Missing the Obvious // Rosanna Shoup


As a behaviorist in a rural health clinic I see a lot of people struggling with a vast kaleidoscope of pathology across a wide spectrum of SES, primarily the upper and lower ends. As one seasoned physician stated, “One visit, I'll be working with a patient on how to navigate the food pantries in a way that will support his diabetes and the very next patient I might meet someone who wants me to work quickly—so he can go fly his private plane that afternoon.” Overall, our rural population struggles mostly with intergenerational trauma, addictions, and financial struggles related to high cost of living and lack of employment. Those who are flying their private airplanes, generally don't need to see their PCP. This aside, one of my favorite aspects of my position is getting to work with the medical residents, many of whom have had less than one course of mental health content and have had little experience meeting the mental health struggles that accompanies lifestyles within underserved populations.

One scenario ended up being a classic missing of the obvious. A future doctor, resident John Doe ,  arrived to ask me to see his most recent patient. “She's presenting with classic anxiety symptoms. She struggles to sleep, has a lot of tension in her body and back, and she reports having panic like symptoms such as shortness of breath. She's also tearful. I'm going to prescribe her a low dose of lorazepam.” At the sound of benzodiazapene my radar began to buzz. “Would you be willing to hold off until I check in with her about current stressors? What's going on in her life? Why is she crying.” The resident shook his head, “We didn't get around to it.” I nodded, hiding my ever growing suspicion.

When I walked into the room, I saw a tearful white woman about age 30. She was slightly overweight and very pretty. “Hello, I just spoke with the doctor and I understand that you have a lot going on with you right now.” The woman burst into tears and told me how her ex boyfriend was continuing to stalk her and her child. Several months ago, her ex had even picked up her son from day care for several hours without her consent. This led to the restraining order. She reported deep fear that it would not be respected...that he would take her son and disappear before he could be found and stopped, or before he hurt him in some way. I validated her experience, referred her to mental health, and provided her with crisis lines. Additionally, we made a plan and discussed ways to coordinate with friends and family to increase safety for the child.

According to Bancroft (2002), while it is argued that while partners regardless of gender or sexual identification may hurt each other abusively, it is only abusive men who pose a mortal threat to their partners after a break up. The risk of a severe life-threatening beating or homicide post break-up increases to 80%. Unfortunately, due to the increased hypervigilence of the victim, reports of stalking or strange occurrences are often dismissed by doctors and mental health providers as delusions or reminders of the trauma. It is rare that someone would not only take seriously this claim, but to ask for more details and to provide adequate support.

When I returned to the doctor-to-be John Doe, he listened and was generally surprised that so much could be happening beyond the physical manifestations of the symptoms of anxiety. He admitted to feeling intimidated by the tears and leaving before asking more questions. Fear of emotional expression and general misgivings about the mind body connection may continue to hamper the medical treatment of women experiencing partner violence and abuse. In a country where 1 in 4 are sexually assaulted, 1 in 5 molested as children, and 1 in 5 women experience interpersonal partner violence, we must ask questions and not take anxious and depression symptoms as an indication for medication, but they may be signs for action or support. It could be that anxiety or depression is a legitimate reaction to the situation.

As an early grad student working in an emergency department, I once had a physician who described their side of the equation through allegory by showing me an X-Ray of a leg, pre and post setting of the bone. “See?” he stated, “I saw the problem, I set the bone, got them casted, and sent them home. Mental health is ambiguous. I can't fix it like this.” Personally, I feel that physicians don't give themselves enough credit. They have compassion and care to do an effective job. They may just miss what appears obvious, if you know the language.

Here are some great resources:

A great resource to understanding cycles of IPV and patterns of abuse and why men, regardless of sexual orientation, are a particular risk:
Bancroft, L. (2002). Why does he do that?: Inside the minds of angry and controlling men. New York: Putnam's Sons.

This book has some great basic questions for PCP's to ask when physical symptoms appear without organic cause:

Clarke, D. D. (2007). They can't find anything wrong!: 7 keys to understanding, treating, and healing stress illness. Boulder, CO: Sentient Publications.

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