The Right Question Can Change a Life

The DSM is aimed at promoting "reliable research, accurate diagnosis [based on symptoms], thus appropriate treatment and patient care." But sometimes patients present with symptoms that are not covered in the manual. This was the case for a patient who came to me after many years of unsuccessful treatment by numerous doctors.

Martha, 40, presented at our first encounter as an alert, well-composed woman of African descent. She had been seen very frequently at the medical clinic, because of her headache, and had been referred to a neurologist, who ruled out brain pathology with a CT scan and agreed with the diagnosis of migraine. None of the prescribed medication had given the hoped-for relief. She appeared frustrated and fed up.

During my medical inquiry, I sensed an impatience and wariness in the patient. While interacting with her, I left the biomedical arena and met Martha as a human being. Who was she? What made her persevere? Within 30 minutes, I learned about her and her husband’s journey with two children from one African country to another, finally arriving in the United States.

She felt comfortable living here but worried about whether her children, aged 10 and 14 at the time, would be able to hold on to their cultural and ethnic roots – their identity. Would they be able to assimilate into modern American society? How would the lifestyle of American youth affect the children and also their parents, particularly Martha’s husband, who seemed to be becoming more conservative and rigid in regard to seemingly lax American mores and values?

In addition, Martha was concerned about resources in the community. Who would advise and guide her children in school, and inform them about college choices in a few years within the context of diversity? She also had concerns about where she and her family would be able to find new spiritual roots, especially considering that she no longer adhered to her Muslim religion.

She left my office with the names of two high school guidance counselors, and I think she parted with a sense of relief and feeling understood.

In a follow-up visit 4 weeks later, Martha reported that she had continued to have almost daily headaches, except on Saturdays and Sundays – when she experienced less stress. This observation was an acknowledgment that stress played a major role in her headache frequency.

Also, she reported that her sinus congestion seemed to contribute to her headaches. So-called sinus headache has in the past been interpreted as part of chronic migraine.

The physical examination confirmed nasal obstruction and inflammation. She also showed tenderness and tightness of the neck and shoulder muscles. The latter pointed to the diagnosis of tension type headache and questionable migraine.

When asked what she would do when stress took the upper hand, she answered with a smile: "I withdraw to my bedroom and dance." She then quickly accepted my suggestion to enroll in a stress reduction program with mindfulness meditation and yoga, a course that happened to start again the next day. For her nasal obstruction, she was prescribed an antihistamine.

The results were stunning: Over the next few weeks, while participating in the mindfulness meditation class, she became almost headache free.

A follow-up phone conversation 1 year later found her in good spirits with no further complaints other than occasional discomfort because of headaches or nasal congestion. She reported happily that her eldest daughter had switched schools – she enjoyed her charter school with its emphasis on art and creative writing. Martha decided that she did not need any further medical attention, because she had become aware of the interrelationship of headache and psychosocial stress, and had learned how to control both.

Martha’s experience supported Dr. Viktor E. Frankl’s insight that, "One has long come to realize that what matters in therapy is not the technique but rather the human relations between the doctor and patient or the personal and existential encounter" (The Will to Meaning, New York: Plume, 1988). I learned from Martha that many immigrant women who had found their promising destination are carried, often unconsciously, by a remarkable inner strength. This light or human spirit, however, is often overshadowed by existential concerns, such as religious uprootedness and worries about the upbringing of children in the modern and bias-filled world.

These subconscious anxieties, even when linked to somatic symptoms, escape medical attention, but they probably have the same or similar negative stimulating effects on the brain, resulting in headache, back and neck pain, intestinal dysfunctions, and palpitation.