Insomnia From Disease or Disaster?

Abstract

To the Editor: We read with interest the article by Ogdie et al1 on the contextual factors of diagnostic errors, and were impressed with the authors’ novel use of narrative discussion to educate residents about such errors. Our own education about the sometimes-misleading power of context occurred in our hospital in May 2011, when an 82-year-old Japanese woman presented with a 2.5-month history of appetite loss, weight loss, and insomnia. She arrived not long after the Great Eastern Japan Earthquake of March 11, 2011. Although she lived in Tokyo, approximately 500 km away from the stricken areas, she reported that after the earthquake, she had felt anxiety and had gradually decreased her oral intake, watching television news programs about the disaster every day. At that time, we knew that the disaster had not only overwhelmed individuals’ daily lives in Eastern Japan but had also had a great impact on the mental status of those who lived far away from the stricken areas. The combination of the patient’s symptoms raised the possibility of a psychosomatic process due to the negative influence of the earthquakes. Still, we discussed her case with an internal medicine resident and evaluated the patient for organic diseases. Her erythrocyte sedimentation rate was 79 mm/h. The laboratory test results were otherwise almost normal. We considered subacute bacterial endocarditis, polymyalgia rheumatica, and a malignant process as differential diagnoses. Blood cultures were sterile. But esophageal-gastro-duodenoscopy revealed an advanced gastric cancer; pathology showed diffuse large B-cell lymphoma. In reflecting on the role of the earthquake in our patient’s condition, we initially speculated that the two events (i.e., the patient’s disease and the earthquake) occurred coincidentally. But we soon saw that this was misleading. In fact, since the disaster, the number of patients in Japan with mood or psychosomatic conditions as well as somatic symptoms has been increasing, which sometimes distracts the decision making of their physicians. For the 82-year old woman, the unprecedented disaster in March 2011 helped make her neurotic, which masked the prodrome of aggressive lymphoma. Unavoidable contextual factors, no matter how “sorrowful” they are, can often psychologically distort physicians’ cognition. Junwa Kunimatsu, MD Attending physician, Department of Internal Medicine, National Center for Global Health and Medicine Hospital, Tokyo, Japan; [email protected] Atsuto Yoshizawa, MD Director, Department of Internal Medicine, National Center for Global Health and Medicine Hospital, Tokyo, Japan.