Dr. Matthew Paldy
COMPASSIONATE, EFFECTIVE PSYCHOTHERAPY

A Case of Psychosomatic Illness in NYC Therapy

By Dr. Matthew Paldy

(Names and details changed to protect the patient's privacy).

Paul is a 48-year-old white male living in Manhattan. He is single, no children, never married, with an associate’s degree. His parents divorced when he was seven. Paul’s father is of European descent, with a misogynistic attitude. His father would often disparage Paul if he discussed difficulties with work, saying things like “you’re lucky to have a job, so quit complaining.” His father would often berate him and be verbally abusive during their visits together. Paul’s mother is a kind person, but is subservient and lacks assertiveness. He has one brother, two years younger, with whom he often argues with and is currently estranged from. Paul has never had healthy intimate relationships with women, but rather a series of one or two-month involvements that never progressed to significant levels of intimacy and instead were fairly shallow and volatile, with most ending in emotional disagreements and misunderstandings.

Paul’s libido decreased as he became more intimate with a woman, resulting in conflict when the woman did not feel sexually desired, and ultimately contributed to the failures of many of his short relationships. He would often say he wanted a relationship so that someone would take care of him when he was older, and he worried that he would be alone as he approached his senior years. It struck me as rather odd that his vision of a relationship seemed to be a purely transactional, with no progression towards love or intimacy, and instead only the fantasy of having someone do mundane things for him, such as bringing him a meal if he was sick in bed. He often said that he still felt like a child despite his chronological age and professional career. Despite my urgings he would not take any steps to develop social connections or attend social activities.

He had a very stable temperament. He was friendly and likeable, with a docile and non-confrontational attitude, and was generally well liked by others. He had very few friends, most of which were not close friendships. Over a span of ten years, from age 35 to 45, he gradually ceased going out on weekends to bars or social events and instead remained inside his apartment, often cuddling up with his dog, who he considered his best friend, and watching movies.

When I asked why he would no longer go out to bars or social events, he often said that he was “too old to date” and that “it’s over,” meaning his life. When asked if he was lonely he would reply, “No, I’m content.” This pattern of staying inside his apartment with his dog with limited social contact persisted for several years. At a certain point his father, age 83, became increasingly senile and frail. It appears that with the same time frame Paul began complaining of physical symptoms including dizziness, tingling and numbness in the extremities, neuralgia, joint pain, fatigue, pain, headache, and delirium. He blamed the symptoms on an adverse reaction to a prescription for the antibiotic Levaquin (levoflaxin), which he briefly took several months earlier. My research shows that Levaquin has been occasionally reported to cause significant lasting side effects such as nerve damage and tendinopathy, but the research on this is inconclusive and most cases are in individuals who are 60+ years old. Paul consulted with multiple physicians and had multiple blood tests and exams, but none was able to confirm any biological basis and some doctors suggested the symptoms were psychosomatic. Over the span of several years Paul self-diagnosed himself with a wide variety of maladies including Epstein-Barr virus, multiple sclerosis, and mononucleosis. He intermittently stayed home sick from work as the symptoms created a consuming and disruptive presence in his life, and he considered going to the emergency room several times when the symptoms were most acute. I often suggested behavioral health counseling, but he said he was not interested.

Interpretation

I propose that the Paul’s symptoms may have been psychosomatic in nature. It seems that Paul’s physical symptoms were an unconscious expression of distress and fear of aging, loneliness, and death. His denial of time passing and fear of growing old with no familial support may have contributed to psychogenic manifestations of unconscious distress or a protest against what he considered to be impending catastrophe and death. Franz Alexander, in his book Psychosomatic Medicine (1965) , describes psychogenic fatigue as “the acute condition of fatigue developed after the patient had to abandon a cherished goal, giving up hope and resigning himself to continue with some distasteful routine against which he had revolted internally.” Paul strongly identified with his father and had adopted many of his father’s misogynistic tendencies, which left him unable to develop healthy, caring relationships and ultimately resulted in extreme feelings of loneliness and hopelessness that most likely found expression in psychosomatic ailments. It is possible that he had unresolved Oedipal issues, however I can only speculate on this because he was a friend and not my analysand. It seems possible that because Paul’s fantasy of a relationship was one where his wife would do things for him, such as cooking, but excluded fantasies of emotional closeness or increasing levels of intimacy. Because his fantasy resembles a childlike regression it suggests that Oedipal issues may be present.

In romantic involvements with women Paul often lost his sexual desire for them as he got to know her. This appears to be an example of what Freud termed “psychic impotence” or the “Madonna-whore complex.” In such cases the person is unable to be affectionate towards the same object to which he sexually desires. Freud posited that such a person suffers from unresolved Oedipal or castration fears in which affection for a past incestuous object cannot be experienced with a woman who he is sexually attracted to. Therefore an unconscious anxiety arises and prevents the person from feeling love (affection) and sexual attraction toward the same object. The person is therefore unable to experience the affection they once had for their mothers in their sexual partner. Paul often seemed to divide women into two groups: those he was sexually attracted to and those he admired, with no overlap between the two. Freud also proposed an alternative explanation that the complex was based on a primary hatred of women which arose from having to experience intolerable frustration or narcissistic injury at the hands of his mother, however I do not think this was the case with the Paul because he seemed to have an amicable relationship with his mother, who he described as reliable and caring, and visited her regularly.