George Dutton walked in again yesterday. He never calls for an appointment. He asks politely if I have time to see him and never demands to be seen right away. Cindy at the front desk always works him in. He doesn’t drive and never seems to have a ride. Driving around town and the nearby countryside, I always see him out walking.
George is a man of few words. Most of his medical issues are straightforward – a chronic hand eczema, an occasional cut that gets infected, some arthritis. His walk-in visits usually run all of five minutes. He always seems eager to leave, almost in a rush.
More often than not, once we have covered the problem that brought George to the clinic, he asks me the same question:
“Hey, Doc, can you give me something for my nerves?”
George has a terrible case of Benign Essential Tremor, a hereditary condition that causes his hands and neck to vibrate with a high frequency. He has seen two neurologists and tried all the appropriate medications, at least for a few days, but nothing has seemed to help him.
When I first met him, I took his question literally. I started asking him all kinds of questions about how he was feeling. He gave me a blank stare.
“I feel fine,” he insisted. “It’s just my nerves, see?” He held his trembling hands out in front of him.
No matter how many times I tried to explain that the root cause of his tremor is not “nerves” in the sense most people refer to them, George remained steadfast in his belief that deep down, his nerves must be real bad for him to shake like that.
During one of my vacations a colleague prescribed an anxiety medication for him, and George insisted it helped his shaking quite a bit. If I sometimes smell his noontime beer on his breath, I have noticed that his tremor seems better than usual.
Yesterday I had my usual impulse to contradict him and explain again that bad shakes don’t necessarily mean bad nerves, but I caught myself and instead asked him if he thought people ever shake when their nerves are okay. He didn’t think so.
That got me thinking. George is such a laconic man, that perhaps his deepest emotions are non-verbal. I often see patients who struggle to find the right words to describe their feelings, but what if he feels something that he never even imagined finding words for? What if he is grappling with feelings so strong that they make him shake? Benign Essential Tremor certainly can get worse with anxiety.
Prescribing a tranquilizer for George always seemed like treating a symptom without the proper diagnosis, and the only one I had for him was Essential Tremor. Tranquilizers aren’t really the best treatment for that diagnosis. George had told me his nerves are bad, but I had demanded explanations and elaborations about his feelings to me.
How fair is it to insist on hearing just the right words to fit my diagnostic template for generalized anxiety disorder? If George had been a child I would not have done that. If he suffered from dementia or a stroke, I would have had to go on what I have seen for myself – a hurried man who seldom speaks, plagued by terrible tremors, helped by tranquilizers or beer.
I hadn’t listened all those times when he literally spelled out his diagnosis for me:
“Hey, Doc, can you give me something for my nerves?”
Acohol IS a great anxiolytic.