R had been my patient for over a year. She was referred to me by a colleague. She had 38 symptoms. All tests and imaging studies failed to find any demonstrable medical disease; I considered her to have “symptoms of unknown origin”.
I had little information on R’s personal and family history. I did know she was 43 years old and was 7 years into her second marriage. Her first marriage ended in divorce from a severe alcoholic husband. She had no children. She dwelled on her many symptoms and avoided all my attempts to gather more personal or social information.
Before I can share my full experience with R, I need to provide some back ground on my clinical thinking.
Over my fifty years in medical practice, I became fascinated by patients who had physical symptoms in the body but no definable medical disease. Many doctors did not like or enjoy such patients and were glad to refer them to me. Some labeled these patients as hypochondriacs, or worse, with pejorative terms such as “crocks” or “turkeys”. I think their frustration with failure to help these patients was the source of their disdain.
Early in my experience with these fascinating patients, I kept asking myself the question, “If these patients with symptoms in the body do not have a medical disease, then what do they have? What is the cause of their symptoms?”
My guiding principle became, “There is not a medical disease behind every symptom but there is a cause if one listens, looks carefully, and engages the patient in the search.” I made a decision to avoid all labels until I was sure of the cause of the symptoms. I found that many labels got in the way of uncovering the real causes of distress.
R was particularly difficult because she spoke so rapidly, running one sentence into another, hardly pausing to breathe. I tried without success to slow her speech so I could get more details of her symptoms. My goal was to dissect each symptom into time of occurrence, location in the body, associations of all sorts – food, time of day, even thoughts or presence of acquaintances. This approach was impossible with R.
I had been able only to make a list of all of her symptoms but with little detail. Her symptoms were:
Dull headaches
Double vision
Itching ear canal
Itching tongue
Deep pain in her throat
Shortness of breath
Dull chest pain
Fullness after eating
Pain with menses
Burning on urination
Difficulty urinating
Painful bowel movements
Constipation
Difficulty swallowing
Pain on swallowing
Aching lower legs, arms, thighs, and shoulders
Periodic nausea
Dark urine
Painful intercourse
Irregular menses
Crawling sensations under the skin of her face
Intolerance to some foods
Dizzy spells
Spots in her field of vision
Abdominal swelling
Swelling in her hands and feet
Red blotches on her neck
Hair falling out
Weak spells but no loss of consciousness
Feeling of impending doom
Sensations of being hot and cold
Tingling sensations in her legs
Decreases in visual acuity that would come and go
Episodes of severe abdominal pains
Loss of energy and tired feelings
Feeling sick all over
It took several visits to gather these symptoms, all said at racing speed. All of her routine lab work, chest x-ray, and some specific disease tests were normal. Her physical examination was normal.
I usually saw R with my nurse Rosie, an astute observer of people.
On one visit, R was unusually rapid in speaking. Without thinking in any detail, I got an idea of a way to slow down her speech.
I turned to Rosie, “Rosie, please bring 3 more chairs into the exam room.”
I then wrote out labels on 3 sheets of paper and taped one to the back of each chair. The first label read “Head symptoms”; the next read “Upper body symptoms”; and the third read “Symptoms below the waist.”
I turned to R and said, “It will help me keep track of each of your symptoms if you will move into the appropriate chair before you discuss symptoms in that part of your body. You speak so rapidly I have difficulty trying to understand you.”
R’s face went blank, almost trance- like, but she then moved into the “Head” chair and began talking about her headaches, quickly jumping to her leg pains, and then to urination problems and back to her chest pains.
I held up my hands. “Wait! Hold it! You are still jumping all over your body. Rosie, please get me 2 more chairs.” I had no idea what I was doing other than trying to slow R’s flight of ideas.
I then added labels of “Arms, legs, feet” and “Stomach and abdomen” to the 2 new chairs. I now had 5 chairs with labels of body parts.
R sat in the “Stomach and abdomen” chair but soon began to laugh. Her laughter got louder and more protracted, doubling over with her head between her knees. She took deep breaths between guffaws, unable to speak from lack of air. Her laughing was infectious. Both Rosie and I started laughing, not knowing why but only in response to R’s nearly hysterical laughter. This went on for several moments, all three of us holding our sides and struggling to breathe.
Between gasping breaths, R finally said, “This is ridiculous. Just plain ridiculous.”
I replied, “Yes it is ridiculous.” And we laughed again, as I looked across the room at the 5 labeled chairs.
R wiped her eyes with her handkerchief. She paused, no longer laughing but staring at the floor. Then she said, after a long silence, “I need to tell you about that sorry husband of mine.”
In slow and deliberate speech, pausing from time to time to collect her thoughts, she described a horrible marriage dating back over 7 years, a marriage of verbal and psychological abuse. Her second husband was also an alcoholic.
I continued to see R over the next several months. She sought help from a marriage counselor. All of her physical symptoms disappeared gradually. She got a divorce within the year and thereafter remained free of symptoms.
My only intention in labeling the chairs with body parts was to try to slow Geraldine’s speech so I could get more details about each symptom. I had nothing else in mind. Why this led R to her insight, I have no idea.
I often wondered if R unconsciously developed symptoms as a way to avoid or slow down her husband’s abuse. I will never know.
I never found a reason to use the chair technique again.
Clifton Meador, MD is a Professor Emeritus of Medicine at Vanderbilt University and a Contributing Editor for THCB
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