BY GOD'S GRACE

My first impression on entering the exam room was that she was suffering from anorexia.  She was attractive, with light make-up, and her Kelly-green top and creased pants suit was a little loose in the hips.  She appeared forty but was only twenty-eight.

Her big mouth and beautiful teeth suggested she was happy but she complained of being tired, and maybe depressed, but wasn't sure.

"How long have you been tired?" I asked.
"As far back as I can remember.  Even since I was a small child."
"Ever seen a doctor about it before now?"
"No.  I'm not really keen on doctors but lately it's started to interfere with my work."
I asked, "What do you do?"
"I've been a paralegal for six years and now I'm losing my focus.  The lawyers I work
     for are noticing and I'm afraid I might lose my job.  I figured I needed to do
     something about it."
"Is there stress at work?"
"Well, it has its moments.  But I don't think it's stressful in a bad way.  I'm just so
     tired.  I get distracted easily."
"Do you have any other stressors in your life?"
She said "Not that I'm aware of."
"Okay.  Are you sleeping well?  Waking up rested?"
"Most days I suppose.  There are days I wake up tired, especially if I dream."
"Do you have bad dreams on these days you wake up tired?"
"Yes, especially when I have one particular dream."
"What's it about?"
She thought a second and took a deep breath. 
"Well, it's hard to explain.  But I'm under water in some kind of pool and I'm being
     pulled downward, deeper, by something.  I can't escape or get to the top.  My
     lungs are bursting, I'm losing my breath, and my back hurts from stretching to the
     top.  It's as if someone turned up the power on gravity and I'm barely able to
     make it to the top, gasping for air."
I kept writing.  "How often do you have this dream?"
"Maybe three or four times a week."
"Is there anything you've associated with what you do during the day with having the
     dreams that night?"
"I really haven't noticed.  But I do seem to have them on the days me and Mama talk
     on the phone or visit."
I asked, "And about how often is that?"
"Maybe four or five times a month.  Which is enough for me."
"Enough? Do y'all have a good relationship?"
"Well, I love my mother but she's so controlling.  She won't answer my calls and quits
     calling me when I do or say something that's disagreeable.  Mama's always wanted
     me to do things that she's wanted me to do.  It's never quite good enough.  
     Whether it's money, job, or clothes, that sort of thing."
"That's interesting," I said.  "She won't let you be yourself?"
"More or less.  She really got upset when I decided to major in criminal justice.  She
     wanted me to go into nursing like she did.  She always holds that over my head
     when we have differences."
"Seems like she's trying to control your life."
"She tries and I'll bring it up to her.  In fact, whenever I've gotten serious with a man
     she's always found something to bitch about him.  Then she'll just be horrible. 
     She won't call, won't visit, and won't answer my calls.  It's like some sort of
     punishment for my not choosing the right man.  Or I should say, choosing the
     wrong man according to her."
"Your mother's divorced?"
"Yes."
"Was your father mean to her?  Did they have a stable relationship?"
"Well, he was my stepfather.  Mama says my real Dad abandoned us before I was
     born.  But Mama says they'd just grown apart."
I said, "Okay.  Back to the nightmares.  It's interesting you're especially tired on these
     days.  What else can you tell me about it?  Where does it take place?  Are there
     any people around?"
"Well, the water I'm in has high walls and I have a feeling of having some kind of
     covering or dome over me."
"Like you're in a domed facility?"
"No, more like a small room with low ceilings, something like it, and I can almost
     reach up and touch it.  I get the feeling as if I could never escape it.  And all during
     the dream the leg pulling comes and goes during the entire dream.  In fact, my
     legs have always hurt.  Then I feel the same thing on my shoulders and arms, then
     I begin to swirl and twist around uncontrollably.  Just talking about it makes me
     nervous.  Just before I wake up I have this feeling I'm going to die."
"Okay."

I tell Brigid we need to do some blood work, check the glucose, the thyroid, and other things.

I tell her, "I think there's enough of a connection between your mother and this
     dream and your relationship that it might be beneficial to get some counseling. 
     Maybe even for the both of you, though I really don't know your mother.  You can
     be the judge of that.  But I think that might be helpful.  Let's see if the blood work
     is normal then we'll go from there."

The lab results all returned normal and Brigid was elated she did not have a serious problem.  She said she would call a psychologist for counseling.

Several weeks later I returned a missed call from Brigid's mother, Evelyn.  She was irate that I recommended counseling to include her.  She had questions but I told her about the HIPAA laws and would be glad to talk but with Brigid's permission.

Two weeks later Evelyn presented.  She was well dressed in church attire and projected an air of confidence and assertiveness.  I recapped Brigid's office visit, and emphasized that Brigid had made an association between her nightmares and their relationship, telling her I thought it was pertinent.

"Doctor, are you suggesting I'm the cause for her problems?  For putting her job in
     jeopardy?"
"Well, no, but to be honest I'm not sure.  There's something there and that's where a
     counselor can make a difference."  I asked, "What's your relationship like?"
"It's fine."
"Well, Brigid suggested you're more or less domineering in her life.  What's your take
     on that?"
She spluttered, then said, "You know, doctor, I raised her more or less as a single
     parent.  My first husband, her father, left me while I was carrying Brigid and I did
     the best I could.  And it bothers me that you and her are suggesting I have
     something to do with her problem.  Doctor, Brigid has always been a nervous and
     moody child.  Complaining and whining all the time about her arms and legs. 
     That's probably why she's not married."
"When you were carrying her did you smoke or drink heavily?  Were there any
     problems with the pregnancy, labor, and delivery?"
"Not really.  No, I didn't smoke or drink."  She paused.  "In fact, not only was the
     entire pregnancy uneventful, my labor was normal and the delivery was normal. 
     Everything went normal.  In fact, this was all in spite of a failed abortion."
"At what month of pregnancy was that?"
"At the end of the sixth month."