Crazy people

I've noticed that there are a number of specific diagnoses that seem to be irresistible to crazy people.  They just can't seem to stay away from them.  Just like fat people lust after the double greaseburger with extra mayo and supersized fries with a side of garlic butter, crazy people absolutely adore certain conditions.  Instinct drives them to be diagnosed with something - it truly gives them a sense of purpose in life.  Life without a medical condition is a life that hasn't met it's full potential.  Whereas normal people find worth in career, family, philanthropy, etc, crazy people find joy in their illnesses.

I use the word crazy very loosely.  It's hard for me to come up with a concise definition of who I consider crazy. The way I see it there are normal people, and there are crazy people.  And every now and again there are really freaking crazy people.  You all know what I'm talking about. A good chunk of crazy people probably have some underlying psychiatric illness.  But there are also those who don't necessarily fit DSM criteria for phyciatric illness, but whom I still consider crazy.  So I guess I use the words mentally ill, weird, and crazy interchangeably.  I know that the term crazy isn't politically correct, which is probably why I like it so much.  If you are offended by it, then I might consider you to be crazy too!

The best test I have found to screen for craziness is to simply add up the total number medication allergies and cats that patients have.  The higher the number, the higher the likelihood that you are crazy.  Less than three is usually normal, and anything greater than five is nearly 100% accurate for a diagnosis of crazy.  Having allergies to cats is usually a good negative predictor unless you have four or more other allergies, in which case you meet criteria for crazy.

When a normal person is diagnosed a condition, he finds out how to compensate so he can maintain a normal life, hold down a normal job, and enjoy normal activities.  He tries not to let it affect his life and wishes that he didn't have it.   A crazy person, on the other hand, looooooves his disease.  It will change his life for the better!  Obtaining that elusive diagnosis is like winning the crazy person lottery!  He will mold his life around his diagnosis.  It becomes his identity.  Deep down he is secretly happy that he was lucky enough to get it.  He will frequently mention it in casual conversation.  Everyone around him knows that he has it.  It becomes an excuse for everything from which he wants to be excused.  And if he can get disability for it, even better!  That way it even feels like a job!  Talk about convenient!  The diagnosis is so powerful that it magically liberates them from all responsibility that life demands.

I'm amazed that the crazies gravitate to many of the same diagnoses.  It's almost like there is an underground convention of crazy people that decreed that all their crazy little followers must go at once to the medical establishment and seek out specific, authorized diagnoses to prove their loyalty and be considered part of the group. They don't like the diseases that actually kill people, but the ones that garner the most attention while allowing them to live semi-normal lives.  They adore conditions with extremely vague, subjective symptoms.   These folks are typically found in highest concentrations in one of a few different clinics.  Of course they all start at their PCP's office but quickly get referred out to a subspecialist because the PCP doesn't have time to deal with their vague, crazy complaints.  From my experience, the highest ratio of crazies are found in one of the following specialties:

Allergy/immunology
Rheumatology
Neurology

They end up in these clinics because these are the specialties where subjectivity is common.  The physician has to take your word for the symptoms you are having.  Specialties such as cardiology, pulmonology, nephrology, endocrine, and orthopedics don't have as many crazies because you can objectively test for stuff.  If you can do scans or blood tests and rule out any problems, you politely tell them that nothing is wrong and they don't need to come back.  This infuriates the crazy patient because he feels that the doctor doesn't believe him.  So what do they do?  They pester their PCP to send them to someone else.  Thus all roads traversed by the crazies eventually end at one of the three specialties noted above.

When they visit these clinics, they have a constellation of symptoms sooooo broad and nonspecific that they could reasonably fit into a number of diagnoses.  The doctor listening to the rambling complaints does his best to make sure nothing real is going on, because crazy people occasionally do have real problems.  The looming threat of a potential lawsuit compells even the most skeptical of physicians to at least do some sort of workup.  And once the workup commences, it's only a matter of time before some of the crazies get a diagnosis that will change their lives forever!  Some of them are diagnosed appropriately, while others are the victims of over-diagnosis.  Crazy patients don't really care if the diagnosis is accurate or not - all they care about is that they got one. 


Let me detail a few of these incredibly powerful diagnoses.  For those of you that have been diagnosed with any of these conditions, this may be the first insight into your potential craziness!  You can thank me later.

At the top of the list of crazy people diagnoses is the dreaded fibromyalgia.  It's a condition in which patients have tenderpoints in their muscles all over their bodies.  There is no objective sign of any dysfunction of the musculoskeletal system.  If you were to biopsy these areas, they would be totally normal.  These patients also have a constellation of symptoms that usually includes depression or anxiety, poor family relationships, physical inactivity, poor sleep habits, obesity, and just flat out being weird.  They are predominantly women, but men are afflicted as well.  These are the people who love to tell you stories about how their bodies don't react like other peoples' bodies do.  There isn't much you can do to treat it.  Nothing works for these people.  About everything in the book has been tried, but they just have pain no matter what.  Eventually someone makes the terrible mistake of giving them a narcotic in attempt to control their pain, which does nothing but make them addicted to opiates.  It rarely helps their pain, yet they won't give them up.

Normal people don't get fibromyalgia.  As a physician, you cringe when you see fibromyalgia on someone's problem list.  You might as well just cross it out and write "crazy" in it's place.  Physicians love to tell stories about their fibromyalgia patients.  "So the other day I had this fibro patient in clinic" is a common way to start a good story.  Heads will turn and attention will be keen, because this story is gonna be good! 

The worst part is that fibro patients see this as a real disorder.  They are completely oblivious to the fact that many physicians use this term synonymously with "crazy".  They love to tell people that they have it.  It's always the number one problem that they list on medical forms.  Forget the diabetes, previous six heart attacks, major stroke, and hypertension - they always list fibromyalgia as number one! 

I once heard a colleague say that he wished fibromyalgia would be renamed "Nobody Loves Me Syndrome."  So much more accurate!  I think I'm gonna start doing that.  

Next most popular diagnosis for crazy people is allergies.  You pick the allergy - it doesn't really matter.  Animals, drugs, foods, chemicals - it doesn't matter.  For some reason they love allergies.  When confronted with negative allergy testing, they refuse to believe it.   Surely the test was wrong!  And none of their so-called allergies react in the typical IgE-mediated fashion - they always have some bizarre type of reaction like "my pinky finger ached for an hour and then it felt all gooey like pudding" or something else ridiculous.  Yesterday I had a patient that was totally convinced that the cortisone injection in her wrist caused her to have pus drain from her eye.  Ummmmm ok. 

I remember a lady complaining of headaches, throat pain, burning in the fingers, abdominal discomfort, and dry skin who was convinced it was due to a food allergy.  Where do they get this stuff?  Is there a crazy people manual out there that I've never seen?

The good thing about allergies is that there aren't many harmful treatments for it, so even if you are mistakenly diagnosed, you don't have to worry about killing a patient with the medication you prescribed. 

How about lupus?  As House MD famously says, "It's not lupus."  Whenever a new patient comes to me with a diagnosis of lupus, I don't believe it until I have reviewed all pertinent records and come to that conclusion myself.  I can't tell you how many people are erroneously diagnosed with it.  And once they are, it sticks with them for life.  Even if you look at their chart and tell them they don't and actually never have met criteria to have lupus, they refuse to believe you.  It's like taking their child away - they won't let you do it!  They'd rather die than lose the precious diagnosis of lupus. 

Seizures are another common complaint.  They like this one because they don't actually have to prove it.  All you need to do is say that you've had them, and no one can disprove it!  Brilliant!  Even a normal EEG and MRI don't rule out epilepsy.  So they really like this one.  One thing they can't do, however, is to perform a proper seizure.  They will occasionally try to seal the diagnosis by seizing in your presence.  It's not easy to do and requires a high level of fitness to contract your muscles intensely for a number of minutes, so most peter out after a few seconds of pathetically flailing around.

Speaking of neurology, multiple sclerosis is also a favorite.  This is another one I doubt by default until I see proof of it.  Like seizures, it's sometimes very difficult to prove, so you can weasel your way into a diagnosis without objective proof of the disease.

Occasionally you get a new feigner of illness who doesn't quite know the ropes who just happens to pick the wrong disease.  I had a guy last week who wanted to be excused from work for 3 weeks because, in his own words, "Doc, I've been spraying blood out of my rectum."  Shockingly, his hemoglobin level was normal.  I never call people out on their lies, because I'm a conflict avoidant person.  Plus, you never get anywhere arguing with the crazies.  But I do enjoy presenting them with the facts and then letting them come to their own conclusions, which always amuse me.  "Wow, I made a remarkable recovery," he told me, suggesting that his uber productive bone marrow had cranked out enough red blood cells in the past 24 hours to replace the gallons of blood he had lost out of his rectum.  Ok dude, whatever.  Go back to work.

These are just a few of the gems that I deal with on a daily basis.  Some days they provide great entertainment.  Other days, however, they make my day a living hell.  But for the most part I've gotten so used to the crazies that I see them as just another patient.  If nothing else, they provide me with highly entertaining story material.   And who knows, if they stopped showing up, life might just be too damn boring.  See you next visit, Mr. Crazy, but don't come back too often!