PTSD in Gynaecology?

Post Traumatic Stress Disorder (or PTSD) is an anxiety disorder caused by being exposed to a traumatic or frightening event. It has been described in various guises since antiquity: http://www.bbc.com/news/health-30957719, but although we have traditionally ascribed it to military veterans, it is by no means confined to those who have been in the midst of battle. Paramedics, police officers, and various other sorts of first-responders are also exposed to frightening and traumatic events. The DSM-5 (the Diagnostic and Statistical Manual of Mental Disorders) has even allowed a variant for those emergency workers even if they are only exposed to disturbing videos in the conduct of their jobs.

So I suppose it should not come as too much of a surprise that someone would take the leap and wonder whether the public, exposed as we all are to social media, would be at risk as well: http://www.bps.org.uk/news/viewing-violent-news-social-media-can-cause-trauma   There followed the usual offence at what seemed like an attempt to demean the diagnosis of PTSD in those felt more worthy of its acquisition, and in conditions far more important and deserving, but nonetheless there is a spectrum of manifestation inherent in most diagnoses.

The BBC posted a helpful primer on PTSD http://www.bbc.com/news/health-26867615 but in brief, the diagnosis requires: flashbacks to the event, avoidance behavior, sleep disturbance, and mood changes.

I have to say I was skeptical that we should even consider that anything found on social media could have such an important impact that could in any way be considered PTSD –however attenuated. It seemed almost an insult, a belittling of those who had undergone real trauma. Until, that is, I remembered Lucille.

She was a young lady visiting from another province who had been sent to me for a second opinion from the emergency department at the hospital across the street. Her problem was abdominal pain –chronic and unexplainable pain in the pelvic region, for which she had been thoroughly investigated elsewhere with ultrasounds, CT scans, an MRI and even –no doubt in desperation- a laparoscopy four or five years ago to view the area more directly. And all, said the accompanying note, were normal.

She was not what I was expecting; rather than an anxious woman sitting quietly in the waiting room with her face locked in pain, instead I found a smiling, smartly dressed young lady happily talking to the pregnant woman in the seat beside her. She smiled when I walked over and immediately extended her hand for me to shake.

“I’m so happy you could see me on such short notice,” she said as I led her down the corridor to my office. And she did indeed seem cheerful and, well, normal as she seated herself across from my desk by the window. “What a wonderful view of the ocean from here,” she almost purred, staring past the buildings and traffic at the almost-invisible water far in the distance. “Vancouver is such a wonderful city…”

I sensed her cheer was other than completely genuine, as her words wound down and slowed. Sometimes, with chronic conditions like pain, I like to wait until the patient is ready to speak -unprovoked, as it were. Unencumbered by a line of questioning known all too well to her that leads… nowhere. She was silent for a while as she turned her attention to the office itself, her eyes alighting like sparrows first on a painting on the wall, then on a wooden carving from Ethiopia I had placed on the desk so it looked out between the leaves of a plant. They stopped no place for long, revisiting their favoured twigs almost at random.

“Offices are all different, aren’t they?” I said, to begin the conversation.

She nodded thoughtfully. “I suspect they reveal a lot about the doctors…”

“And the patients who notice.” It provoked another smile.

Her face became serious –a major change. “Look, I don’t want to waste your time, doctor. I’m certainly grateful you could see me, but maybe I should wait until I get back to Ontario to get it checked out.”

“It..?” She looked down at her lap, as if the little sparrows were tired of flitting about. “The note from the ER said you were having some pain… Care to tell me a bit about it?”

She still seemed reluctant to look up. “Oh, I get these pains every now and then. No big deal, though.”

She risked a glance and I immediately seized the opportunity. “Well, suppose I just take a brief history and then if you feel you want to wait till you get back to Ontario, I can fill your doctor in as to what happened while you were here in paradise.”

She nodded her assent and for the first time, her eyes didn’t flee from my face. Was it hope? Or merely resignation that it was beginning again?

We all expect that we will be able to find the treasure where nobody has succeeded before, but the only thing I could discover in her history that might be remotely related to her pain was an episode of Chlamydia –a sexually transmitted condition- several years before. It had been treated and subsequent cultures had demonstrated cure. “When did the pain start?” I asked, almost as an afterthought, but I think she could see through my strategy.

The memory seemed uncomfortable to her, and she looked out the window again.

After an awkward moment of fidgetting silence, I said, “Sexual diseases are always difficult to talk about, I think…”

“My friend didn’t think so,” she suddenly blurted out before I could even finish my poorly worded attempt to console her. “She got an STI and had to be hospitalized when it spread through her abdomen… They even had to operate to remove the pus. She sent me a picture of her tubes they took during the operation…” She looked as if she were about to cry, but grabbed a tissue from the desk and dabbed her eyes to recover. She lapsed into a morose silence and turned her head so she could see the door.

“You know, I’d been fond of the guy who gave it to me; I’d gone out with him for a couple of years… And yes we used condoms!” She stabbed me with a sudden glare and turned her head away again. “I did everything right, but I still got it.” She sighed heavily and stared at her lap again. “I mean, how do I know I don’t still have it -but without symptoms? Or that I haven’t gotten it again from somebody?” Her hands were nervously clasping and unclasping. “They did a laparoscopy shortly after the infection and it was normal, but that was years ago…”

The time for my questions was over; I let her talk.

“I read that PID [pelvic inflammatory disease] can be silent after an infection and the damage can be going on even without symptoms…” She considered that for a second or two. “I suppose I twisted my doctor’s arm to do the laparoscopy. But anyway, she didn’t find anything. Nothing abnormal.” Another sigh. But my girlfriend kept warning me about it, so of course I read as much about it as I could online. I even looked at videos of operations for PID…” Her eyes teared up immediately. “I couldn’t stop looking at them,” she managed to whisper between sobs. “They were terrible! Frightening: great slimy fat tubes stuck to bowels and everything… And in some of the videos, when they tried to dissect them, there was blood everywhere! And pus oozing out of dark little spaces the tubes had walled off…” She considered the implications of what she’d said and closed her eyes briefly. Hid behind her face. “I’ve hardly had sex since that Email and I’m never going to trust anybody again,” she blurted out abruptly with her fists clenched. “I mean I keep thinking about those videos; I wake up in the middle of the night, and there they are, running through my mind!”

She stared at my face for a second. “You think I’m stupid for watching all those videos, don’t you?” she yelled at me. “But I couldn’t help it! I just knew that it was going on inside of me: big fat greasy sausages filled with sticky white ooze..!” And then, just as suddenly she stood up and pinned me to the wall with venomed eyes. “You’re the same as all the rest, you know. And I know you don’t believe me!”

She turned and walked to the door. “And don’t bother sending anything to my doctor in Ontario, either. I’m gonna find another one.”

She disappeared through the door leaving me wondering how I could have handled things differently. But in a moment a head poked around the door again –but only briefly. Awkwardly. “I’m sorry doctor… You’re really great! Honestly.” And then it disappeared into whatever hellish world it was forced to inhabit.

Did she have PTSD? A variation of it somewhere on the spectrum? Or was she just embarrassed that she’d disclosed so much to a stranger? I suppose I’ll never know, but I hope that somebody, somewhere, takes her seriously. She, just like anybody else with PTSD has a life to live. Deserves to live.

The Loneliness of Social Media

There comes a time when solitude is not enough. When weekends are deserts that must be crossed to get to people on the other side. Where there are eyes that welcome, ears that hear, voices that desire a response. When your own voice is not rusty with disuse and your mind not imprisoned inside a page you’ve just read twice.

That, almost word for word, is what a patient told me recently after a routine gynaecologic examination at my office. She’d had no need to visit me other than getting a pap smear that wasn’t due for another year. She’d asked her family doctor for a referral but I’m not sure what she told him –there was no letter. I suspect she simply took up too much time. Was too vague to slot into one diagnostic category or another.

Doctors are busy; we deal in diagnoses, descriptions we can place in algorithms that lead to conclusions and thence to prescriptions… We are computers, but not as fast. And without recognizeable data to input, goal-oriented analyses, interpretation and even investigations are difficult to devise. Especially in the fifteen or so minutes usually alloted for their resolution.

I don’t mean to disparage my colleagues with this quick dissection –I, too, am prey to its siren song. But sometimes, the scramble for parsable phrases, or attributable words, leads nowhere but to confusion. Sometimes the only thing necessary is listening. Patience. Time.

Strange isn’t it? The answers usually surface, bubble to the top, when you least expect them. When you haven’t even asked. When you yourself are often at risk of capsizing in the turbulent sea of emotive misdirection. No, not misdirection exactly –the patient truly wants help- but more like multidirection. Stochastic: random observations from the maelstrom in which they are living.

And the diagnosis for my patient? Well, I am certainly no psychiatrist and pretend no background in psychology, but from what I could gather, she wasn’t clinically depressed (a selective differentiation I’ve never really understood)–or any more so than anyone else in her situation at any rate. If I were listening as her friend and not her doctor, I would be fairly convinced I knew what the problem was: loneliness. I certainly wouldn’t honor it with a DSM-5 categorization –even if I knew how to use the manual. Some things are just obvious. Or become obvious if you simply listen. Hear.

Her problem troubled me and I suppose one of the reasons was that although she had tried the usual methods of meeting people at work and at clubs, she had been singularly unsuccessful. A friend had suggested an online dating site and that’s where her real problems had begun. It was not that there hadn’t been an over-abundance of interesting profiles –apparently a buzz-word in that community for acceptable suitors- but that the ones she had agreed to meet were lies. Is that the right word? People who had misrepresented themselves in the categories that had most interested her. She had become disillusioned with the whole process. Exasperated. And other websites seemed no better.

While I’m sure that some dating sites are better than others –more reliable, more responsible and trustworthy- she seemed to think they all attracted the same clientel –or at least the same type of person. She had even done a reverse look-up of some of the pictures submitted (I have no idea how you do this) and discovered the same pictures on different sites –some with different names.

I had no solution for her, obviously, but it got me thinking about the issue of loneliness. It has always been with us, of course, but the prevalence in this age of ubiquitous, omnipresent social media surprised me. I had assumed –naively- that our almost universal and continuous interconnectedness would have banished loneliness to a locked, unroutered closet somewhere off the grid. But I was wrong.

If anything, social media as a solution to loneliness is an illusion, a bedtime story meant to lull us into complacency. There is an existential reality it simply does not confront: although it allows –indeed fosters- communication, it does so once-removed. You need eyes to communicate. Faces with expressions to analyse and judge. You need to be able to touch and maybe to hug in order to communicate meaningfully. That is really what socialization implies.

You can say or declare anything online, but there is still a gap. It’s the very same space where loneliness lives. And where people –real people- don’t. I wish my patient well, and all the others who come to me with masks. It is my job to look behind them, coax them off. But even after all these years, I still may not recognize what they hope I’ll see; sometimes I can only look for clues, or wait with patience painted on my face, and trust they’ll understand. We can communicate in the old way…

I can’t help but remember what Iago said in Shakespeare’s Othello: “How poor are they that have not patience! What wound did ever heal but by degrees?” Isn’t loneliness a wound?