agonyaunt | Dear Prudence: The Plot Thickens

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Dear Prudence: The Plot Thickens

Two letters that seem to be about the same incident, and which offer very different perspectives.

The first letter was published October 3:

Q. Hypochondriac In Love: Is it a red flag that my partner initially refused to take me to the emergency room? I am a young woman who is living with my boyfriend of over six years. We are very happy except for my chronic medical issues occasionally causing me great pain and some tension between us. The other night I was having serious abdominal pain and vomiting. I begged him several times to take me to the ER and he refused, reminding me that I’ve gone to the ER before for what my insurance considered non-emergencies and charged me extra for it. Finally, I called 911 for an ambulance and he took the phone from me and told them not to come. He drove me then to the ER and was angry when I threw up in his car. They did a CT scan and diagnosed me with acute colitis, cystitis, and a kidney infection. I apologized to him and I admit I can sometimes be a bit of a hypochondriac and he’s normally compassionate about my illnesses. I love him very much but I wonder if I should take this as a bad sign.

A: No, you shouldn’t take it as a bad sign. You should take it as a relationship-ending, unforgivable sign.

The second letter was published today, October 29:

My wife (“Laura”) and I have been together for 10 years and we’ve mostly had a good relationship until the past couple of years. Laura is a hypochondriac. In the beginning, it was really minor and barely noticeable—she insisted any cold she got was actually pneumonia or an upset stomach was appendicitis. As time went on, she became convinced she was suffering from an undiagnosed illness and after years of seeing doctors and getting tested, a doctor diagnosed her with a syndrome that mostly consists of a collection of symptoms with no other cause, no test to confirm the diagnosis, and no treatment except lifestyle and diet changes. I had hoped by getting a diagnosis her hypochondria would calm down.

It has not and I fear it is getting worse and turning into Munchausen syndrome. It was brought to my attention recently that Laura may have written into this column about an incident that happened a few weeks ago where she was vomiting and I wouldn’t take her to the hospital and prevented an ambulance from coming to get her. In the letter, she changed some identifying information—but the other details matched an incident that happened between us. My concern with the letter was her presentation of her diagnosis with medical terms derived from the CT scan and not the actual diagnosis the ER doc gave her, as well as leaving out key information, such as the questionable leftover chicken she had eaten earlier that day and the UTI she was diagnosed with earlier in the week and was supposed to be taking antibiotics for. She wrote that she was diagnosed with “acute colitis, cystitis, and a kidney infection”, however, except for alluding to her UTI moving into her kidneys, the doctor told her that she likely had food poisoning (acute colitis) and needed stronger antibiotics for her UTI because of the slight bladder and kidney inflammation (cystitis). He gave her new antibiotics for the UTI and when I went to throw away the old ones when we got home, I noticed that they were much fuller than they should be and asked her if she’d been taking them. She said that she may have missed a “couple of doses” but there were a lot of pills remaining.

I’m really scared that she is trying to make herself sick. If she did write the letter, then I am also scared that she is trying to get public validation and sympathy and that she may continue to escalate. I’ve alluded previously that this is all in her head and it did not go well so I hesitate to ask her outright but I need to do something. I don’t want her to hurt herself and I want her to get the help she needs. Should I try to talk to her therapist about my fears? I know he can’t break doctor-patient confidentiality but can family members tell them about their fears so they can do some probing? Should I mention my fears to her physician? Her family? Even before this incident, I knew some sort of intervention needed to happen as we have nearly $10,000 in medical debt from her various tests and medical visits. Her health is more important than the money, but if this is Munchausen and it can be fixed by therapy, then I’d prefer that than to keep adding to our debt.

—In Love With a Hypochondriac

Dear In Love,

Well this complicates things… Sorry for telling her to leave you. I don’t know what a therapist or doctor will do with the information you provide, but it can’t hurt to share your concerns with them as well as a couple of trusted family members. I will add that, whether she made herself sick or not, she was actually sick and you should have helped her get to the hospital. If your suspicions are true, I hope she can get help but in the meantime, you should make it a priority to respond to her very real illness and suffering, despite your belief about its origins.

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ETA: Thinking about this a little more, I think the most telling thing about the response here is that in each case, Prudie seemed to accept relatively uncritically the version of events that particular LW was giving. I feel confident in saying that neither Letter 1 nor Letter 2 is a comprehensive account of what happened, but Prudie seemed to miss that something was being elided in Letter 1, and then basically overwrote Letter 1 with LW2's version of events when responding to Letter 2.

Regarding the advice for LW2 to speak to LW1's doctor or therapist (if she has one): I definitely agree with other folks who've pointed out that that has the potential to be really harmful by leading a doctor to discount her symptoms as psychosomatic. On the other hand, if there is a psych issue here (Munchausen's or otherwise), LW1 might not be in a position to recognize an issue herself: depending on the condition, psych symptoms can often be hard to notice in oneself, especially when someone hasn't been diagnosed and therefore isn't on the lookout. If LW1 does see a therapist, I wonder if LW2 telling his concerns to the therapist, but not to LW1's primary care doctor, would be an appropriate way to thread that line?

Initial comment:

Both of Prudie's responses strike me as somewhat inadequate. ("Sorry for telling her to leave you" cracks me up!) But I think it's a good example of why letters that seem to have an immediately obvious answer, especially when the answer is "LW, you are 100% justified," might not actually be so easy.

The initial letter is missing a lot of information – all we have is that she had a stomachache and was throwing up, and he wouldn't take her to the ER for...a stomachache and throwing up? Which doesn't strike me as something one would usually go to the ER for, especially since there's no mention of a fever, or that the chronic medical issues the LW references make throwing up particularly worrisome? If I were Prudie, I think – or like to think, as it's easy to be an armchair critic – that I'd've passed on answering the first letter because it's just too light on the details, and seems like it might be glossing over things that don't favor the LW.

Not that I'd've sided with the boyfriend on the facts presented in the letter! If your partner says they need to go to the hospital, take them to the hospital!!! But it does read like something's being left out, and for that reason I'd have been hesitant to call it "a relationship-ending, unforgivable sin."

As for the response to the second: If I'm recalling correctly, Prudies old and new, as well as other Slate columnists, not infrequently reach out to experts about issues that come up in letters. This seems like it would've been a great time to do it! Asking "Hey, Dr. So-and-so who reads Slate, how would you react if the spouse of a patient told you he was worried the patient had Munchausen's, and gave you a list of the reasons he was worried?" and giving the answer in the response would have made it a lot more helpful than just "I don't know, but it can't hurt!"

Edited 2022-10-30 05:50 (UTC)

all we have is that she had a stomachache and was throwing up, and he wouldn't take her to the ER for...a stomachache and throwing up? Which doesn't strike me as something one would usually go to the ER

I dunno, this seems sufficient to me if it's a particularly exceptional case of discomfort. Going to the ER for stomachache & nausea are how I discovered I had a kidney stone, and I wasn't even throwing up yet.

That's fair. What I was thinking was that although he should definitely have taken her when she said she needed to go to the ER, there's a difference between not taking your partner to the ER when you don't think it's justified (especially when you're concerned about incurring further medical debt) and not taking them to the ER when they obviously need to go (e.g., broken bone, deliriously high fever). Neither is good!! But one is much worse than the other.

(I'm sorry to hear about your kidney stone! That sucks.)

Edited 2022-10-30 22:55 (UTC)

Ahahaha, do you know what this reminded me of?

A discussion I read once about whether it was "less bad" to beat one's kid with a wide belt vs a narrow belt, which made me think about my carefree (/s) childhood. Having Been Hit With Both I can say the wide belt is "less bad" in that it's broader so it inflicts bruises rather than ripping the skin open. But they are both sufficiently bad. Obviously, kids shouldn't be hit with belts (or anything except the occasional pillow when equally armed). Similarly it's worse to refuse to take someone who's having layman-evident symptoms to the ER than someone who is complaining of non-layman-evident symptoms, but both refusals are sufficiently cruel that they should not happen in an allegedly loving relationship, so it's rather a distinction without a difference

(Oh, I nearly forgot -- thank you about the kidney stone. Hydration is important.)

Edited 2022-10-31 02:39 (UTC)

We have a flowchart. It runs basically like this:

1. Did I at any point think perhaps we should go to the hospital?

If Yes, go to the hospital.

If no, go to 2.

2. Why am I even looking at this flowchart? Is it because I should go to the hospital?

In conclusion, thinking that maybe you ought to go to the hospital is probably enough of a reason to go to the hospital, with or without the armchair psych diagnoses.

I used to work security in an emergency room, and I'll tell you, there are a LOT of people who go to the ER for things that really do not qualify for emergency treatment; these people then get very frustrated when they end up in the waiting room for several hours because they are not an urgent/priority case. It's the same thing as the people who think an ambulance will get them seen faster - that's not true, unless you're an actual trauma you're still going through triage like everyone else.

I had a coworker at the hospital who went to the ER at 7:30 in the morning because he stubbed his toe getting out of bed when he really should have gone to an urgent care when it opened at 8; we were all pretty stunned by that one.

Okay, well, sure some people should not go to the ER.

But since I am not a medical professional, I can't do my own triage. I'd rather risk sitting around in a waiting room than risk, y'know, more dire consequences.

Given they way women in particular with chronic illnesses are dismissed as hypochondriacs - even in cases where actual tests can confirm their illness objectively (e.g. endometriosis, fibroids) - then I am side-eying the second LW hard.

It’s possible first LW is bad about taking their pills (and is this related to their illness), its even possible that LW1 is really a hypochondriac, but based on both letters Im pretty sure LW2 is an asshole who just doesn’t believe in LW1’s health issues because thats an overly common narrative.

I am totally biased because I have a friend whose first marriage blew up because of this sort of thing and she still has to fight for decent medical care because things added to her chart because of her exes “concern”.

There's also a third option, though not one I particularly think is happening here: LW *is* a hypochondriac or even has Munchausen's (though my understanding is that this is actually quite a rare disorder) but also had and may still have a serious illness.

It is entirely possible for hypochondriacs to get sick with acute or even chronic diseases. It's not like hypochondria is a magic potion that keeps you well.

Uh. Why is everyone involved here acting like the husband's account means the hospital visit wasn't justified? Kidney infections can hurt a LOT and severe abdominal pain + vomiting is ABSOLUTELY justified to get medical help, it could be on par with a kidney stone or appendicitis for pain!

Like the original LW's account does seem to be slanted in a particular way, but also the husband's account is setting off ALL my alarm bells, and Pru seems to have missed them entirely. She was diagnosed with a chronic illness! She was in probably severe pain! He brushes off her diagnosed chronic illness, yelled at her for vomiting when she had food poisoning, grabbed the phone out of her hand to stop her while she was calling 911, minimized *a kidney infection*, badgered her into apologizing for needing to go to the hospital *while they were at the hospital*... and is doing a very good job of smoothing everything over with a bit of "ignore the little woman, I suspect she's got a touch of hysteria".

If she did deliberately stop taking her antibiotics just so she could be "legitimately" sick, that's concerning, but it's *probably* because she's married to a total asshole who has been invalidating her real health concerns for a decade!

How do you get this interpretation from either Conuly’s comment or mine?????

I am legit confused

Yes, I am also confused. I thought maybe it was a reference to the comments on the Dear Prudence page, but I don't see any there.

Sorry, I was mostly aiming that "everyone involved" at Husband and Pru and Pru's editors, because I was very angry (although re-reading it now, even Pru's answer isn't quite as bad as I remember it being, I think I was reading Pru's "very real illness" to mean Husband's hypochondria when on re-read they are probably more on LW's side.) That Husband thinks his letter justified himself at all is just. More reason she should leave him.

You all weren't directly involved! I didn't mean you!

Edited 2022-10-30 19:55 (UTC)

Yeah, he admits that he “prevented an ambulance from coming to get her,” but elides whether he “took the phone from [her] and told them not to come” — which he would have had to do in order for an ambulance not to respond to a 911 call asking for an emergency pickup.

Especially given the history of how women with chronic illness/pain tend to be treated as “hypochondriacs,” he sounds abusive, and may be a danger to her.

(Calling doctors and therapists to tell them not to believe her *causes her harm.*)

Actual Munchausen’s is very, very rare, and is pretty much only known to the public because of super-sensationalized media representation.

Also, it’s pretty damn hard to deliberately give yourself a kidney infection. Did he consider that the nausea/vomiting might have contributed to missed antibiotic doses?

Basically, even going so far as to assume the best of intentions on his part… he doesn’t trust his wife, he invalidates her experience of her own body, and he admits to doing some abusive shit.

DTMFA.

(Calling doctors and therapists to tell them not to believe her *causes her harm.*)

I had an experience in 2011 when I was bleeding very heavily [menstrual period that had gone on for months and ended up needing multiple surgeries to stop]

and I turned gray and nonverbal on an commercial aircraft flight, so much so that the flight attendant spontaneously came over to me and fitted an oxygen mask on me without me having pressed the call sign or attracted her attention in any way.

I went straight to the hospital afterwards.

The doctor asked my partner at the time if my symptoms were normal for me. My symptoms were not normal for me, but my partner at the time had Asperger's and was very literal and he said yes [because I had previously had completely different symptoms of chronic health conditions and also because he found the hospital environment stressful and wanted to go home]

after that, nothing I could say or do made the doctors take me seriously or run appropriate health tests

because the word of a male partner counts more than the word of the woman whose body it is

I was sent home, far too unwell to be sent home, and several things occurred after being sent home where I genuinely could have died

including

a) having to get up steep, wet, slippery outdoor stairs that had a very rusty shaky handrail UNASSISTED when my balance was so bad that I was toppling forwards out of a manual wheelchair;

b) being left in bed and not checked on for several days when I couldn't get out of bed to get myself a glass of water and was bleeding very heavily;

c) after telling my partner that he needed to manage my medication because my short term memory was currently so bad that I couldn't remember if I'd taken 10 seconds before, he dumped all the medication on the table next to my bed and refused to help me with it in any way, even tho it included
Paracetamol/acetaminophen/Tylenol which can cause death by liver failure if you accidentally take too much. [The excuse he gave when I confronted him about it was that he didn't want to be woken up by me in the morning just so that I could take medication]

Edited 2022-10-30 05:33 (UTC)

I am so, so incredibly sorry — and grateful that you are out of that relationship.

Well, he's a charming asshole, isn't he. I'm glad you made it out of that relationship.

As a woman with a chronic illness,

who knows many other women (and Assigned Female At Birth people) who have had their chronic illnesses minimised or dismissed entirely by male partners and also by doctors I do not think LW is a reliable narrator.

Munchausen syndrome is quite rare.

People with genuine physical chronic illnesses being dismissed by their partners and by doctors is incredibly common.

Statistically, it's not likely to be Munchausen syndrome.

Edited 2022-10-30 05:16 (UTC)

Yeah, I mean, Munchausen's is a wild reach. And even if she does have health anxiety, *hypochondriacs can get sick.* The answer can't be, "So you are never allowed to seek medical attention again," and getting hypochondria or, God forbidden, Munchausen's documented in your medical records *kills people.* Especially women, since gid knows doctors assume hypochondria in women anyway.

My lovely GP (who is 40 something now), when she was younger (but still a fully qualified GP) rocked up to a Dr

and said "Hi, I'm a fully qualified and currently practising GP but we're discouraged from writing our own referrals, I've found a lump in my breast and I would like a referral for a breast ultrasound"

The Dr she saw scoffed at her and told her she was far too young to have breast cancer, she must be Depressed (on no evidence except wanting a breast ultrasound) and wrote her a script for anti-depressants

Fortunately, she then went and saw a different Dr, because Guess what? It was breast cancer!

I heard that story and thought "God, if even fully qualified GPs get brushed off for being women, what hope do other women have?"

She's an excellent Dr because she vowed to never, ever do that to her own patients, so now if she thinks there's a 10% chance of a problem, she still gets people tested to rule it out

Yes. God, exactly, this shit happens so often.
And I also always think, you know who behaves like a hypochondriac? Frequently seeking medical attention, researching their symptoms, maybe even deliberately worsening their symptoms in the hope they'll be harder to dismiss? *Sick people who can't get their symptoms taken seriously.*
I've done things to deliberately flare up symptoms before a doctor's appointment in the past, in the hope that if they're at their worst when I'm actually in front of the doctor they'll take me more seriously. It took *years* for me to get a doctor to consider that dislocating joints and a standing heart rate of 160 might actually indicate a problem rather than just hysteria. Turns out I have EDS, not Munchausen's, but if they'd ever found out that I sometimes deliberately triggered the tachycardia before seeing them, I never would have been diagnosed. But I also probably wouldn't have been diagnosed if I hadn't done it, you know?
I'm willing to bet LW is an abled person who doesn't believe sick people ever get dismissed or go undiagnosed. And even if she does have health anxiety, which came first, the knowledge that doctors and her husband wouldn't take her seriously or help her if she was sick, or the anxiety?

Ohai, fellow zebra!

And, yes, I’ve never FAKED a symptom, but I absolutely have had to do things that are intended to make an intermittent symptom actually show up to be observed by a doctor.

Cautious fistbump!
Yeah, I think it's an experience most disabled and chronically ill people have and very few abled people get - you have to *perform* your symptoms just right to get taken seriously, and from the outside it can sound like "faking" or exaggerating. Who knows what's actually happening with this letter, but that's definitely one plausible read.

That is such bullshit, in multiple ways, because (a) of course young women sometimes get breast cancer and it's likely to be a way more dangerous form if you're young, and (b) young women get fibroadenomas all the damn time (they are most common at 15-35, up to 9% of women get them), and while benign, they frequently need treatment.

It took two years for me to manage to get a gallbladder full of stones (described "chock-full of pebbles" by the surgeon who removed it) removed, because I was diagnosed with hypochondria. \o/

Now I am a hypochondriac, because I know that if I have something wrong with me, I'm going to have to catch it early and fight fight fight for my care.

Right. That.

I had my first gallstone attack when I was 15. I finally got diagnosed when I was 37. I have very little trust of the medical establishment.

I'm lucky. My mother's a doctor. It gets me places sometimes when nothing else will.

Yeah, agreed. LW2's story fills in some gaps and also makes it comprehensible how LW2 can justify their actions to themselves without looking like a cartoon villain, but they're still not okay or even really justifiable actions. Aside from the "you go to the hospital!" point introduced by multiple people above and getting mad about vomiting in the car (???), preventing a 911 call from coming seems unjustifiable to my mind.

However, I'm not 100% convinced how that worked, because I've been given to understand that operators have to send someone anyway? The second person on the phone could be an abuser or attacker telling them not to come, and coercion could be involved even if they get the first person back on the phone to agree. That's why 911 hangups still have to send cops to respond. That happened to me as a teenager - I misdialled it for area code 913 and the police who showed up had to hear what had happened and asked to see everyone who was home at the time to make sure. However, it could be that in practice those guidelines aren't always followed.

I have some sympathy for their stated belief that their partner is a hypochondriac and their worry about the medication, of course. But that in no way justifies their reactions to the food poisoning incident.

Soooo as someone who is a hypochondriac, I have feelings about this.

People use the term "hypochondriac" so liberally that it means almost nothing. It runs the gamut from "is really whiny when they have a cold" to "genuinely terrified all the time", and I live on the "terrified" end of the scale. I don't mistake my anxiety symptoms for illnesses (though that is common), but have enough medical and biological knowledge to notice many things that "don't seem right". Of course, in actuality, the human body is a complex system and an ever-changing environment, and today's lumps, bumps, aches and pains are most likely gone and forgotten by next week -- I just lack the ability to be chill about that, even as I intellectually recognise it.

There is actually a point at which it is kinder and safer for those who love me to refuse to enable my fears. It rarely arrives, because I have a lot of insight into my disorder and generally rein myself in -- but if I wanted to go to A&E for something that was 99% likely just minor food poisoning (reminder that foodborne illness can kill, though: 420,000 people worldwide die of foodborne illness each year, albeit mostly in low-income countries), then I'd expect them to offer something else instead. (In the UK, they could call 111 to get advice, putting it in the hands of professionals without going as far as taking me to A&E. I don't know what may be available elsewhere.) That's an understanding we all mutually have, though, and absolutely requires my understanding that my symptoms are non-urgent and may also be clinically non-significant.

So, if you don't have that understanding, take your partner to the goddamn A&E.

Also, an inappropriately-treated urinary tract infection is dangerous; if it isn't sensitive to the antibiotics, or they aren't being taken correctly for any other reason -- more of that in a moment -- then you absolutely need to get that treated properly, and with urgency. Vomiting can be a sign of systemic spread, and is bad. (A lot of the time doctors take a shortcut in prescribing for UTI and pick an antibiotic without testing for susceptibility, which is very poor antibiotic stewardship and often leads to the first course of antibiotics being ineffective.)

The "more of that" part: antibiotics in themselves can make you quite sick. Trimethoprim is commonly given for UTI, and it makes me very ill. There are ways to mitigate that which I use (never, ever have an empty stomach the entire time you're taking it) but which this person may not have known. This kind of side effect can lead to poor compliance with taking antibiotics, and may be part of what was happening too. No need to invoke Munchausen syndrome.

Anyway, in all of that, if this person is a hypochondriac, they need support and love, not judgement and being yelled at for being sick. The fear that some hypochondriacs live with is genuine and can be unbearable. I can guarantee that you are not helping by being an arsehole about it.

A cautionary tale: I was originally labelled a "hypochondriac" because I kept presenting with abdominal pain, and I was a female-bodied person aged 20 who had just left home and was under stress at university. They decided it was gas and anxiety. It was gallstones, and it took two years of escalating episodes of me ending up sobbing on the ground begging for help for me to actually receive any. At which point they scheduled me for ultrasounds and surgery and still didn't provide any pain relief. (Hyoscine butylbromide is available OTC in the UK and is better than traditional painkillers for the relief of gallbladder-related pain, if anyone needs this information.) My hypochondria developed directly out of that episode. Congratulations, doctors! You made a mentally healthy person profoundly unwell by assuming that they were mentally unwell when they had a physical ailment.

Yes! Hypochondriacs also sometimes get sick, and medical trauma from not being believed or treated is a pretty common cause of hypochondria.
I'm sorry that happened to you.

I appreciate you sharing your experience with this really vulnerable topic <3

Someone close to me had a different outcome (medical PTSD + anxiety), because they have had a number of life-threatening medical situations that required hospitalization or surgery, a couple of which were missed or neglected by doctors despite reporting the symptoms early-on.

I think the crux of it is here:

[W]hether she made herself sick or not, she was actually sick and you should have helped her get to the hospital.

The biggest villain here seems to be the United States medical system, but LW2 should have helped LW1. LW1 might have deliberately or subconsicously made herself sick, but she was vomiting uncontrollably and needed medical help at that point in time.

I can imagine LW1 dumping LW2 if next time she needs medical help he makes her beg many times (it's noted that he's 'normally compassionate' - maybe this was an aberration?), or LW2 dumping LW1 if she can't meet him halfway about maintaining her health (therapy for possible Munchausen's, lifestyle changes that are recommended for her diagnosed condition if she hasn't already made them).

She should absolutely leave this man. Anyone who will take the phone out of another adult's hand when they're calling 911 is not a safe person to be around.

I think it would be better for both LWs for them to separate. LW2 is not a safe person for LW1. He is actively interfering in her medical care. His behavior appears driven, at least in part, by fear, confusion, and lack of trust. I can't say how well founded any of his suspicions are, but I can say none of those factors make for a healthy relationship. Both these LWs would be better off apart.

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Dear Prudence: The Plot Thickens

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