Abstract
This story is a reflection on the evolving relationship of a family physician with a patient suffering from a severe conversion disorder, expressed inter alia through “blindness.” The narrative follows our journey as I attempt to unravel the meaning of the symptoms as a metaphoric expression of her agony. Eventually, I conclude that clinicians at times also may have a “blind spot” that prevents us from entirely grasping patients’ complex inner struggles.
“I have sudden bouts of blindness,” Lisa proclaimed at our weekly meeting at the clinic. “Blindness?” I asked, surprised. This was a new addition to her shortness of breath, chest pains, trembling hands, faintness, weakness in the legs, and stomach aches. Over the years Lisa has undergone comprehensive examinations for all of her physical complaints, yet no organic reasons were ever found.
Lisa and I met at the clinic that serves a group of neighboring villages in the Judean hills where I have been working as a family physician for the last 20 years. As such, I am also the family physician of her entire extended family, making me familiar with much of her background and history. Thus, I knew Lisa suffered many traumatic experiences throughout her life, which she presented mostly through her physical symptoms, eventually leading to a diagnosis of conversion disorder. However, I did not entirely dismiss her symptoms and showed my concern for her through my medical and personal attention to her many ailments. I understood her need for nearly weekly meetings to discuss her physical symptoms as a reflection of an underlying need for connection and care. Listening to her empathically nearly every week was part of her treatment, although this was never explicitly formulated as psychotherapy.
“What do you mean, blindness?” I asked in my typical manner, both to gain some extra time and to obtain a richer description of the symptom, in her own words. Lisa described a lack of vision in her peripheral vision, lasting anywhere from a few minutes to a few hours, occurring several times every day.
I took her complaints seriously, for there was indeed a name for this phenomenon—bitemporal hemianopsia—as well as an anatomic explanation: lesions of the optic chiasm. The cause may be the pressure of a pituitary tumor or an aneurysm. I knew she was unaware of these specific medical facts, so I became quite worried.
An examination of her vision field produced precisely what Lisa described: she could not see anything in the temporal vision field of both eyes. The ophthalmologist and neurologist immediately joined in my concern. She was urgently referred for a brain MRI. The findings were negative.
“Negative, in medicine, means everything is fine. Your brain, your pituitary gland, and your blood vessels look completely normal,” I explained to her a few days later. Again, I was confused and unsure whether there was indeed a medical issue underlying the symptom, or if the cause was once again psychogenic. I felt it was important for me to believe Lisa, and to understand her inner experience. Perhaps if she sensed I truly believed her, Lisa would trust me enough to open up about other aspects of her life. I told her I believed her, yet perhaps she sensed an ambivalence I was not fully aware of in myself. I realized this only as she pursed her lips, briskly grabbed her referrals from my desk, and left my office, to embark on another round of visits and tests with neurologists. She had an angiography, an EEG, comprehensive eye examinations, as well as other brain imaging. Not a single finding.
“You think I’m lying!” Lisa exclaimed one day at the clinic, showing me her file with the vast assortment of test results as well as suggestions for further tests as recommended by various specialists.
“We’ve known each other for years,” I replied, “and I know you have suffered quite a few personal tragedies in your short life. Maybe we can look at this together. I think there’s a lot of emotional pain underneath some of these symptoms.”
“So you’re saying I’m making this up.” Lisa responded through her tears. She continued: “The heart palpitations, the shortness of breath, the shivering…those were maybe emotional…but now—now this is real!” she managed to emit.
I tried to comfort her, yet inside I could feel a growing frustration, which Lisa immediately sensed. I was simply exhausted at her lack of belief in my care for her. She left my office coldly and escaped into the arms of the clinic nurse.
The illness did not pass, but only increased. She reported falling down and loss of orientation. She was unable to drive to work. The blindness extended into longer periods of time and she was scared of completely losing her sight. At this point her actual visits to the clinic became less frequent, and communication between us was only through the computerized system, through which she continued to ask for referrals, sick days, and medications, as recommended by the various specialists she consulted. I agreed and signed, embarrassed by the failure of our therapeutic relationship.
Lisa grew up in my clinic. Her father died young. The paramedics found in his pocket a referral for the emergency unit he had been given three days earlier. He never went to the ER, and chain-smoked himself into a heart attack and death. In the village where he lived, it was said he died of a broken heart. Pearl, his eldest daughter and Lisa’s sister, fell in love with an Arab boy she worked with and married him against her father’s wishes. Although some cases of intermarriage between Jews and Arabs exist in Israel, this is largely a huge taboo. No one in the family was allowed to attend her wedding. When Lisa’s father died, Pearl was forcibly banned from attending his funeral.
It was at this time that twelve-year-old Lisa was brought to the clinic with her first complaints of shortness of breath, which would later be called by many names: psychosomatic, hysterical, conversion, and even “a fake.”
Now at thirty, Lisa bravely shouldered responsibility for her family, their rented home, her intermittingly unemployed husband, and two young children.
“Today we will pay Lisa a home visit.” I surprised my nurse one day. “A home visit? She is not elderly or home-bound…” she questioned. “I am not giving up on her yet.” I responded. “Maybe in a different atmosphere she will open up and we can mend our relationship.” I believed Lisa’s physical ailments were her only way of reaching out to us. If she could no longer communicate about that in person, then we would lose any chance of ever truly reaching her inner world, where I sensed much healing was needed.
Surprise home visits are a natural and acceptable part of our clinic’s routine. Our clinic serves patients from a number of nearby villages, and the atmosphere is often informal. Home visits are often initiated by the physician in cases where the patient has not appeared for a long time. Additionally, the nurses who work at the clinic live in these very same villages; thus, the casual relationships between the nurses and many of the clients enable such surprise home visits to feel quite natural. This is particularly useful as I come from a different ethnic and socioeconomic background from most of the residents of the villages I serve; thus, my nurse also often serves as a cultural bridge between my clients and myself.
The modest house in the village was clean and tidy. Lisa greeted us warmly, placing scrumptious foods before us. I was not surprised at her warmth, as this was part of her culture, to gracefully accept visitors. What did surprise me was her willingness to be truly open with us. I managed to mumble as my excuse for our visit, “We came to hear your story, without the pressure of other patients in the hallway—in your home, under your conditions.” Although I hoped for such an open conversation, I was surprised at her candor. She told us of her poor childhood, with a constantly anxious father and a sickly mother. She talked about her elder sister’s marriage. Lisa and Pearl shared a room, as well as their deepest secrets throughout her childhood. She told about the ban on any contact with her sister as enforced by her father. She told of a life filled with anger and shame.
As if this weren’t enough, Lisa recounted what I already knew: she had married her childhood boyfriend, a caring man who engulfed her with warmth and softness. Together they built their new family and gave birth to a son. Her husband died in a tragic accident before their son’s first birthday, a shock that destroyed whatever vitality was left in Lisa. At that time, she displayed physical symptoms and was treated by the clinic staff with much compassion. “The body is screaming what words cannot express,” I explained to Lisa at the time.
As her family physician, I suggested she exercise in the fresh air, as a way of maintaining good health and a positive mood, comforting both heart and soul. With lips clamped shut, she did her daily rounds around the village. She was a young and beautiful woman. Her future husband saw her during one of her regular walks. He slowed his car to follow her, and weeks later confessed his wish to marry her. Lisa agreed.
“Why now, when we are building our new family, working, taking loans, filling the house with food and love for our children, …why is this happening now?” she exclaimed, referring to her bouts of blindness.
“Why now?” I silently ask myself and continued out loud: “You only look ahead, correct?” and I continue to unweave the metaphor: “You’re not allowed to look back, the past is too painful. You cannot look to the sides, life is too demanding with emotional and financial dangers lurking in every corner.” Lisa did not relate to this metaphorical interpretation of her blindness, insisting, “I simply have these physical symptoms.” I let go of my complex interpretations, relaxing into the atmosphere of her home and our renewed connection.
Lisa returned to the clinic, yet she also turned to a mind-body clinic, thus beginning to acknowledge the connection between her body and her inner self. She began practicing self-relaxation techniques. Something began to shift within her and Lisa began to accept that the source of her physical symptoms was not merely biological. She now agreed to take antidepressants, which also helped improve her condition.
In reflecting on my relationship with Lisa over the years, I still feel there is a missing link in my understanding of her. Yet I have come to accept that perhaps there will always be a missing link, a “blind spot,” something about her I will never know or fully comprehend. And despite that blindness, which may be my own, my role as her physician is to care for her completely, to enable her to trust me, by trusting her, and trusting in the process of our relationship. I didn’t give up on Lisa; I never forgot her. Although at times I would despair of ever reaching the psychological core of her issues, I showed her I was not going to give up trying. I think she eventually responded to that.
The window Lisa opened to her complex inner world was through her physical ailments. Sometimes the only way into a patient’s world is through the window they offer. It is important to follow that lead. When she felt that window close, she retreated into her home, communicating with me only through the computer. When I dared knock at her door, she opened it. It was almost as if she was waiting for me. Immediately afterwards, things began changing in her treatment of her symptoms. As a result, her bouts of blindness significantly decreased.
Although her blindness still occasionally visits, she is well aware of its illusory nature. When it arrives, she takes it to battle, with the support of those she is willing to trust, together with medication, and with the fortitude of her faith and spirit.
Footnotes
Conflicts of interest: authors report none.
- Received for publication November 22, 2017.
- Revision received February 24, 2018.
- Accepted for publication March 29, 2018.
- © 2018 Annals of Family Medicine, Inc.