Private Narratives

Chuck's palms are rough and thick. “This started when I cut one palm at my job,” he said. “I work at a nuclear plant.”

I tell Chuck he has psoriasis, adding that the cut may have triggered its onset but hasn't caused its persistence, much less its appearance on the other palm. “Also,” I say, “radioactivity has nothing to do with it.”

“You mean I won't glow in the dark?” Chuck laughs nervously.

A few years ago, I pointed out some ways symptoms can have private meanings that make them more disturbing or threatening than one would expect. There is a short list of illness narratives that apply to most everyone, including I caught this; I'm allergic to that; trauma damaged me and made me weak; I have cancer inside; and I've grown old.

But sometimes there are special circumstances, unique to a particular person, that make these general concerns even more pointed than usual. Chuck's basic worry is that the cut on his palm brought on his problem. Had it been a splinter, he wouldn't care much—just some roughness that makes it awkward to shake hands sometimes. But what if the splinter is radioactive? That means every time his scaliness comes back, worsens, or fails to go away when treated—he'll glow in the dark. Creams will help Chuck. Undoing his narrative will help even more.

Or consider Becky. Her lips are red and scaly and are resistant to topical therapy. This is common enough and worthy of concern. Her lips look and feel funny, and she keeps licking them, which makes them worse. People can see the problem, which is embarrassing, especially because lip problems have sexual overtones. But Becky's worries are special to her.

“I work in a brewery,” she says. “If this is some kind of yeast infection, maybe it has something to do with beer and I'll have to give up my job.”

I have to confess that I don't routinely ask, “Do you work in a brewery and fear for your job?” Maybe I should. But when Becky brings the question up, she helps me understand what—for her, at least—is the central issue. She could live with some scaling and redness, she might even be able to ignore the lips long enough to stop licking them once she knows that every return of symptoms doesn't mean unemployment and retraining.

Personal angles like these come up all the time. Given a minute or two, patients bring them up all by themselves. Like Phil, who has a keloid on his chest. He's a middle-aged guy who doesn't seem likely to take his shirt off much. What bothers him about it? Appearance? Fear of cancer?

“I'm a courier for a clinical lab,” he explains, “so I'm in and out of the car all the time. And every time I fasten my seat belt it rubs this and it hurts.”

So that's it—fear of trauma (frequent rubbing could cause cancer, and so forth), but of a very specific, and unavoidable, sort. Easy to address, once you know what the worry is.

But the prize in my recent experience goes to Harold, who presents with a fairly large epidermoid cyst on his back. A common enough complaint—why is it there, is it a tumor, and so on. But Harold too has something particular in mind.

“The bump hurts when I take part in medieval recreations,” he says.

“You mean like the Society for Creative Anachronism?” I exclaim.

“Exactly,” says Harold.

That group, in case you're unfamiliar with it, is devoted to re-creating the Middle Ages in authentic detail. These folks put a lot of effort into getting everything just right. This means that his cyst bothers Harold because it rubs against his armor.

So he has two choices: to remove the cyst or to wear flexible armor, which wouldn't be authentic. So he really has only one choice.

I am not suggesting that we all add questions like, “Are you afraid you're radioactive?” or “Do you joust?” to our standard repertoire. But listening to patients' sometimes idiosyncratic personal spin on their symptoms and fears can be illuminating and helpful. Not to mention bemusing.

Chuck's palms are rough and thick. “This started when I cut one palm at my job,” he said. “I work at a nuclear plant.”

I tell Chuck he has psoriasis, adding that the cut may have triggered its onset but hasn't caused its persistence, much less its appearance on the other palm. “Also,” I say, “radioactivity has nothing to do with it.”

“You mean I won't glow in the dark?” Chuck laughs nervously.

A few years ago, I pointed out some ways symptoms can have private meanings that make them more disturbing or threatening than one would expect. There is a short list of illness narratives that apply to most everyone, including I caught this; I'm allergic to that; trauma damaged me and made me weak; I have cancer inside; and I've grown old.

But sometimes there are special circumstances, unique to a particular person, that make these general concerns even more pointed than usual. Chuck's basic worry is that the cut on his palm brought on his problem. Had it been a splinter, he wouldn't care much—just some roughness that makes it awkward to shake hands sometimes. But what if the splinter is radioactive? That means every time his scaliness comes back, worsens, or fails to go away when treated—he'll glow in the dark. Creams will help Chuck. Undoing his narrative will help even more.

Or consider Becky. Her lips are red and scaly and are resistant to topical therapy. This is common enough and worthy of concern. Her lips look and feel funny, and she keeps licking them, which makes them worse. People can see the problem, which is embarrassing, especially because lip problems have sexual overtones. But Becky's worries are special to her.

“I work in a brewery,” she says. “If this is some kind of yeast infection, maybe it has something to do with beer and I'll have to give up my job.”

I have to confess that I don't routinely ask, “Do you work in a brewery and fear for your job?” Maybe I should. But when Becky brings the question up, she helps me understand what—for her, at least—is the central issue. She could live with some scaling and redness, she might even be able to ignore the lips long enough to stop licking them once she knows that every return of symptoms doesn't mean unemployment and retraining.

Personal angles like these come up all the time. Given a minute or two, patients bring them up all by themselves. Like Phil, who has a keloid on his chest. He's a middle-aged guy who doesn't seem likely to take his shirt off much. What bothers him about it? Appearance? Fear of cancer?

“I'm a courier for a clinical lab,” he explains, “so I'm in and out of the car all the time. And every time I fasten my seat belt it rubs this and it hurts.”

So that's it—fear of trauma (frequent rubbing could cause cancer, and so forth), but of a very specific, and unavoidable, sort. Easy to address, once you know what the worry is.

But the prize in my recent experience goes to Harold, who presents with a fairly large epidermoid cyst on his back. A common enough complaint—why is it there, is it a tumor, and so on. But Harold too has something particular in mind.

“The bump hurts when I take part in medieval recreations,” he says.

“You mean like the Society for Creative Anachronism?” I exclaim.

“Exactly,” says Harold.

That group, in case you're unfamiliar with it, is devoted to re-creating the Middle Ages in authentic detail. These folks put a lot of effort into getting everything just right. This means that his cyst bothers Harold because it rubs against his armor.

So he has two choices: to remove the cyst or to wear flexible armor, which wouldn't be authentic. So he really has only one choice.

I am not suggesting that we all add questions like, “Are you afraid you're radioactive?” or “Do you joust?” to our standard repertoire. But listening to patients' sometimes idiosyncratic personal spin on their symptoms and fears can be illuminating and helpful. Not to mention bemusing.

Chuck's palms are rough and thick. “This started when I cut one palm at my job,” he said. “I work at a nuclear plant.”

I tell Chuck he has psoriasis, adding that the cut may have triggered its onset but hasn't caused its persistence, much less its appearance on the other palm. “Also,” I say, “radioactivity has nothing to do with it.”

“You mean I won't glow in the dark?” Chuck laughs nervously.

A few years ago, I pointed out some ways symptoms can have private meanings that make them more disturbing or threatening than one would expect. There is a short list of illness narratives that apply to most everyone, including I caught this; I'm allergic to that; trauma damaged me and made me weak; I have cancer inside; and I've grown old.

But sometimes there are special circumstances, unique to a particular person, that make these general concerns even more pointed than usual. Chuck's basic worry is that the cut on his palm brought on his problem. Had it been a splinter, he wouldn't care much—just some roughness that makes it awkward to shake hands sometimes. But what if the splinter is radioactive? That means every time his scaliness comes back, worsens, or fails to go away when treated—he'll glow in the dark. Creams will help Chuck. Undoing his narrative will help even more.

Or consider Becky. Her lips are red and scaly and are resistant to topical therapy. This is common enough and worthy of concern. Her lips look and feel funny, and she keeps licking them, which makes them worse. People can see the problem, which is embarrassing, especially because lip problems have sexual overtones. But Becky's worries are special to her.

“I work in a brewery,” she says. “If this is some kind of yeast infection, maybe it has something to do with beer and I'll have to give up my job.”

I have to confess that I don't routinely ask, “Do you work in a brewery and fear for your job?” Maybe I should. But when Becky brings the question up, she helps me understand what—for her, at least—is the central issue. She could live with some scaling and redness, she might even be able to ignore the lips long enough to stop licking them once she knows that every return of symptoms doesn't mean unemployment and retraining.

Personal angles like these come up all the time. Given a minute or two, patients bring them up all by themselves. Like Phil, who has a keloid on his chest. He's a middle-aged guy who doesn't seem likely to take his shirt off much. What bothers him about it? Appearance? Fear of cancer?

“I'm a courier for a clinical lab,” he explains, “so I'm in and out of the car all the time. And every time I fasten my seat belt it rubs this and it hurts.”

So that's it—fear of trauma (frequent rubbing could cause cancer, and so forth), but of a very specific, and unavoidable, sort. Easy to address, once you know what the worry is.

But the prize in my recent experience goes to Harold, who presents with a fairly large epidermoid cyst on his back. A common enough complaint—why is it there, is it a tumor, and so on. But Harold too has something particular in mind.

“The bump hurts when I take part in medieval recreations,” he says.

“You mean like the Society for Creative Anachronism?” I exclaim.

“Exactly,” says Harold.

That group, in case you're unfamiliar with it, is devoted to re-creating the Middle Ages in authentic detail. These folks put a lot of effort into getting everything just right. This means that his cyst bothers Harold because it rubs against his armor.

So he has two choices: to remove the cyst or to wear flexible armor, which wouldn't be authentic. So he really has only one choice.

I am not suggesting that we all add questions like, “Are you afraid you're radioactive?” or “Do you joust?” to our standard repertoire. But listening to patients' sometimes idiosyncratic personal spin on their symptoms and fears can be illuminating and helpful. Not to mention bemusing.