How Mental is My Chest Pain?

Recently I evaluated a 50 year-old Somalian immigrant in the ED for chest pain and shortness of breath. She had a soft, but emaciated expression that was a uneasy mixture of worry and fatigue. The woman was fairly well known to the ED - she had been in multiple times with this complaint. Every time she was given an EKG, a chest xray, and her blood was tested for cardiac enzymes that show if a heart attack had occurred. These had always been negative. She had a cardiac stress test done as an outpatient some months back that also showed no cardiac disease. Yet, still it is hard to ignore chest pain that seems to cripple a patient.

Three of her children were present when I saw her, two grown ups and an adolescent. Her eldest son, around 30 years-old was professionally dressed in a collared shirt and spoke English very well. It was clear he was educated and was her main health care decision maker, as she spoke no English. Everyone asked me over and over, almost out of desperation, what had been causing her pain. It was clear from this questioning that in their many unfortunate encounters with the American health care system, no doctor had provided a very good - or very understandable - explanation. The son told me that his mother was upset at him because he was not able to find an explanation - or find a doctor who could give an explanation. He was at his wit's end, exhausted and frustrated.

It was clear to me that there was more to the story than heart or lung disease. On my psychiatry rotation last month I spent a day each week at a volunteer psychiatric clinic for immigrants - especially those from war-torn areas such as Africa, Vietnam, the Balkans - and learned a great deal there about how psychosocial context for people in this unique situation can exacerbate medical illnesses.

It turned that this woman's chest pain episodes started six years ago when she came to the US. Her son said that she had always been somewhat of an anxious person, but that it never led to inexorable chest pain that required emergency care in Somalia. She was also living in a broken family that caused her considerable grief: her youngest son, only 10 years-old, was still in Somalia with her husband.

A lot of symptoms that doctors cannot explain get chalked up to anxiety, depression, and stress. And many patients resent this. They feel their doctors are telling them that their symptoms are all somaticized, "between their ears," made-up fake symptoms that are not worth testing, treating, or even empathy. And many doctors dislike patients with somaticized symptoms because they have a strong suspicion that tests will not reveal a diagnosis. And so they are reluctant to treat pain that they feel has no "organic," that is anatomical or physiological, basis. To an extent this is understandable: treating chronic back pain, for instance, that is largely aggravated by anxiety and poor living habits with a narcotic runs a significant risk of dependence. Long term use of narcotics will address chronic pain (and anxiety) very well but at the expense of reducing that person's overall functionality - their ability to work, parent, etc. So in the end the doctor has addressed one problem by creating a larger one. This happens all the time because chronic pain is so damn elusive.

OK, back to my Somalian woman in the ED. She has chronic pain. She has no identifiable (at least by our diagnostic tools) biological cause for that pain. She is that difficult patient many MDs loathe to treat because the direction and outcome of a treatment are not clear. This is because the cause of her pain is anxiety and depression from being uprooted from her traditional community and living in a fragmented family. On top of that, she has very limited resources to turn to here in Portland, Maine. There are no traditional Somalian healers. There are no Somali (and possibly no Arabic) speaking MDs. There is no free psychiatric clinic for refugees. There is no pill or surgery or test or procedure that will fix any of this. The English-speaking American MD has very little to offer this woman because her needs are not medical in nature. And yet, her suffering manifests itself as a medical condition.

I spoke at length with the family in the ED (a privilege I have as a medical student unbound by the obligations of high patient turn-over) and explained to them what I thought was the cause of her recurring chest pain. In a nutshell I told them it was in fact "between her ears," which I believe is true, but in such a way as to not dismiss the fact that she really did have chest pain, that her symptoms were not just illusory manifestations of her broken psychosocial context. I urged the family to understand the relationship of this pain to her social circumstances, that it was not unlike having a headache caused by poor sleep due to stress. I also apologized to the family for the fact that there was nothing I could offer them except a pill - a benzodiazapine which is essentially a martini in pill form, a very effective medication for anxiety. I recommended that she follow up with a family doctor and consider getting a prescription so she could have this medicine around when the pain gets really bad. Most likely it would keep from coming back to the ED, getting all those senseless tests done over again by a doctor who probably will not have the time to talk to her like I had.

In the end it seemed the family was satisfied with this explanation, although the son was reluctant to have his mom start popping pills. He preferred she do yoga or meditate, both of which I readily encouraged, although, I explained, these methods are better thought of as prophylactics and would unlikely help in a severe, acute situation.

As I enter my last year of medical school I am more and more convinced that nearly every medical condition has an underlying psychiatric one. This story is an obvious example, but in many cases the relationship is subtle and indirect. It is convenient and simple to think of so-called "adult-onset" diabetes (type 2, associated with obesity) as just a medical problem, which is, the condition in which the body's tissues lose their ability to respond to insulin, resulting in an elevation of blood sugar. Yet, nearly every patient with type 2 diabetes is overweight, eats poorly, and does not exercise. Obesity is itself is an interesting phenomenon in this country - indeed all post-industrial societies - and my gut instinct is that there are a handful of anomalous psychiatric states underlying these lifestyles that are so self-destructive, such as depression and addiction.