by The Naked Lady Who Stood on Her Head: A Psychiatrist's Stories of His Most Bizarre Cases
“So you think her back pain is referred from her esophagus or stomach,” I said.
“Yes, and we’ve stopped the ibuprofen. I ordered an upper GI series for this afternoon.”
“What do you think about all this medical meddling of hers?”
“My God, I’ve never met anyone—not even a surgeon—who is so opinionated and convinced of their diagnostic abilities,” Lisa said with a laugh. “She does have a fair amount of lay medical knowledge, but she’s so pushy that it’s irritating.”
“Have you met the son?” I asked.
“Yes, once. He’s a little intense like his mother, but he seems like a normal guy,” she said. “His mother talks about him nonstop, and she’s really anxious.”
“Maybe her anxiety is contributing to the gastritis,” I said.
“Definitely. I’m convinced that most GI disorders have a psychological component.”
Colitis and irritable bowel syndrome are classic examples of psychosomatic illnesses—true physical disorders that are influenced or aggravated by psychological factors. Many people share the misconception that physical symptoms resulting from stress are not serious or real. However, the emotional stress contributing to a psychosomatic illness can exacerbate physical symptoms that are just as real and potentially dangerous as those from any physical cause.
The interplay of psychological and physical components of psychosomatic illnesses in the GI tract is complex. For years, doctors believed that caffeine, antiinflammatory drugs, alcohol, and stress caused stomach ulcers. Although stress and diet can contribute to ulcer symptoms, in 2005 Barry Marshall and Robin Warren won the Nobel Prize in Physiology or Medicine for their discovery that the bacterium Helicobacter pylori can cause gastritis and peptic ulcer disease. Now, instead of taking months or years of dietary and other symptomatic treatments to heal an ulcer, a simple course of antibiotics often does the trick.
In the late 1980s, the antibiotic treatment for gastritis and ulcer disease had not yet been discovered. However, we did know that antiinflammatory medicines like Motrin could irritate the stomach lining and cause bleeding and discomfort, essentially an ulcer.
“It’s fascinating how the mind can make the body sick,” I said. “It’s nice that you seem to be using both your psychiatric and medical training.”
“If only I could double-bill for it.” She smiled. “I’ll let you know the results of her GI series as soon as I get them.”
“Thanks,” I said. “And why did Mrs. Wilson ask to be transferred to a private room?”
“She didn’t. Her roommates did.”
Carol Wilson’s upper GI series came back positive for an esophageal ulcer, and she was started on antacids and an ulcer-friendly diet. Although forced to give up her conviction that she had a kidney stone, she was thrilled to receive a new, official diagnosis—one that Michael would have to take seriously. She had an appointment to come back and meet with me after she was discharged.
A week later Carol walked into my office wearing a tailored suit and coifed hair. Wedged under her arm was a folded New York Times. She sat on the sofa and smiled. “Dr. Small, it’s a delight to see you again.” She looked around the office, “I love the ambience, so UCLA.”
I laughed and said, “I’m glad you’re here, Carol. How are you feeling?”
“I’m happy to report that my ulcer is completely gone.” She leaned in. “Don’t tell Dr. Chung, but I’ve been sneaking an occasional cigarette with my morning coffee, and it hasn’t hurt a bit.”
“I’m glad you’re feeling better, but take it easy on the caffeine, and you have to stop smoking. Have you been using the antacids?” I asked.
“Of course. You sound like my mother.” She pulled out a roll of Tums and popped one into her mouth. She offered me one, but I declined. She crossed her legs and winced in pain.
“Are you okay?” I asked.
She changed her position on the sofa to get more comfortable, “I’m fine, I just have this ruptured L4-L5 disc in my spine. There is a new procedure at the Mayo Clinic that I’ve been considering, but I refuse to be a guinea pig. Once you start messing with your back…oh, I don’t want to get into it.”
I was seeing a pattern. For Carol, every new day brought a new symptom, injury, or disease, and I suspected that each problem got a rise out of Michael. She could have Munchausen’s syndrome, where one fabricates illness to get attention. She also had a classic histrionic personality, which is essentially a long-term pattern of chronic attention seeking and emotional excitability.
She tried to put on a brave face but seemed distracted by her back pain. I changed the subject, “What’s been going on since you left the hospital?”
“I’m very concerned about Michael. At first I was worried that he might have a serious ailment because of his headaches and nausea, but now I’m not so sure.”
“What do you mean?” I asked.
“I think it may be psychosomatic,” she said.
That’s certainly the pot calling the kettle black, I thought to myself, sounding just like my father. Instead I said, “Psychosomatic?”
“You must have heard of medical studentitis,” she said.
“You mean when medical students imagine they have every horrible disease they read about in their textbooks?” I asked.
“Yes. These kids get obsessed with all the illnesses they’re learning about, and I think that could be what’s happening to Michael. He’s always been very sensitive and susceptible to suggestion.”
Medical studentitis, also known as medical student disease, is believed to affect nearly 60 percent of all doctors at some point in their training. The condition is a form of hypochondriasis, or excessive preoccupation and worry about having a serious illness. It’s no surprise that the voluminous and morbid details of medical training can trigger this kind of worry and anxiety. Although it’s usually short-lived, some students get into a vicious cycle of maladaptive behavior—they frequently check their body for lesions and pore over their medical books for clues to the suspected malignant nature of their everyday bodily sensations. A transient ache in the groin becomes testicular cancer; craving liquids on a hot day turns into a sign of adult-onset diabetes; and writer’s cramp from taking notes is evidence of incipient rheumatoid arthritis. The particular disease or organ under study in class is often the student’s focus for his hypochondriacal concerns. As medical students gain more experience and knowledge, they usually become less anxious and their studentitis tends to disappear.
Michael was a first-year student, so he was at risk for this common syndrome. He originally went to the student health service because of anxiety, but he didn’t strike me as particularly anxious. And he had already told me at the hospital that he was playing up his symptoms to get out of being around his mother.
“It’s possible that Michael has this student disorder, but—”
Carol interrupted, “It’s more than possible, it’s highly likely. I think it would be extremely helpful if you could meet with us together. Then we could get to the bottom of what’s going on.”
It sounded like Carol was again trying to avoid dealing with her own issues by focusing our therapy on her son, but I also thought it might be helpful to observe more of the dynamic between them. “I could meet with the two of you. Let me give you some times so you can both check your schedules.”
“Can’t you just stop by my place tomorrow around five? Michael promised to come over after class and stay for dinner. My condo is right here in Westwood, just down the street. I’d really appreciate it if you’d make a house call.”
Unlike most doctors, geriatric psychiatrists did make house calls on occasion because some of their patients were housebound. Although this wasn’t a geriatric case, I felt it would be interesting to observe Carol on her own turf, especially with her son there. People reveal quite a bit about themselves in the comfort of their own home, and their surroundings tell even more.
I checked my calendar and said, “Fine. Wh
y don’t you let Michael know, and I’ll be at your place tomorrow around five-thirty.”
Carol lived just five minutes from UCLA on Wilshire Boulevard, the main east-west thoroughfare in Los Angeles. Her building was among a cluster of high-rises that offered views of the ocean, mountains, and downtown skyline, in one of the most desirable residential areas on the West Coast.
I pulled up to Carol’s building, and the valet took my car. As I entered the elegant, high-ceilinged foyer, a doorman welcomed me and phoned up to Carol, announcing my arrival before he’d allow me on the elevators.
My ears popped as I approached the twenty-second floor. The elevator was covered in gold-plated mirrors, so I checked myself out—I looked pretty frumpy after a long day. I straightened my tie, tucked in my shirt, and ran my fingers through my hair, going for that casual but professional house-call look.
The elevator opened directly into Carol’s apartment. I stepped in and was impressed by the view of West Los Angeles and the Pacific Ocean beyond. Carol ran up to greet me holding a martini and wearing a neck brace. “Please come in, Dr. Small. What are you drinking?” She leaned in and whispered, “You could have a cocktail and I won’t tell…”
“Perrier, please, straight up,” I said. “What happened to your neck, Carol?”
“Well, it’s silly, but I’ve had this intermittent hacking cough—which I told Dr. Chung could be the onset of emphysema, and the cough upset my C4-C5 whiplash disc protrusion.”
I thought to myself that this seemed too over-the-top to be Munchausen’s and perhaps she was just a hypochondriac with a histrionic personality. I decided not to nag her about the martini and her ulcer, but if she lit a cigarette, I’d have to speak up…especially now that she had self-diagnosed emphysema.
“Michael’s not here yet,” she said, “but I wanted to talk to you alone for a few minutes anyway. I think we should do couples therapy.”
“With who?” I asked.
“Michael and me, of course.”
“Carol, couples therapy usually involves a couple, like a husband and wife.”
“Not according to the eminent family therapist Salvador Minuchin. He’s used his structural family therapy model to resolve many parent/child difficulties.”
Carol was right. Minuchin often worked with nuclear families, as well as subsets of family members, to help them understand what was dysfunctional in the way they interacted. His methods were especially helpful for enmeshed relationships, where he would show family members how to define healthier boundaries. He believed that therapeutic change could only occur when the family members recognized the patterns in their relationships and were willing to modify them. Minuchin’s approach could help Carol and Michael, but behind her request I suspected yet another ploy to spend more time with Michael.
“You know, Carol, both parties have to want couples therapy, and Michael is not a child.”
“No, I’m not,” Michael said as he stepped off the elevator. “And what’s wrong with you now, Mother? Your whiplash kicking up again?”
“It’s nothing, sweetie. Let me get you a glass of that merlot you love. You two sit down in the living room.”
We walked to the step-down living room as Carol headed for the kitchen and called out, “Luticia? Could you please open a bottle of the merlot and help me with the hors d’oeuvres?”
Michael and I sat across from each other on Carol’s white couches. “I didn’t know doctors still made house calls.” He shook his head and said, “I don’t think I like that.”
“Don’t worry, most doctors don’t.” Luticia brought out a plate of hot hors d’oeuvres. I sipped my Perrier and noticed a volume of Harrison’s Principles of Internal Medicine on the coffee table. It was the standard textbook for medical students and practicing physicians. “I see you’ve been studying over here.”
“No way.”
Carol came in, handed Michael a glass of wine, and sat next to him on the couch. “Mother, did you sneak into my apartment and borrow my volume one of Harrison’s?” he asked.
She laughed, “Don’t be silly, dear. You know how much I love to read nonfiction. And this was on sale at Dutton’s.”
“But this isn’t just nonfiction, Mother,” he said. “It’s a medical textbook.”
“I find it interesting,” she said. “Besides, I want to be able to talk to you about what you’re learning.”
As I watched them interact, I realized how Carol had manipulated the scene. I was seated across from the two of them, who were sharing a sofa, perfectly poised for couples therapy.
“Look, Mom, we can talk about this later. I want to know what you and Dr. Small were discussing when I came in,” Michael said.
“I was saying how worried I am about you lately,” she said.
“Tell me something I don’t know. Every time I sneeze you act like I’m dying.”
“That’s absurd!” Carol exclaimed. “I’m simply concerned, darling.”
“About what, Mother?”
“That you have medical studentitis.”
Michael laughed and shook his head. “Maybe you should stop reading Harrison’s and stick to biographies.”
“Think what you like, dear, but it’s extremely common in first-year medical students, and there’s nothing to be ashamed of.” She winced in pain again, “Ouch, I get this throbbing headache whenever my neck acts up.”
I noticed that when Michael didn’t buy her studentitis diagnosis, she changed the subject to her own pain.
“You know, Mother, the most common cause of headache is muscle tension and stress. So don’t start thinking you have a brain tumor.”
Carol started crying.
“Are you okay, Mom?”
“What’s the matter, Carol?” I asked.
“Nothing, it’s just this headache.” Michael put his arm around her to comfort her. Carol continued, “Dr. Small, could you ask Luticia for some Tylenol?” It seemed like Michael’s sarcastic comment about the brain tumor triggered Carol’s tears, and now she was once again in control.
I walked to the kitchen and couldn’t find Luticia, so I headed down the hall to the bathroom. I found some Tylenol in the medicine cabinet and started back to the living room, but as I passed the library, I noticed a large stack of medical books. I was intrigued—Carol had nearly every first-year medical text piled on the desk. I thumbed through one of them and found the pages covered with yellow highlighting. This was more than casual nonfiction reading—Carol appeared to be studying them, as if she was going to medical school.
I returned to the living room and handed Carol two Tylenols. She washed them down with her martini.
“Are you okay, Mom?” Michael asked.
“Yes, honey. It’s so comforting to have you home.”
“I’m glad you’re feeling better, Carol,” I said. “You know, when I passed the library, I noticed that you have a lot of first-year medical texts.”
Michael pulled away. “What? What are you talking about?” He dashed down the hall.
Carol hissed at me, “I didn’t take you for a snoop.”
Michael yelled from the library, “I can’t believe this, Mother! So now you’re my classmate? Why don’t you just move into the apartment with Mia and me?”
I called to him, “Michael, please come back. Let’s talk about it.”
As Michael marched down the hall carrying a pile of the books, Carol glared at me and said, “He’ll never talk to me now.”
“Don’t be so sure,” I said.
Michael dropped the heavy books on the coffee table and sat back down. “So who’s the med student here, you or me?”
Carol said sheepishly, “I just wanted to stay close to you.” She looked at me. “Is that so bad?”
“Well, I don’t want you that close!” Michael yelled. “I want to have my own life.”
I realized that I’d better grab the reins of this session before it got totally out of hand. I stood up. “Let’s slow down and try to understand what’s g
oing on here.” They looked up at me, seeming to respond to the authority in my voice. “Carol, you’re having a tough time dealing with your grown son moving out. And Michael, you can’t please your mother completely and have your own separate life. I think you both need to set some boundaries in your relationship.”
Carol spoke up. “I can deal with boundaries. But he’s in denial, and that Mia supports it.”
“You always call her ‘that Mia’ like she’s a car or something. She’s my girlfriend for God’s sake, and I love her. Why can’t you accept that? Why can’t you accept me?”
Carol started crying again. “I really do want you to be happy, Michael. I just don’t know if she’s right for you.”
“Well, how are you ever going to get to know her if you don’t give her a chance?” Michael asked.
“I’m willing to give her a chance, but I’m worried that she buys into your studentitis.”
I sat on a chair next to them. “Carol, I’m glad you’re going to try to get to know Mia, but I think you should also focus less on Michael’s symptoms and look more honestly at your own. I’m sorry, but if anybody has medical studentitis, it’s you.”
They were staring at me in silence. Had I said too much? I felt they both needed a dose of truth.
Carol broke the silence. “How could I have studentitis? I don’t go to medical school.”
“But you’re reading every one of my textbooks. It’s like you want to be one of my classmates.”
“I don’t know why I got the books, Michael. I just wanted to feel closer to you.”
“By studying my medical texts?” he asked. “No wonder I always feel like we’re competing when we talk about school.”
I interrupted them. “Carol, regardless of why you’re reading these books, it’s certainly possible that they’re feeding into your worries about your own medical problems.” I was trying to soften my earlier interpretation.
“I just wanted to be able to discuss what was going on in Michael’s life,” she said.
“But Mother, school isn’t my whole life.”
“I know. Maybe I did get carried away.”