Insight is Out of Sight

A little girl this morning with vomiting once or twice every day this week.

A 9th grader yesterday who has been having waves of shortness of breath and difficulty focusing in school.

Sometimes, when a diagnosis isn’t clear to me, I ask the patient for help.

“What do you think is going on?”

“It’s because I’m anxious and stressed,” says the 10 year old.

“I’m overwhelmed and stressed out starting high school,” says the 9th grader.

The moms nod confidently in agreement.

There was a time when I hesitated, sometimes for weeks or months, to mention the possibility that a patient’s physical symptoms might be related to a behavioral health diagnosis such as anxiety or depression.

Now, here before me, sit these children, telling me that they’re pretty sure that their bodies are listening to inappropriate messages from their brains, and that they would like some help figuring out what to do about it, please.

I tend to err on the side of caution–don’t want to miss something bad– so I still ask more questions, consider doing labs, look at other possible triggers such as viruses or August allergies.

But it is lovely to have the most probable diagnosis, anxiety associated with the start of school, sitting right on the table before us instead of locked carefully and menacingly in the back of my brain, unsaid because I didn’t want to suggest that “it’s all in their head.” Because it’s not. The symptoms they are having are real, inconvenient, sometimes terrifying, always disturbing.

I ask the ten year old about other symptoms. Is there fever? How is she between episodes of vomiting? When do they occur? Any possibility of urinary tract infection? She and I don’t come up with any red flags.

I ask the teen about other health issues as well. Certainly her asthma is triggered by anxiety, but her asthma makes her worry as well, as do some other physical health problems she is struggling with. “I spend all day, every day just worrying,” she tells me. “I am terrified a teacher will call on me and I won’t know the answer. The buildings are far away from each other and I don’t know where I’m going or if I’ll have an asthma attack on the way.” She has asked her mother to homeschool her to get her away from these people who used to be (and still are) her friends, but who now make her heart race with fear sometimes.

I love being able to tell both girls that what they are going through is common and very treatable, that they have the most powerful form of medicine inside themselves if they will let me help them tap into it. Medication is sometimes needed to treat anxiety, but first line therapy should really always include a prescription for some good work with a well-trained counselor.

The 10 year old is thrilled about the idea of counseling. She loves to talk, loves to learn, has never met a stranger. And she has observed in her own family that medications alone are at best not 100% therapeutic; at worst, she knows, they can be fatal. She is ALL IN for the idea of talking with someone about learning strategies to control her worries and their effects on her body. Meanwhile, she’ll take a little medication to help reduce the acid in her stomach that her anxious body has churned up.

The older child is skeptical about counseling. She would rather take a pill and be done with it. After all, talking to strangers is what stresses her out the absolute most. She is terrified that she’ll be called on in class, here in high school where no one raises their hand anymore so a teacher just calls on whomever she pleases and expects a response. Why would it be helpful for her to speak with another stranger?

So I pop down the hall to find our fancy new co-located counselor. After a few minutes listening to this professionally trained person describe what she does and how she does it,  I watch mom and teen’s shoulders relax as they understand that some of the tools the counselor can share might just be helpful for a lifetime. “Now I want counseling too,” says the mom, who had been skeptical just moments before. The strategies a counselor shares can mean that she won’t need medication forever. Counseling does not mean lying on a couch and talking about what happened when you were two and your cat died (or maybe it might, but it’s up to you).  It might be practicing some meditation or yoga techniques or tapping into exercise to release stress. A counselor will help her climb back in the control seat, help her control her thoughts rather than letting her thoughts control her.

There was a time in my practice when, faced with unusual symptoms, I did lab after lab, radiology study after radiology study, referred to subspecialist after subspecialist before meekly inquiring about whether there may be any sources of stress in the family. (If you know a family where there are no sources of stress, please introduce them to me. I have never met one).

I’ve come a long way.  I’ve realized that, when treating chronic health issues, good longterm outcomes rely on treating both physical and mental health issues together, through teamwork, open-mindedness, and patience. What a gift it was this week to hear my patients tell me unashamedly that their physical health problems were associated with mental health issues and that they wanted help with both.

We have a lot to learn about how to manage these problems in different people with different minds, different bodies, different experiences. It’s hard to help someone get better when you have no idea what you are treating. A patient’s insight is not only the best clue to diagnosis, but the best, most powerful first step in treatment as well.




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