A case of arrested rheumatic heart disease with severe neurosis mistaken for “ulcerative colitis”

Abstract

This patient experienced a disturbed childhood in which there was little opportunity for the usual affectionate parent-child relationships. The development of a chronic illness, rheumatic heart disease, with subsequent prolonged periods of bed rest accentuated an infantile attitude, an immature approach to sexual matters, a feeling of tremendous insecurity and a marked hostility toward her family. During the bulk of the interviews the patient was permitted to speak freely of whatever she wished. She talked excessively about sex matters. When it became apparent that she was fundamentally a person with strength of character, it seemed advisable to stop further probing. Instead a course of reassurance and explanation of material at the conscious level was instituted. In effect she was led to conclude that the “strange sensations” were of no importance and that she was completely adequate to handle her reality problems. She was discharged from the hospital before she became too dependent. She was then helped in the Outpatient Department to face her problems at home. The psychiatric interviews helped her in several ways. The more obvious ones were: (1) Relieving her anxiety over the “strange feelings” by explaining them as harmless vasomotor phenomena to be expected when fears about masturbation arose. (2) Talking to her as an adult worthy of respect. This includes not letting her become too dependent and flirtatious. (3) Steering the talks away from sex with which she was preoccupied. This made her learn that she could have a close relationship with a man (her therapist) without any risk of falling into her immature pattern of seduction and elopement. (4) When vomiting and retching were substituted as symptoms for the “strange feelings,” paying little attention to them, and turning the interviews to her reality problems of home and job. (5) Giving her confidence by always being willing to listen and by repeatedly explaining her lack of confidence in herself on the basis of her childhood deprivations and invalidism. The prognosis for the immediate future is good. She can continue to look after her family with occasional trips to the Outpatient Department for support of her morale. In the long view the inevitable break in cardiac compensation will pose a serious medical problem complicated by the old neurosis which will doubtless recur at that time. Perhaps enough self-confidence can be built up in the intervening years to enable her to face this situation with courage and without regression to childhood patterns. The “ulcerative colitis” for which she was admitted was, fortunately, a mistake in diagnosis. The bleeding in the colon was probably due to superficial ulceration caused by aureomycin. Her psychologic structure was not the one often found in patients with ulcerative colitis: deep depression and schizoid trends. True, she was mildly depressed but her reactions were “hysterical” in type, i.e., immature, regressive, dependent. She made use of symptoms to control her environment (“conversion”). She changed from one symptom to another. She had an actual sex problem that was unsolved at first and apparently led to feelings of guilt and anxiety. All this fits in with the diagnosis of neurosis.