Introduction
Functional symptoms which are either severe, persistent or
both are a common clinical problem in adults. These complaints are often
seen in patients suffering from chronic emotional stress. For example,
recent reports have described an association between functional symptoms
in adults and a history of abuse when they were children.1,2,3,4,5
An approach to the diagnosis and treatment of functionally ill patients
will be described.
Common Characteristics
The ideas presented are intended
for practical application in a primary care or referral setting. They
were developed by the author based on literature review, collaboration
with several mental health professionals and detailed interviews with
well over 1000 patients (since 1983) referred to a gastroenterology
practice. These patients shared three general characteristics. First,
no organic etiology for their symptoms was identified after diagnostic
evaluation. Second, there was a history of chronic emotional stress
and frequently a history of events in childhood that, as a common denominator,
had a negative impact on the patient's self-esteem. This may have included
physical, sexual or verbal abuse, physical or emotional neglect, parental
abuse of drugs or alcohol or recurring violence in the home. Third,
these patients achieved resolution of symptoms with counseling, support
groups, classes or books directed at the source of chronic stress or
childhood issues.
Case 1 illustrates many typical features of this group.
Case 1
A 36-year-old white female was referred from a University Gastroenterology
department with a two year history of having bowel movements only once
every two to six weeks. This habit persisted despite daily ingestion
of approximately double the usual dose of milk of magnesia, bisacodyl,
docusate and fiber supplements. An extensive evaluation had been entirely
normal. She denied any emotional stress but was then asked about stress
during childhood. She gave a history of penile-vaginal intercourse with
her father on a weekly basis from age 4 to age 11. Asked again about
stressful events at the time of onset of her illness she reported that
the opposite had occurred. Just before her symptoms began she had quit
her job as a part-time bank teller because of harassment (non-sexual)
from her supervisor. She was quite happy at her current bank and was
also happily married, had two healthy children and was financially secure.
The patient was referred for counseling for the sexual abuse. Her bowel
habits returned to normal in about two months.
Diagnosis
The diagnostic evaluation of these patients depends on the
nature and severity of their symptoms and will vary by individual. Contrary
to common practice and as recommended by Barbour,6 it can
be very helpful to include emotional stress in your earliest discussions
of possible etiologies. When clinicians point out that emotional stress
is capable of causing symptoms that are just as 'real' as symptoms caused
by, say, tumors or inflammation, patients will appreciate your thoroughness.
This approach enables the evaluation for sources of stress to proceed
concurrently with the work-up for an organic etiology, possibly over
several visits.
Begin by ruling out significant current sources of emotional stress.
These include problems within the family, domestic violence, problems
at work, chronically insufficient personal time, and any source of substantial
anxiety. Occasionally a major negative life event will be found to have
coincided with the onset of symptoms. The next step is inquiry about
vegetative symptoms of depression such as early morning awakening or
other sleep disruption, persistent fatigue, change in appetite, spontaneous
tearfulness, anhedonia and suicidal ideation.
Follow this by inquiring about stress in childhood. It is diagnostically
and therapeutically helpful to elicit as detailed a history of childhood
stress as time and the patient's comfort level will allow. Non-threatening
questions such as "Were you under stress as a child?", "Can
you tell me more about what went on?", "How often did that
happen?" are most useful. It is important to elicit a history of
any childhood stress that produces a lowered self-esteem in the child.
Significant functional symptoms can occur in adults in the absence of
what is commonly considered abusive treatment if childhood self-esteem
was substantially and adversely impacted. Cases 2 and 3 are examples.
Case 2
A 31-year-old white female was admitted for diarrhea and orthostatic
vital sign changes. She reported that during the 18 months prior to
admission she experienced 5-10 non-bloody bowel movements per day on
3-4 days per week associated with a documented 81 lb weight loss to
117 lb. On the remaining 3-4 days per week she was asymptomatic. An
extensive evaluation did not determine an etiology. The patient denied
significant current stress and any physical or sexual abuse in childhood
or later. She had some symptoms of depression. She also recalled that
it was her father's habit, on a daily basis from her earliest years,
to spend most of the evening meal discussing his children's flaws and
recommending methods for improving. This practice continued less regularly
during her adult years. The patient recalled "never being able
to please him." After discussion of these issues she felt a great
sense of relief, became asymptomatic for the next four months (but was
then lost to follow-up) and regained 15 lb in three weeks.
Case 3
A 54-year-old white female was admitted for uncontrollable nausea,
vomiting and vertigo. She reported a 15 year history of episodic attacks
of these symptoms 6-10 times annually. She had been evaluated by "every
GI, Neurologist and ENT" at a University Hospital and by many other
physicians in her community as well. There was no history of significant
current stress, depression or physical or sexual abuse in childhood
or later. However she did recall growing up "like Cinderella but
without the prince" with very poor treatment by her mother after
the mother divorced and remarried when she was age two. She reported
as well that driving through a particular town (25 miles from her home)
"always" led to one of her attacks. Further questioning revealed
that the only occasion that led her to pass through that town was while
on her way to visit her mother. Driving the same distance in the opposite
direction never produced an attack. After this revelation she became
and remained asymptomatic.
Typical Findings in Adult Survivors of Child Abuse
The amount of time you devote to a patient's childhood stress
history will depend on your index of suspicion regarding its relevance.
It has been my experience that several findings in the history of the
patient's teen/adult years are characteristic of adult survivors of
child abuse. The more of these that you identify in reviewing records
or in taking the history, the higher will be your index of suspicion
that you are treating a child abuse survivor. These include a history
of:
- Early adult personal relationships in which the patient was treated
poorly.
- Prior negative medical evaluations.
- Prior mental health treatment.
- Suicide attempt(s) or self-mutilation.
- Abuse of drugs and/or alcohol.
- Smoking, particularly those who do not wish to quit.
- Anorexia nervosa or bulimia.
- Concerns about ability to appropriately discipline their children.
- Feeling that the patient's life is better than ever but that something
could go terribly wrong at any moment.
- Belief that they are not as capable as their peers believe them
to be.
- Perfectionism.
- Caring for problems of others so much they neglect their own problems.
- Outbursts of anger that seem to have insufficient cause.
- A major positive life event just prior to the onset of symptoms.
When the history is positive for significant childhood emotional stress
in a patient with a negative medical evaluation it is reasonable to
recommend that the childhood issues be addressed as an adjunct to planned
medical therapy. This process is described in the next section.
Treatment
Begin with a simplified explanation of how symptoms could
be linked to stress. Despite our poor understanding of the physiologic
basis of these symptoms patients find this very helpful. A typical discussion
that patients across the spectrum of educational backgrounds can comprehend
is as follows:
"There is an area in your brain that manages stress. When it has
too much to deal with it sends out nerve impulses to relieve the overload.
These nerve impulses go to various parts of your body and cause symptoms.
The best way to confirm that this is happening is to reduce the stress
and then see if your symptoms improve."
Patients who have symptoms of depression appreciate the following addendum:
"If the stress manager in your brain is working too hard it may
use too much of its chemical supply. This can cause trouble sleeping,
persistent fatigue, change in appetite, loss of interest in activities
you enjoy and even depression and suicidal thoughts. There are medications
available that are neither addictive nor tranquilizing that can restore
those chemicals to the levels that nature intended. Using these medications
is therefore much like a diabetic using insulin."
Supported by this information my patients have been able to focus on
reducing sources of stress. When childhood issues are present, useful
treatment resources developed for "Adult Children of Dysfunctional
Families" are now widely available. They include self-help books,7
support groups (through Al-Anon or the patient's church), educational
classes and mental health professionals with specialized interest and
training. A knowledgeable social worker can be invaluable in triaging
patients among these resources.
In my experience, the combination of the discussion described above,
symptomatic treatment, anti-depressant medication where indicated and
addressing childhood issues, if any, generally produces a definite improvement
in symptoms at the initial follow-up visit. Complete resolution of symptoms
generally takes a few months to a few years. Often there are relapses
and remissions superimposed on steady general improvement.
A very small number of patients may acknowledge the importance of the
childhood issues but be psychologically incapable of addressing them
immediately. Even these patients generally experience some alleviation
of their symptoms after discussion. Other patients will hear and appreciate
your recommendations but state that they do not believe their admittedly
significant childhood issues are a factor in their illness. It has been
my experience that in most of these cases the patient's perception is
correct.
Common Themes
Detailed interviews with over 1000 adult survivors of child
abuse who presented with functional symptoms revealed that they often
share certain personality characteristics. Familiarity with these is
a useful background for clinicians who work with them.
As children many of these patients responded to the abuse or other
trauma with hard work in school and at home. They were perpetually "on
their best behavior." Many took on parental roles with respect
to cooking, cleaning and other household duties. As adults these qualities
made them ideal employees, colleagues and friends though often they
would take on so much that they had little time for themselves.
As young adults, low self-esteem led them away from mutually supportive
personal relationships and toward individuals whose treatment of them
was more consistent with what they had experienced as children. As a
result, a history of marriage to an abusive and/or alcoholic spouse
or spouses is common.
As their hard work results in worldly success, however, self-esteem
begins to improve which often leads to a positive, stable long-term
personal relationship. Ironically this development is often very stressful
because it challenges long-held views of their low value and creates
anxiety about whether such a relationship can last. It is common for
functional symptoms to appear soon after the start of the patient's
first relationship with a supportive partner. In a variation on this
theme, Case 1's symptoms began when she developed enough self-esteem
to end the only negative relationship in her life, the one with her
supervisor.
Mistreated children typically suspect that their abuse is partially
deserved. But as self-esteem strengthens in the adult years their early
experiences will increasingly be viewed as inappropriate. Anger, often
unexpressed, about this treatment becomes more difficult to ignore.
When a parent or other loved one was the perpetrator, the anger is often
suppressed. Surprisingly to many, this suppression is commonly due to
a desire for a healthy, positive relationship with that individual.
These antagonistic emotions are difficult to resolve without expert
assistance. The next case illustrates.
Case 4
An 83-year-old white female had a 25 year history of abdominal cramps,
bloating and alternating constipation and diarrhea. An extensive evaluation
over the years had been negative. From her earliest memories she recalled
approximately weekly beatings with strap, baseball bat, or two-by-four
by her father. She married at age 15 in order to leave this situation
and was unhappily married for the next 63 years until her husband died.
When her father developed prostate cancer she moved out of state (late
in her sixth decade) and cared for him in his home for 18 months until
he died. She and her father never discussed the physical abuse. The
patient recalled hoping that her father would express affection for
her and/or remorse for his abuse of her but this did not occur. Her
gastrointestinal symptoms began soon after he died and she had returned
home. With counseling her symptoms improved significantly although they
did not completely resolve.
These common themes should be kept in mind when listening to patients
describe themselves and their lives. The ability to recognize, understand,
and respond to a survivor of child abuse will improve significantly.
Conclusion
This approach has favorably altered the course of patients
who had previously frustrated the diagnostic and/or therapeutic efforts
of one or more clinicians. However, the ideas expressed here are based
on the experience of one individual with a selected group of patients.
They have not been tested against a control group. No firm conclusion
is possible regarding the success of the approach in other settings.
Nevertheless the concepts presented may aid others in developing their
expertise with this very treatable group of patients.
References
