Excerpt 2: They Can’t Find Anything Wrong!

Childhood Stress: Karen

When Karen's diarrhea caused her to lose eighty-seven lbs. in eighteen months, you did not need to be a doctor to see she had a serious problem. She was afraid she had cancer, but looked surprisingly healthy at 115 lbs. Her physician hospitalized her for tests, all of which were normal. As we talked, she mentioned a remarkable feature of her illness: she had severe diarrhea only three or four days each week. The other days she felt fine. Few if any diseases caused by tumors, inflammation, infection or other visible abnormality would cause diarrhea that fluctuated so dramatically.

Stress illness, on the other hand, is often associated with highly variable symptoms, but none of her other doctors had inquired about stress. Our conversation reviewed all five types. Karen was 34, married to a bus driver, and they had a two year old son. She enjoyed her job making baked goods for a supermarket. She had never suffered a significant trauma and had no symptoms of anxiety or depression. Karen also had not experienced any obvious form of childhood mistreatment. If her illness was due to stress, I was missing something. My inquiry about childhood stress had focused on specific issues such as molestation and parental alcohol abuse. Perhaps I had been too specific. I tried to think of a more general and open-ended question.

"Did anything happen to you as a child that significantly lowered your self-esteem?" I asked.
"Oh, yes!" she replied immediately. "Every night at dinner my mom would talk to my sister and me about everything we had done wrong that day and what we should do to improve."

Night after night as she grew up, she endured this criticism. There was far less in the way of praise or support and Karen's self-esteem suffered significantly. Interviews with thousands of survivors of child abuse have taught me the enduring power of Karen's experience. Children will go through walls to please a parent and only a few stop trying when they become adults.

"How is your relationship with her now?" I asked.
"She's still doing it," she sighed.

Six months after Karen's son was born her mother started finding fault with her again. Not only did she criticize Karen's skills as a mother, but she commented on the shortcomings of her infant son, too. Karen's mother was important to her and she wanted her to have contact with her grandchild, but at the same time, she was very unhappy about her unrelenting disapproval. Sometimes Karen did not know if she wanted to hug her mother or kick her off the front porch. Karen definitely did not want her son to suffer as she had. There seemed to be no way out. The diarrhea began, her appetite declined and she shed five pounds each month.

"Karen, after all that you've been through, it's no wonder you became ill," I said.

As we spoke in her hospital room, she began to understand the impact of her mother's behavior on her self-esteem. After a long discussion, Karen understood how the return of her critical words left her feelings for her mother trapped between affection and resentment. She recognized how single-minded she had become in her endless attempts to gain her mother's approval. She became confident that she could share her concerns with her mother. I saw Karen's shoulders relax. Then she leaned back in the bed and took a deep breath. It was rewarding to see her determined expression as she spoke about her plans for coping with her mother.

The next day she was able to leave the hospital and the diarrhea never returned. She regained fifteen lbs. in three weeks and kept her weight steady thereafter. Then Karen and her mother had a conversation that helped clarify the harm of her mother's well-intentioned comments. The mother was defensive at first, but eventually she understood Karen's point of view. Their interactions became much more positive.

Karen's case illustrates the central importance of self-esteem. She never suffered any form of abuse that involved physical contact and her childhood home was stable, yet her mother's damaging words lowered Karen's self-esteem as much as other forms of abuse could have. To some people her mother's criticism and the prospect of enduring it for years to come may not seem sufficient to cause a severe illness. However, children will do nearly anything to earn parental approval. When they receive no praise, when nothing they accomplish is good enough, this emotional abuse can cause enduring harm that has led to physical illness in scores of my patients.

The repetition of Karen's childhood stress in her adult years is one way these issues can cause symptoms. In many other patients, the connection between adverse early experience and stress illness later in life is not obvious. A large number of my patients become ill years or even decades after they have grown and moved away from their dysfunctional family. In these cases, the illness is the result of the long-term consequences of childhood stress, a process usually hidden from those experiencing it. You will learn about this process in the next three sections and then more illustrative stories follow.