PERIPHERALIA

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One of the advantages of general practice is that one can 
observe patients over a long period. Every now and again,  
I have had the feeling that a few of my patients seem to have 
“become” their illnesses. When they started out, the condition 
and its symptoms were vague and unformed. Slowly, as more 
information was obtained and labels were applied, they 
began to identify with the labels and almost live them. If the 
mask is worn long enough, they say, it becomes the face. 

These conditions may affect their relationships, and can 
be used by the patient to avoid personal, social or work 
responsibility. It is often difficult to know whether this is 
performed consciously, or whether they are no longer able to 
view it from an external perspective. The condition takes on 
a life of its own. Perception starts to outweigh reality. There 
is often a marked disparity between the subjective reality 
of the patient, and the hard analytic reality of the doctor, 
or even the obverse, of the subjective views of the doctor 
and the life world of the patient. In order to move forward, 
I sometimes find that I have to sacrifice some of my own 
realities and perspectives for those of the patient, as long as  
I can judge that there is no harm in doing so.

As the journey of the illness continues, the patient and the 
doctor may build up the condition as further tests are carried 
out, and they both place their beliefs and agendas into the 
mix (known as the joint construction of narrative). Parts of 
the story are added by specialists and other alternative 
agencies, such as homeopathy and physical therapists.

The condition may start off in the eyes of medical science as 
a false premise, and then become a self-fulfilling prophecy as 
the patient searches for confirming evidence. The sociologist, 
Robert Merton, called a self-fulfilling prophecy a situation 
where “a false definition in the beginning evokes a new 
behaviour, which makes the original false conception come 
true”. The alleged causes allow the patient to make sense of 
their world in ways that medical theories may not accept. 
This is, in some ways, a good thing, and therapeutic for the 
patient, as well as having its disadvantages.

Reducing an experience into a diagnosis may embed it 
further, especially in a patient with a disposition that is 
susceptible to suggestion. An existential transference may 
occur, although this does not need to be consistent with all 
facets of the patient’s life. It may only occur within certain 
relationships, or in consultation with the doctor. It may not 

be present unless social stressors arise in the rest of the 
patient’s everyday life. We all carry several identities, and 
I often wonder about all the parallel universes in which we 
live. This occurs when a patient leaves my consulting room 
after a consultation involving much angst and despair. I then 
see, through the window, that she is merrily greeting and 
laughing with friends in the car park. 

The patient’s belief in the cause and description of his or 
her illness is often an imaginative enterprise. There are 
reference points from the past, i.e. “Since the accident” and “It 
gradually came on after”, which are told as epiphanies or as 
Damascene life events. This is part of what is called narrative 
reconstruction. Over time, as the patient repeats the story to 
doctors and family members, the condition firms up, and the 
patient may start to communicate through their new illness 
persona. Many of these patients may not fully accept the 
medical explanations of their illnesses, and add in other more 
mystical and social dimensions. This can be both beneficial 
and detrimental.

One can gain control over an illness by justifying a cause, but 
also by denying it, or at least denying some of the alternative 
explanations. There are many theories around this way of 
being, which include the patient adopting what is called the 
sick role or having secondary gains or a hidden agenda. 

Many of these illnesses are forms of pain and fatigue 
syndromes, as well as psychiatric diagnoses, and may carry 
different meanings for the patient and the doctor, as well as 
advantages and disadvantages to both parties.

The Roman philosopher, Seneca, famously said that it was 
part of the cure to wish to be cured, and I often find in these 
cases that I have acquiesced into a listening and agreeing 
mode. Perhaps one of the ways of coming to terms with 
some of these life worlds is to grok them. “Grok” means to 
understand deeply or intuitively, and is a sort of advanced 
empathy. It was coined by Robert Heinlein in his book, 
Stranger in a strange land. To grok something is to be one 
with it in a way whereby the observer and the observed get 
onto the same wavelength, and then move forward in a joint 
venture of healing.

Dr Chris Ellis, Family Physician,  
Pietermaritzburg, KwaZulu-Natal 
email: cristobalellis@gmail.com

Becoming the illness

“What you think, you become” – 
Buddha