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April 12, 2006

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I have been moderating message boards for people (one woman-centered and one not) with heart arrhythmias for almost six years and the story I hear over and over and over and over is that a young woman went to her doctor with palpitations, dizziness, chest pain, etc and was told it was stress when it was later (anywhere from months to years) discovered to be any one of a number of serious but treatable heart conditions.

Or worse, it is called mitral valve prolapse and then the patient is told that it is nothing to worry about and to go home.

I have yet to read of a man being "pooh-pooh-ed" out of the doctor's office.

Please don't conflate the E.D. and a doctor's office. Common wisdom to the contrary notwithstanding, what happens in each location could not differ more.

If this woman had presented to a doctor with whom she had already established a therapeutic alliance, I daresay her horror story might have changed somewhat.

best,

Flea

only slightly. she might have been able to cut out one visit. i know women who have gone to the doctor with MS and MS in particular seems to be a bugaboo to getting diagnosed.

also, over the course of six years, i've seen a mix in ER/ED vs doctor office visit issues and there are plenty of stupid, age-biased doctors out and about.

It's even harder to get your family doctor to listen when you are a young, female, medical student! My physician is always saying "beware the med student syndrome; you'll think you have every disease you are studying!"

I've never been to the ER (as a patient, that is) and I hope to keep it that way. Part of that involves catching things early with my doc, so I make sure he knows I'm serious when I do go see him with a problem.

Cheers,

Jessica
http://jaotte.wordpress.com

Think from the perspective of the ER doctors.

Every day, plenty of people present to the ER with symptoms of palpitations and fainting and most of them will turn out to be benign (not serious). (not so sure about paroxysmal numbness of half the body, though)

They can't possibly scan every one of those patients - consider the cost (esp MRI) and radiation (CT), etc.

It is therefore probably not just the group of patients likely to be hysterics, ie young women, who gets treated in that manner.

However, they are very good with more 'concrete' symptoms and signs, eg worst headache ever, severe abdominal pain, fitting, central crushing chest pain, high fever, etc.

Thanks for the comments everyone.

So, Eddie, not to pick on you, but if you're going to use a phrase like this:

"the group of patients likely to be hysterics, ie young women"

I would love to have your source cited for that likelihood.

I'm not, as I point out often, in the medical industry, so if this is a proven fact, I am not aware of it and would appreciate being pointed to the study on it.

Thanks!

I have to agree with Eddie. And it's not just the ER; the family doctors I've worked with have a similar situation. We've been told, by both male and female doctors, that up to fifty percent of patients who present in a primary care office have a psychiatric issue underlying any medical issues. Unfortunately, from my limited experience, it is true that women more commonly present like this. I have seen plenty of "hypochondriac" women who have a good relationship with their internist - who knows to listen to them kindly, suggest one or two comfort measures, and pursue no expensive, intrusive tests. I would guess there is roughly a 1:5 ratio of men to women whom I have personally met with non-physiological health complaints. And, if this helps, doctors are quite capable of ignoring men with impossible sypmtoms. Also, it's common wisdom among doctors that women are more likely to come to the doctor in any case. Thus, when the men do show up, they're more likely to have an advanced stage of whatever it is they've been ignoring. Maybe it balances out.

As for your friend, if she were seen in an office setting, and known to have no previous medical or psychiatric history, her story most strongly suggests a cardiac issue. (ER may not have the time to consider such a non-emergent problem.)

Haha.

I knew i would get into trouble for saying that.

Just 2 points before i take on your challenge:
1. i am somewhat apprehensive of the increasing tendency and need to have to justify every phrase or sentence with sound scientific evidence.

Person01: the sun is round.
Person02: i won't believe you unless you show me a large, multi centre, prospective, double blind, randomised controlled trial that proves that.

2. i had thought that if you weren't a medical person, you'd be less inclined to demand evidence for a statement, rather than more.

Before we move on to the evidence, let us ponder hysteria.
1. Is hysteria real?
I think the very fact that this ancient term describing a vague inorganic disorder has survived until recent times is a testament to the reality of the disease. An interesting excerpt from http://www.whonamedit.com/doctor.cfm/19.html
(Charcot is the famous French neurologist in the 1800s, Babinski is his famous student)

"Charcot, thought he had discovered a new disease he called "hystero-epilepsy," a disorder of mind and brain combining features of hysteria and epilepsy. The patients displayed a variety of symptoms, including convulsions, contortions, fainting, and transient impairment of consciousness.

Joseph Babinski, his student, however, decided that Charcot had invented rather than discovered hystero-epilepsy. The patients had come to the hospital with vague complaints of distress and demoralization. Charcot had persuaded them that they were victims of hystero-epilepsy and should join the others under his care. Charcot's interest in their problems, the encouragement of attendants, and the example of others on the same ward prompted patients to accept Charcot's view of them and eventually to display the expected symptoms. These symptoms resembled epilepsy, Babinski believed, because of a municipal decision to house epileptic and hysterical patients together (both having "episodic" conditions). The hysterical patients, already vulnerable to suggestion and persuasion, were continually subjected to life on the ward and to Charcot's neuropsychiatric examinations. They began to imitate the epileptic attacks they repeatedly witnessed.

Babinski eventually won the argument. In fact, he persuaded Charcot that doctors can induce a variety of physical and mental disorders, especially in young, inexperienced, emotionally troubled women. There was no "hystero-epilepsy." These patients were afflicted not by a disease but by an idea."

2. If it is real, why haven't we heard more about it?
Hysteria was more popular in the early days of neurology and psychiatry, ie in the 1800s. Charcot, i believe, was the first expert on it. However, in recent times, the term itself has fallen out of favor (like how idiot has given way to more politically correct words such as mentally retarded, intellectually disabled and intellectually challenged respectively over the years). Now, the correct term for hysteria would be conversion or somatisation disorder.

Lastly, are young women more affected by hysteria?
I think yes, because:
1. the word hysteria is derived from the greek word 'hystera' which means uterus and which only women have.
2. as stated above in the excerpt, "in young, inexperienced, emotionally troubled women"
3. I scoured the literature and this seemed to be a reasonable study to prove my point: Jain et al. Is hysteria still prevailing? A retrospective study of sociodemographic and clinical characteristics. Indian Journal of Medical Sciences. 54(9):395-7, 2000 Sep

Abstract:
A retrospective study was conducted in a psychiatric setup of S.P. Medical College, Bikaner (Raj.) to assess the social demographic and clinical characteristics of hysterical patients. The illness was more common in female patients. Most of the patients were young, married and illiterate. Nearly half of them had faced some stress prior to onset of their illness. Fits of unconsciousness and aphonia were the commonest presentation in female and male patients respectively. Duration of stay was 2-3 days and most of the patient responded well to different treatment modalities.

The abstract can be found at:
http://www.indianjmedsci.org/article.asp?issn=0019-5359;year=2000;volume=54;issue=9;spage=395;epage=7;aulast=Jain;type=0

From the patient's perspective:

For 18+ years (until I was about 32), I was _always_ tired, cold, living between naps, and not "up". I was told "your thyroid is fine" because the values fell in normative ranges (at least 4 different times with different docs). I was told to take a vacation, to see a counselor, and so on. I _did_ all the counseling things I could. I studied stress management, relaxation techniques, assertiveness skills, and more (when I was awake). I took vacations ... and slept through them. I even dragged myself through graduate school for 2 Masters degrees!

While an antidepressant helped some with mood (dysthymia); it _wasn't_ the entire answer. It didn't take care of feeling cold all the time, nor resolve the constant fatigue and overall stiffness. Until the psychiatrist put me on thryoxine - I could eat lunch and not fall asleep at my desk. I was able to stay awake through the day. Though I was cooler than most, I was no longer freezing. It also helped with the mood - I actually felt energetic at times!

A thyroid test provides comparison against HEALTHY ranges for people who do NOT have a thyroid problem. If you have a younger woman who is complaining of dragging herself around all day long and the TSH is near the top quarter of the reference range ... please consider a trial of low dose thyroid supplementation. Retesting in about 2 months will show if the body has adjusted its own thyroxine production - which would prove if the Rx was unnecessary. Plus, around 40% of individuals with a diagnosable major depression also have a problem with the hypothalmus-pituitary-thyroid axis. It could help a depressed patient have enough energy to get to counseling or function enough better to manage without it.

I'd like to get back those 18 years when no one thought to prescribe a low dose of thyroxine (with appropriate cautions and instructions about possible adverse effects) and see if it helped. I will always wonder how my life might have been if I'd actually been awake for it! Grump!

A coworker related the following story to me, which took place 18 years ago: When his son was 7 years old, the boy began to have headaches and behave somewhat strangely. A neurologist at a Children's hospital decided that there was nothing wrong with the boy since a CAT scan showed nothing abnormal. The parents were told that the boy was suffering from emotional problems due to a new baby in the household.

8 month later, the boy's pediatrician still believed that something had to be wrong. He sent the boy for an MRI, which showed a tumor, which turned out to be malignant.

The moral of the story - even a 7 year old boy can be thought of as hysterical, even though he lacked a uterus.

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