My patient suddenly leaned forward, swung her hair up, and began to push it this way and that, determined to find and show me the partitions that her hair made when rested in a new equilibrium.
It was a warm Thursday afternoon and we were in dermatology clinic. This 20-something young professional had come to have her scalp examined. She'd noticed a sudden increase in the quantity of hair follicles that parted ways in the shower, after an ordinary brush, on her pillowcase, and she was worried that she had developed female-pattern hair loss.
As the medical student, I was ushered in first and alone, as usual, to talk to her and see what I could make of her symptoms. Seeing how she was knotting her fingers in anxiety, I decided on open-ended questions. What's concerning you? What's been different?
She began to recount her early symptoms, how she started to notice that when she braided her hair, it looked less thick. How a friend took a picture of her in the sun and it inadvertently illuminated a wide partition on her head. How she began to notice her tub needed more frequent dollops of Drano to clear the clots made by wet clumps of hair.
She reached into her bag and pulled out her iPhone.
"I don't want you to think I'm just imaging this," she said, "because I've been to my primary care doctor a few months ago and he told me that this was all psychosomatic from my anxiety and to take some Biotin pills if I was really concerned."
She opened her camera app and began to show me a series of selfies, if you could call them that, of her scalp. She'd taken these at various divers occasions -- in the morning, after a shower, before going out, in a dressing room, in different sorts of lighting. Her scalp was frequently drawn and quartered, as she pushed it aside with her fingers to pull the areas of thinning into greater prominence. I scrolled through them, noting the time stamps above each cluster of photos. More recently, she had grown even more obsessive with documenting the progression of the hair loss, with numbers rising from single digits into double under each date.
I looked up to see that she was watching my face nervously.
"I believe you," I said, and she visibly relaxed, but simultaneously scrunched her face and began to cry.
The same impulse that had driven her to track her alopecia was causing her grief now. Documenting the damage, I imagine, thrilled her in her validation but devastated her in its proof. I suspected that her primary care physician was not the first to casually dismiss her fears without even attempting to disprove them with a good listen and thorough exam. Now she was vindicated, but the implications of having her fears acknowledged were overwhelming.
I asked her if the hair loss was limiting her life in any way. She nodded fervently. She'd stopped going to the beach because she was afraid the wind would upend her careful setting every morning. She used to like getting caught in the rain, but now she feared it would expose her losses to the world. She was generally less spontaneous, more restrained. She had begun to obsess over it, watching how her friends were so carefree about their own fringes and feeling inordinately jealous and lonely in her affliction.
I listened to her, thinking about the ways in which I could relate. I had my own guilt/indulgence cycles, after all. The ways in which people, but more frequently, young women, choose to represent reality in a distorted manner, whether that be about their appearances or their circumstances, choose to exaggerate their deficiencies, in order to feel something like anguish, are a common enough societal phenomena.
Back in my attending's office, I caught a title of dermatology textbook, Atlas of Dermatoses, upside down, and in attempting to interpret it lopsided, thought it read Atlas of Dreamatoses. How appropriate! I think many people, even with legitimate concerns, suffer more insistently than their peers when they languish in these dreamtoses, these preoccupations with their illnesses that prolong and exacerbate even genuine symptoms. Still, without being directly affected so, it's impossible to judge.
The thing about playing doctor to a patient like this, with a complaint so universal and easily relatable, is that one must consciously assert these roles: doctor, patient. I restrained myself from trying to comfort her with examples from my own experiences, worrying that this would set us down a very long path of sharing neuroses with each other. I listened patiently, asked more follow-up questions that would get at the heart of a full differential, and performed a comprehensive exam. Thanked her for her patience with me and promised to relay my findings to my attending.
Eventually, we three, my attending, patient and I, decided that to perform a scalp biopsy. While it would have been reasonable to wait and see if the hair loss would temporize and perhaps improve, we felt that the patient would benefit from the peace of mind that would come with knowing, definitively, the nature of her condition.
The biopsy was scheduled for the following week.