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The Art of Digging

Is it a difficult diagnosis or a difficult patient? We learn to walk past the expression to find where the pain lives. We need to know not just where, but when to dig.

Tim Powell - This life we’ve chosen

You know her name. Usually her. Your name is different from mine. But they’re sisters. You see her name on the schedule and your stomach tightens. The ever - shifting symptoms are exhausting and frustrating. Problems you’ll never solve.

There are many layers, like an archaeological dig. On the top layer we have the physical complaint – back pain, weight gain, headaches, fatigue. The patient comes to you hoping for a diagnosis external to her essence.

Many doctors stop there after running some tests or prescribing some medication. Or they kick the ball to a specialist. Problems in search of a label. The label always comes.

For the patient this label has a real function. I can’t go to work because I have a back spasm. I need to be alone because I have migraines. It is fibromyalgia that makes me so tired. The label offers legitimization. It carries rights and privileges. Others might even look after them or help them out. At least excuse them. Perhaps the patient can even excuse themselves.

A deeper evaluation reveals depression and anxiety – the most common expression of psychic distress. This is less a specific diagnosis than a description. It is an almost universal manifestation of dis-ease – thus the huge market in antidepressants.

But another level down, we may see the effects of self-medication: alcohol abuse, drugs, and often violence in the home. This is harder to talk about. Much harder to treat. Most doctors don’t go near this. A box you don’t want to open. You only have 20 minutes.

The next layer down reveals a lack of love and intimacy. These go hand in hand with a lack of self-esteem, shame, and a deep sense of humiliation. Humiliation is the well that everything comes from. The anger that comes from humiliation underlies everything else. It’s the propellant.

Women tend to internalize their anger. They’re not allowed to express it, so they turn it on themselves with depression, eating disorders, suicide attempts and trips to the doctor. Men usually turn their anger outward as aggression. Men are easier to eject from the practice based on objectionable behavior. Harder to look past the expression to the pain hiding behind.

Where to start? Take a careful, detailed longitudinal history. The devil, God and the diagnosis are in the details.

Many of these women are neglected. Not abused. Just ignored. Emotional neglect is so powerful. People can be married for forty years, but that doesn’t explain what is happening. The temperature of the relationship can be close to zero degrees. You cannot live well without love. It is not possible. Even our pets need to be loved.

Unloved person as a diagnostic category? Neglect resurfacing as chronic unexplained pain? Is there a DSM code for that? Now you have the diagnosis, you begin to dig again. What care plan do you offer?

Tim Powell MD

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