Somatization Is Something To Talk About

I was working in psychiatry at one of those university medical centers, in a big city in the middle of a sparsely populated state. This 54 year old Caucasian farm wife had been referred to me by a surgeon — a rare state of affairs, since most of the surgeons I knew at that time and place did not believe in psychiatry and would not have referred a patient unless out of desperation.  No note, no phone call to the front desk of the psychiatry clinic, no nothing.  She just walked in and explained that the surgeon had basically kicked her out and said she was crazy. I asked her why they sent her.  Her answer is so burned into my consciousness that I can give it verbatim these many years later.

“It really bothers me that I don’t have a belly button.”

Now, even if I did stipulate the possibility (which might result from an immaculate birth situation) – I had to ask for a little more information. She lifted her shirtwaist to show me and said, “They did so many operations on me I don’t have a belly button.” I tried not to look shocked, but really, this is not your typical psychiatric referral. There was nothing psychiatric in her history; she had never seen a psychiatrist before. I could not get her to admit to the subtlest symptom of anxiety or depression, let alone the “biggies” like psychosis (hearing voices or seeing things that were not part of communal reality) or bipolar illness (wild mood swings, getting hyper). No–there was none of that. She was clearly not a high-maintenance woman,dressed in “sensible shoes” (comfortable tie-ups, like my mother of blessed memory would have favored) and the simplest cotton print dress. The only thing she could talk about that meant anything to her were her series of operations. I slipped out the office and asked the chart room to fetch her file while she patiently waited.  When it arrived, I noticed that details of her last operation — quite recent by the still-pink scar on her tummy — were still awaiting transcription and signature of the surgeon’s dictation. I could not talk to her surgeon right then and there. He was (would you believe) in the Operating Room working on another patient. She was normal in every way I could determine — but one. A childhood without major family; a rural life which sounded dull and uneventful to me, undistinguished school performance, no desire to follow any career except wife and mother.  

She professed a true enjoyment of baking and home canning, but she did not seem excessively excited when I made her talk about them.  No real outside interests, although I prodded her a bit incredulously on this one.  I mean, this was no feminist.  She did not know what feminism was, knew almost nothing about current events or world news. The one way in which she seemed abnormal was her fixation on her surgeries. As far as I could figure, she had suffered a bonafide appendicitis maybe 15 years or so before.  She had two little kids already by then (she now had four).  Family came from a distance to help her with them.  It sounded as if she received a lot of attention during that time; maybe even a little more home care than one would expect after an uncomplicated appendix.  She said she had a small pelvis and a lot of pain and the two deliveries after the appendix were Cesarean. There were some abdominal pains of unknown origin resulting in gall bladder removal.  Later an exploratory to investigate mysterious symptoms. Eventually, she lost count of the times she had gone under the knife. I plowed through my diagnostic manual to verify the criteria, because I sure knew what it sounded like.

Sure enough — This lady had a somatization disorder. It was as if she were not in possession of the normal vocabulary to discuss emotions or feelings.  As gruesome as it sounds, her vocabulary became unexplained pains and lots of surgery. During out little “show-and-tell” session, I noticed not only the absence of a navel “innie,” but a scarred abdomen that looked like a railway map of the Union Pacific line.

Like your average Union Pacific map, this patient had no belly button.

I remember one line in the diagnostic manual, something about how the people who got this thing were not particularly educated, and sometimes got better if they could get more verbally articulate. I also remember that there was a recommendation that reassurance from a physician– not a psychiatrist — that someone was actually healthy would help. I had no patient the next hour and she was in no hurry.  So I dug in like I never had before.  She told me that she thought she didn’t need a psychiatrist, but maybe an artificial belly button would help. I started by explaining that after birth, when the umbilical cord was no longer functional, the belly button was a vestigial organ – meaning completely useless — so she could be perfectly happy without one.  Of course, I did this in really simple words. She said that was no help, as her surgeon had told her exactly the same thing, but she really, really missed her belly button I told her that even though she had a lot of operations, she was basically healthy, and that with a couple of checkups, that would be obvious.  I mean, she had her family and they were loving, and they had come to help her when she was ill.  And there was the canning and whatever else that made life satisfying. Maybe besides supporting her through pain and illness, the family could share happy times, too.  Maybe she was not all that sick. Another miss.  She said nobody would have the kind of abdomen crossed with scars that she did unless they had been really sick.  She had no idea what would go wrong next, but she was pretty sure something could. I tried to get releases to talk to her surgeon, to her husband, her clergyman, everyone but the kitchen sink.  I had to try to get this woman out of this pattern. All releases except the one to her surgeon were refused.  She said this was a medical problem. I asked her about friends and her life in society and there was not much of one I could discern.  I could succeed only in making her angry. I finally told her, after two hours, that I would talk to her surgeon and see her again as soon as she could come back to the city. I promised to try to help her, for she was suffering and I wanted her to be happier with her life and her body. Maybe, just maybe, there was something her surgeon knew that could help, and there was a communication problem between them.  I would work very hard with her, give her all I had, and try to make her happier and worry less. I saw the hesitation in her eyes.

She laughed and patted my hand.  She told me I was a very nice lady who certainly worked very hard, but that I should not worry about her. Her life was her life and she would carry on with it. I was pretty sure she would not come back, and indeed, I never saw her again. She was not the type to turn suicidal and certainly would never harm anyone else, so I thought of her, but didn’t worry about her.

I told my preceptor, who was amused that I had been naive enough to spend two hours with this woman. He shook his head and congratulated me on generating two hours of billing for the department.  (That is more important to administrators than actually helping a patient, I have discovered). He said that somatization disorders this pure were rarely seen. I did finally connect with the surgeon, who was a little annoyed I hadn’t fixed her.  I told him the best thing to do was to take someone not needed for more important work – like a resident — and assign him or her administer regular, reassuring, “normal” checkups.  It would take a while, but it was far and away the best documented treatment to help… As long as she believed the resident, of course.  This surgeon had enough ego I was not crazy enough to suggest he do the exams himself. The thing that bothered me most about this case– this woman was a high school dropout and inarticulate.  Virtually all of the information I could find suggested this was a disorder of inarticulate people, often women. I thought of how many times I sat in rural restaurants, hearing women — mostly older farm wives — discuss their aches and pains as if they were an art form. I wonder what these people would discuss if they were educated and articulate, or what they would do. I have not found any convincing literature on the evolution of somatization disorder. Taxonomy – classifying things and naming them — is not as fun as actually helping someone; maybe even curing them. I want to know what happens when people who have traditionally been without useful voices are able to have real voices. This is an argument for feminism. I want to know who women are, and what they say.