mindbody connections, but these concessions were hurriedly overlaid with statements like ‘there is nothing wrong with my head.’

Back pain

Peter, aged 30, presented with ten years of severe back pain following an injury sustained during a diving expedition. Extensive and varied attempts at treatment and rehabilitation had failed. General physical activity, sexual intercourse, and sleep were profoundly affected. He had not worked for the ten years since the original injury, except for occasional very brief and unsuccessful forays into jobs ultimately found to be unsuitable. Surgery had been recommended because magnetic resonance scanning showed lumbar four and five disc narrowing, disc dessication, and oedema in adjacent vertebra. He had refused this option, terrified that it might lead to even more disability.

During the first consultation he lay on the floor while we talked, being unable to sit on an ordinary chair. The other most obvious features were the exquisite tenderness of his back muscles on examination, his profound suspicion of me, and his huge anger towards his third party financial funding source.

His ‘story’ can be told another way. He was (in his view) the unwelcome last-born of numerous children, and the only one who had failed academically.  He established his self-esteem through sporting prowess. As a child his angry temperament was notorious, to the extent he was given a nick-name to reflect this.  He left school early, with a strong sense of academic failure which he compensated for by excellence in sport. The ‘broken back’ caused by the diving injury symbolized the destruction of his capacity for sporting excellence, of his worth and competency. In his view surgery on his back might just complete the crippling process, the destruction. Thus surgery was a terrifying prospect. Because of his pain he was unable to re-establish himself in sport. As a person who was an academic failure he could not imagine developing alternative non-physical ‘head’ skills to replace his loss of physical competence. He was enraged with his funding organization because of the pressures they put on him, and afraid they would terminate his support, and leave him stranded. They and the various medical specialists concerned with his care were almost entirely focused on his physical body, and had no understanding whatsoever of what was going on in his subjectivity. Not only was the latter divided off, it was also invisible.

After acting as a mediator with his third-party funding source I did nine sessions with Peter. My notes record: ‘we have both found the intensity of the encounters almost intolerable.’ He raged on endlessly about his funding institution. It was extremely difficult to get him to focus on his anger issues, and how his anger might be perpetuating his back pain. At the ninth session, in utter frustration, I informed him I could not work with him unless he agreed to stop talking about his problems with the funding source, and focused more upon the role of his anger in his back pain. I thought I had lost him but he returned three weeks later, willing to stop focusing upon the funding source. A remarkable process of change ensued. Seven sessions later he was running his own business involving considerable physical activity. He was continuing to get some minor pain if he did too much lifting, but he was essentially living a normal life.

Chronic fatigue

Ellen is aged thirty-nine, and was a valued employee in a business whose growth had been phenomenal, and staffing had not kept up with the work-load increases. She took on more and more responsibility and became progressively more exhausted. Her husband said ‘she can never say: “No”!’ Apparently this was a long-standing pattern seen in all aspects of her life. Eventually an unexplained episode of deafness in one ear took her to the doctor, who was unable to provide a satisfactory explanation. She returned straight to work and thereupon suddenly collapsed. She described the sensation as an ‘incredible heaviness;’ ‘it was like my spine was collapsing, shrinking down until it was only two inches long.’ She was conscious during this first event but unable to move her limbs, which she described as ‘paralyzed and heavy.’ When she recovered from the paralysis the deafness had gone. She had intensive neurological investigations but no definitive diagnosis was made, and three years later, at the time of consultation with me, was chronically fatigued, unable to work, and was having three to four collapse episodes a day, all rather similar to the original collapse. She hesitated to leave the house. She frequently got collapse episodes as her husband left for work. She was confined to home doing gardening, which she enjoyed greatly. She was very angry that the medical profession was dismissive of her symptoms, because she did not fit into their usual diagnostic classification systems and because they were powerless to help her.

What are the perpetuating factors here? We can guess at them because they are always popping up in these situations in different variations: lack of a diagnosis; fear of something serious being missed, of the unknown, and of the future; negative interactions with the medical profession; frustration at being so constrained; relief at not having to go back into the world and take on all the burdens again; an ongoing background reward from people attending to her needs; and legitimation of her own identity–she can her gardening at home without feeling guilt for being self-centered. During the course of five sessions, as these factors were discussed and resolved, she got a complete remission of her symptoms and resumed normal activities.

Eczema

A woman in her thirties presents with severe eczema, particularly of her hands, which are severely inflamed, cracked, bleeding, and unresponsive to steroid creams. She has two infant children born eleven months apart and finds managing their bathing, nappy-changing, and dressing very difficult. The eczema had got dramatically worse following the birth of the second child. She does have some allergies, particularly to house dust mite, and her hands get very itchy in contact with house dust. We decided to try desensitizing her to the house dust mite, but some weeks into the treatment she pressured me for some better answers. We talked together about her life, and she disclosed that she was the eldest child in a large family, and that she had had to carry a lot of responsibility because her mother was often ill. A key current issue for her in adult life and at the time her eczema worsened was that her husband was frequently away from home due to his work. In a dramatic unself-conscious gesture she lifted her hands in the air and exclaimed: ‘And he leaves me carrying everything!’ I was struck by this and said: “Look at your hands: carrying everything and covered with eczema!’ She laughed and then nodded. She went on to do thirteen sessions with a psychotherapist, and her hands settled. I continued the allergy desensitisation process, but both she and I felt that the most important intervention had been around dealing with her issues of carrying everything, and the way this issue had been repeated in her relationship with her husband, and stirred up by the arrival of her children.

Vertebral arthritis

A couple were referred because of marital difficulty. The husband was very controlling and unable to let his wife be free to be herself or to make independent decisions. In the course of the first session he complained of back-pain, and we enquired further about this. He had been previously diagnosed with ankylosing spondylitis, which is an inflammatory arthritis of the vertebral column leading, eventually, to a rigid fusion of all the vertebrae. Asked when the problem began, without any hesitation he gave the following intriguing story. Seven years before he had been present at his wife’s first labour, during which an epidural anesthetic was given. He was absolutely appalled at the sight of the needle being inserted into his wife’s spinal column, and collapsed in a faint on to the floor. He woke up with pain in his back, and had been ‘feeling her pain’ ever since. We know that a certain genetic profile can predispose a person to ankylosing spondylitis, but we do not know the cause(s).