It was a magical day, that day last winter at the beach. Just after a storm, the leaden gray skies were giving way to bright blue, the sun was beginning to warm the sand, and the waves were frosted with foam. On a whim, I had decided to take a few hours off and go down to the ocean with my 4-year-old son, Joey. The middle child, his soft, contemplative personality is often overpowered by his extroverted older brother and his precocious younger sister, so I was happy to be able to spend some time alone with him. While his brother would have been running into the water and throwing rocks, and his sister would have been busily discussing what sort of dress she wanted, Joey was content to sit quietly with me, watch the birds, and eat his Cheerios.
When a particularly brazen seagull stole an errant morsel, Joey, in his typical way, tilted his head and watched, with a puzzled half-smile on his face. Hesitantly, he threw a Cheerio and giggled as another bird swooped down. A few more Cheerios, a few more birds. A little more confident now, Joey stood up. No longer the introvert, surrounded by seagulls, he was the king amongst his adoring audience. As he threw out the Cheerios he would laugh as the birds stumbled all over each other to get them.
There we were, the Cheerio King and I, dancing and laughing on the desolate beach, amidst the seagulls and the cereal. I can't recall ever feeling so free.
When the bag was finished, he looked down and said sadly, "Bye everyone." And then, perhaps struck by the shimmering water, the scent of the ocean, or just the silliness of the situation, he put up his hands and started to dance, slowly. Silhouetted against the deep blue ocean and the marshmallow clouds, my very reserved son danced faster and faster, his head thrown back with laughter. Entranced by the radiant smile that had taken over his normally serious face, I, too, got up and started to sway. And there we were, the Cheerio King and I, dancing and laughing on the desolate beach to the sound of the crashing surf, amidst the seagulls and the cereal. I can't recall ever feeling so free.
I've been thinking a lot about the meaning of freedom lately.
In the ten years that I have been practicing medicine, I have noticed a curious trend. A large number of patients come in with specific complaints that I can not attribute to any medical illness -- chest pain, abdominal pain, sleep disturbance, low back pain -- all real physical symptoms that exhaustive work-ups do not find the source of. At first, I assumed it was my inexperience, but as test after test came back negative, I began to wonder if something else was happening. As I started listening to my patients less about the type of their pain, and more about the quality of their lives, a troubling fact began to emerge: stress and anxiety are rampant, and they manifest as almost any medical symptom.
I did not recognize the magnitude of the problem until I opened a practice in the middle of Beverly Hills.
A few months ago, a middle aged woman came to my office distraught that her hair was falling out in clumps. A high-level manager for the government, in her conservative suit she appeared competent and no-nonsense, not prone to histrionics, and indeed when I examined her head, there were patches of scalp showing. She denied symptoms of anemia, thyroid or dermatologic disease -- all common causes of hair loss, and a thorough workup, including scalp biopsy, revealed nothing.
When I asked her about stress she appeared indignant, as if I was implying this was all in her head, but she did state that her new boss was trying to sabotage her. Not at all convinced when I said anxiety could be the culprit and discussed stress reduction techniques, she left my office annoyed, no doubt to find a better diagnostician. It was only when she called me while relaxing on her vacation in Maui a few weeks later, and the hair loss had stopped, that she was convinced.
More recently, a young woman came to see me for the first time. Blond, thin, and fashionably dressed, she epitomized the Southern California stereotype. With an actor's magnetism, she had engaged the old people in the waiting room and was glowingly chatting. When her name was called, she stood up dramatically, flashed them a sparkling smile, and was led into my office. She had barely shut the door and turned around and the facade was gone.
Her eyes filled with tears, she mumbled, "I'm so sorry," and slumped into the chair. "I can't handle it, I can't keep it together. I'm a failure," she sniffled.
After a few deep breaths, she relayed her very familiar story. She had come to Los Angeles from the Midwest to "make it" in the film industry. Two years of auditions had yielded only rejection.
"…and now I'm having heart problems -- sometimes it beats so fast I can't breathe. I get shaky and my hands get numb." She looked up, her bright face now ashen. "Please help me, I'm so scared. I think I'm going to die."
Because occasionally young people do have arrhythmias that cause similar episodes and can lead to sudden death, I attached her to a 24° heart monitor. Not surprisingly, her palpitations corresponded not to any underlying cardiac condition, but rather to periods of emotional stress. She was having classic panic attacks.
A couple of weeks ago a banker in his early 40's came to see me. Perfectly coiffed, dressed in an expensive suit, he exuded power and prestige. He was concerned, he said, because he was having episodes of chest pain radiating down his left arm associated with shortness of breath and sweating. During the time he was telling me this, his cell phone rang twice, his beeper went off and his Blackberry buzzed. He had reason to be concerned; even I was so convinced he was having angina that I called a cardiologist friend and arranged for him to go directly to the hospital for tests. I was shocked that all the tests were negative -- this was not a heart problem.
What astounds me most is not that anxiety can masquerade as such a myriad of symptoms, but how common and insidious it is.
He came for follow-up a few days later and I told him this could all be due to stress. "Yeah," he began, "I was trying to hold it all together… so many clients, the mortgage, the kids…" At that point his cell phone rang and with clenched jaw, he answered. The frazzled look in his eyes told me what he was too busy to.
After hearing story after story like these, what astounds me most is not that anxiety can masquerade as such a myriad of symptoms, but how common and insidious it is. Daily, patients come in with similar weary tales.
As an internist, my main objective is to rule out physical causes of their symptoms, beyond that, all I can do is just listen. Frequently I refer to therapists, occasionally, when symptoms warrant, I prescribe anti-anxiety medicine.
What I have learned by listening to their stories is how complex the nature of freedom is. In a sun-drenched city, where there are over 9000 different drink combinations available at Starbucks, day after day, I see seemingly successful, productive people so imprisoned by stress and anxiety that their bodies are beginning to rebel. They do not have to wear veils, can choose their own president, and indeed customize a cup of coffee, but they are so miserable they can barely function.
So many choices, but is this freedom?
And if freedom is not about choices, what is it about?
These are a few questions I have been pondering lately.
I think back to that glorious winter's day at the beach with my little Cheerio King. Maybe it is less about answering every phone call and more about turning the phone off, and taking the time, every once in a while, to dance barefoot in the soft sand. I am beginning to think maybe it is not so complicated after all. Maybe freedom is simple, as simple as a bag of Cheerios and the warm sunlight.