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    Thursday, September 17, 2015

    Making Patients Feel Worse Without Really Trying


    It was clear that little Aracely was going to have a problem.  Not only was her hair falling out, leaving small bald patches, but now it was coming out in clumps from all over, leaving her thin up front and on the sides.

    It would take a skin biopsy to be sure, but the most likely diagnosis seemed to be alopecia areata. This is a fairly common condition, but one where treatment options are limited when the affected area is extensive, as it was in Aracely’s case.  Her mother Luisa was understandably concerned.

    “Her doctors keep asking me if she is worried about something, if there is something wrong at school, or at home,” said Luisa.  “I keep telling them no, there is nothing wrong.  She is just losing her hair.”

    “The reason they are asking you that,” I told her, “is that for a long time the textbooks have said that alopecia is caused by stress.  I wish they wouldn’t say that, because it isn’t true.  By the way,” I continued,” how often do you shampoo her hair?”

    “I’m afraid to!” answered her mother, as I suspected she might.  “Every time I do, more hair falls out, so they told me not to shampoo her too often.”

    “It doesn’t matter,” I told her.  “The hairs that come out are going to come out anyway.  You’re not making more of them fall out by touching them.”

    “You mean it’s OK for me to wash her head two or three times a week?” Luisa asked.

    “Sure,” I said.

    Aracely’s doctors had told her mother that alopecia is “caused by stress.”  The books have been saying that forever, because each book quotes the previous ones.

    Suppose it is.  So what?  Will the hair grow back if Aracely calms down or goes into therapy?  It will not.

    What will certainly happen is that her family will be even more miserable than they already are.  They will assume that if they had just made their daughter calmer and happier, her hair loss would never have happened.  After all, the doctors keep asking if something is emotionally wrong.

    Also, people like to shampoo.  It doesn’t feel right if they don’t—they feel dirty.  But it’s logical for people with alopecia or their families to assume that shampooing must be bad—hair comes out in the shower, doesn’t it?  So they’re afraid to wash, and if their caregivers reinforce this fear, the patient and her family end up feeling even worse.

    Don’t take my word for this.  Ask Luisa.  I did the hair biopsy and told her I’d call her with the results.  I did not sugarcoat the outlook, but instead made it clear that it might well turn out that there wasn’t going to be much we could do for Aracely except wait for the hair to grow in by itself.  That might take a long time and not be complete even then.

    This is what Luisa replied.  “You know,” she said, with her first smile of the whole visit, “just knowing that it isn’t caused by nerves and stress, and that I can shampoo her hair whenever I want—that makes me feel better already.”

    Doctors need to make a diagnosis and prescribe the right treatment, if there is one.  If they figure into their counseling how patients think and how they’re going to react to what they’re told, regardless of what medicine can actually accomplish, doctors can make people feel a lot better.  If not, they can make them feel a lot worse.

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     This topic brought to you from psychologytoday.com
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