Sunday, December 26, 2021
Alexander Papp MD and Julie Myers PsyD
Winston came to see us when he was 58, with the diagnosis of health anxiety, which in the old days would have been called hypochondriasis. He became terrified when, after he complained to his primary care physician about some clumsiness in his hands, he was referred to a neurologist for evaluation for Lou Gehrig’s disease, otherwise known as amyotrophic lateral sclerosis, ALS. The information was given to him in a clumsy and unsupportive way which caused in him an overwhelming shock reaction.
Winston has always been an anxious person. All through his life he has been extremely afraid of being “discovered”, e.g. for not being smart enough, for being an impostor, which would lead to loss of his job, resulting in huge financial losses, which would be catastrophic to his family. He could be “discovered” in various ways, during simple conversations with others, while giving talks, doing work-related projects. He has always had trouble sleeping due to awakening in the middle of the night with anxious ruminations.
It was therefore not surprising that his anxiety got even worse after the idea was put in his head that he may have a severe neurological disease. He came to our clinic reporting loss of appetite (he had lost about 10 pounds and had to force himself to eat), difficulty concentrating, abdominal tightness, headaches. He had a constant sense of dread, he lost interest in doing pleasurable things but he did not feel depressed, hopeless or suicidal. He was able to go to see the neurologist but was too anxious to be able to look at the testing results (electromyography)
He engaged both ins psychotherapy and medical treatment, focusing on treating his anxiety.
In psychotherapy, he received biofeedback treatment and was taught behavioral methods to control his anxiety. The psychiatrist prescribed Lexapro (escitalopram) 20 mg for the anxiety and Trazodone 200 mg for sleep at nights. As a result of this combined treatment, his preoccupation with having a deadly illness has diminished, he sleep has improved, even his performance anxiety, fueled by his fear of being “discovered”, got better with using relaxation techniques and taking low dose Propranolol before meetings. The EMG results turned out to be negative.
With his anxiety under control for the first time in his life, Winston started to thrive. His relationship with his wife improved. He started to enjoy driving, something he always dreaded in the past. He even decided to leave his long term employment and start a new business with a friend of his.
Unfortunately life decided to play a cruel joke on Winston. On his next visit to the neurologist, the repeat EMG did find signs indicative of ALS. We learned about this by receiving the following text message:
Hi, Dr Papp. I went and saw the ALS specialist and the diagnosis is that I have the disease. It did not surprise me as the symptoms we’re becoming more evident. I am coping with it knowing that there is a small chance that I could live quite a few years with this illness. … I would like to remain on my meds. I would also like to cancel my appointment this coming Saturday as I have already accepted the fact that I have this disease. If I feel I need to see you, I’ll certainly call and arrange an appointment. Right now I just want to spend time with my family and concentrate on my health. I hope you understand. Thank you.
Winston stopped coming for visits after that but he continued sending us requests for medication refills every 3 – 4 months. In his message he always assured us about how much he appreciated the help he received from us, has maintained a positive attitude (“With all the support I have, though, I couldn’t be doing any better” – was typical for the kind of things he wrote) and he always asked me to give his best to Dr Myers.
It was about 14 months after his message in which he revealed his diagnosis when we last heard from Winston. He asked for another refill of his Lexapro, asked us if he had a good Christmas and told us that he had a “really good one”. “Please say hi to Dr Myers” were the last words we ever saw from him.
We did not receive news from the family but we understood at some point that Winston must have left this world. We truly hope his life was a “really good one”.
