a chaos of hard clay. Byron, Darkness
Darkness Visible: A Life in Chaos
It takes almost a decade to train a physician: at least seven years for a family practitioner and up to ten for cardiac- and neurosurgeons. We become technically proficient in treating diseases, but are not as adept at treating the illnesses that people present with. How often do we get, or make, the time to really get to know our patients? Physicians are comfortable with disorders that are clear-cut: diabetes, skin cancer, hypertension, and on and on. Yet, there is a subset of humanity with medically unexplained symptoms (MUS). Thirty to 50% of people seen by primary care physicians have MUS.1 These are often individuals whose lives are so mired in chaos that it is hard to figure out what is going on, and hence it’s difficult treat them. Many of them see a variety of physicians and receive blood tests, scans, biopsies, drugs and surgeries; the underlying turmoil of their lives is rarely addressed.
Tammy Duncan is a 48-year-old woman with multiple somatic and psychiatric complaints. Her personal care attendant brought her to see me for formication’s on her feet, scalp and rectum. She has seen things crawling in her stool and coming out of her arms and feet. She complained of black marks on the plantar aspect of her feet (this turned out to be lint from her socks). Tammy has seen multiple providers: an internist, a physician assistant, a gastroenterologist, a rheumatologist, a cardiologist, a psychiatrist, a psychologist and a dermatologist.
What I learned about her social history is dark. She met her husband when she was 16, got pregnant but had a miscarriage. Eventually, she had two sons with him and finally they married. A daughter, age 14, was born later. Her husband died five years ago from a drug overdose. Tammy had been addicted to Dilaudid (hydromorphone) that was initially prescribed for the pain of her rheumatoid arthritis. Since her husband died she has gone downhill. Her weight has dropped from 162 to 72 pounds.
Her medications include Zoloft, Lasix, Klonopin, Adderall, atenolol, prednisone, and, significantly, Suboxone.
Tammy’s problem list includes rheumatoid arthritis, fibromyalgia, hypertension, hepatitis C and anxiety. The physical examination showed a frail, asthenic. edentulous woman with a querulous facial expression. Her hair was very short (she claims it is stays way without being cut). She has a tattoo on her back of a young bride with a skeleton groom
From a dermatologic standpoint she has delusional infestations with features of Morgellons.1,2
This woman’s life is chaotic. I learned the few facts reported during her first office visit; but how much more is there? Clearly, she just scratches the surface. We don’t know enough about the circumstances of her life to begin to help her. I haven’t forged a relationship with her yet. It’s much easier to put her on another medication, an atypical antipsychotic, for her delusions or refer her for psychiatric care. Can someone this broken the helped? We must try.
After all my years of training and practice, I am ill-equipped to help Tammy, yet I still aspire to be a healer.
- Medically unexplained symptoms. Isaac ML, Paauw DS. Med Clin North Am. 2014 May;98(3):663-72. Review.
- Delusional Infestation: State of the Art. Vulink NC. Acta Derm Venereol. 2016 Aug 23;96(217):58-63. Free Full Text
- History of Morgellons disease: from delusion to definition.
Middelveen MJ, Fesler MC, Stricker RB. Clin Cosmet Investig Dermatol. 2018 Feb 9;11:71-90.