He Found his Own Path Back to Good Health
By Marc Siegel
L. A. Times, June 28, 2004
Mr. "Enrand" came to me with depression, weight gain, high cholesterol and elevated blood pressure. Each of these abnormalities was mild, but they were likely to get worse if left untreated.
Enrand, a police detective, had endured the stress of many undercover investigations. He had just turned 40 and planned to retire from the police force in five years with a good pension. In the meantime, he was finding his job more and more difficult.
Formerly a clap-you-on-the-shoulder type, on this visit he was timid, speaking too softly to be easily understood. His hair was uncombed.
I can't sleep, he offered. Things aren't good with my wife, he added.
He described a home situation that had deteriorated into screaming fights in front of the children. She yelled at him for coming home late. He yelled at her for yelling. She accused him of being with other women. I suspected she was probably right.
I suggested that he see a therapist for the anxiety. He refused.
I was tempted to treat his anxiety with Valium and perhaps Prozac. For his rising blood pressure I had in mind a blood vessel dilator named lisinopril, and for his high cholesterol, I offered the ever-popular Lipitor. Once his blood pressure was under control, I could add the well-proven phentermine (a kind of speed) for his obesity, and if his blood pressure rose as a result, I would increase the blood pressure medicine to compensate.
He showed little interest in these suggestions. Soon he stopped coming to his appointments.
I finally managed to persuade him to see me one more time. Knowing this might be his final visit, I decided to rethink my approach. Trying to force him onto medications only underlined his deterioration and made him identify himself as sick. I was seen as the messenger of doom, rather than as a healer.
During our next meeting, Enrand admitted that he had an overriding fear of losing everything — his health, his job, his family. Most of all, with paralyzing middle-of-the-night bouts of sleepless fright, he was afraid he was losing his mind.
I realized that the paralyzing fear of a midlife crisis was his illness, not the high blood pressure, obesity or cholesterol that developed as a result. I had no choice but to allow him to remain in control as, bit by bit, he reinstituted his disciplines.
He continued working. He wouldn't go for psychotherapy or couples therapy, but I think he was reassured by the simple fact that his wife stayed with him.
He asked me for Valium to take in the middle of the night, as his one medicine to break the cycle of worry. He said he was depressed but didn't want an anti-depressant. I think he took pride in fighting depression without pills, and used this pride to help rebuild his self-esteem.
In the mornings, he willed himself to jog, three miles a day before work. He ate two to three meals daily but didn't binge. He allowed himself two cigars every week, calling them his lone remaining vice.
He missed many doctor's visits, but continued his routine. When he did come, I examined him and recorded his improving blood pressure. I suspected I was recording the physiological effects of a diminishing fear. Mostly I just sat and talked with him in my consultation room.
There was a correlation between his returning well-being and his personal grooming. On a visit when I noticed his hair was combed carefully in the old fashion, he told me that things were better between him and his wife: He was no longer sleeping on the couch; he was no longer staying out late.
His trust in everyone was gradually returning. He began to enjoy his cronies at work again, the brief interludes of clowning and kidding. He talked with enthusiasm about tracking down evidence needed to convict a child molester.
Eight months after relinquishing my control, I took Enrand's blood pressure and discovered it was back to normal without medication. The scale indicated that he had lost 30 pounds during that time. His cholesterol was back below 200. Now he was sleeping through the night without Valium.
Looking at him sitting relaxed on the couch, I knew that I would miss our talks — but I was glad to see the return of his focused expression.
Things had been happening to him, he said. There was nothing he could do. He latched onto the worry and analyzed it, doubting himself more. He said he could feel it, as if it were real. It gripped him, and it grew.
Enrand said that sticking to routines, boring rituals, replaced the worry, little by little. Then he started to enjoy the routines.
One more thing, he said. He loved his sons more than anything, and he grew stronger by refusing to let go of them.
Now that Enrand had passed through his midlife crisis and the crippling anxiety accompanying it, I realized that he'd been doing the doctoring. He'd learned to treat — not illness — but the fear that ran through the heart of it.
In the end, his plan was better than mine. He lost weight, his blood pressure and cholesterol went down, his spirits and his marriage improved. I suspected that his stress hormones (adrenaline, catecholamines, and cortisol), which were at least partly responsible for his high blood pressure and anxiety, were diminishing as he regained his courage.
Although I was merely a witness to this change, I learned a big lesson from it. Committing him to three or four new pills might have led me to the erroneous conclusion that the medicines were responsible for the improvements, rather than the crisis passing and his lifestyle improving. And once started, how would I have known when to stop them?
Marc Siegel is an associate professor of medicine at New York University School of Medicine. He can be reached at firstname.lastname@example.org.