Curing a case of deep denial

FRANK was a 50-year-old jeweler who loved to drink, eat and stay out late in bars. He weighed well over 300 pounds, smoked two packs of cigarettes daily and admitted to me, his physician and friend, that he was probably on his way to an early grave.

His father, also a patient of mine, had suffered a severe heart attack at age 39. The scare led him to stop smoking and to begin taking long walks and improve his diet. Despite this family history, though, Frank refused to reform. It was as if he felt resigned to a heart attack.

He was like a lot of men I’ve taken care of, living in denial until a medical scare reminds them of their vulnerability. Why this is often the case, I’m not sure, but I suspect it has a lot to do with how we men see our role in society.

We’re stuck on the outdated concept that we are the protectors who cannot admit weakness. And by the time a man realizes he has to change, sometimes it’s too late to save his health.

Two years ago, Frank began to experience bouts of chest pressure. Although he was worried it was his heart, he swigged Mylanta and tried to ignore the symptoms. I urged him to schedule a stress test, but he began to dodge my phone calls and canceled multiple office visits.

Finally, when the chest pain became so severe it wouldn’t remit, he went to the emergency room. The ER doctor called me fearing the worst.

But Frank’s electrocardiogram was normal, his cardiac enzymes (which test for heart damage) were negative, and he was discharged with the stomach pill Prevacid for a presumed case of gastritis.

He acknowledged my suggestion that he go see a gastroenterologist, writing down the doctor’s name -- but he never made an appointment. Frank returned to his lifestyle of heavy eating and smoking. He said the negative results in the ER had reassured him, and now he seemed to be in even more denial. He popped a Prevacid whenever he felt the slightest discomfort.

“Maybe I’ll be spared my father’s fate,” he said hopefully.

But he continued to experience chest pains, and after a few months, he was back in the ER. The initial tests were once again negative, but this time I kept him overnight for observation and arranged for a stress test before discharging him.

The final results were also negative, and I anticipated Frank would quickly return to a lifestyle of binging. He had every major cardiac risk factor: family history, smoking, obesity, unregulated high blood pressure and diabetes. He might not have heart disease now, but I felt certain he eventually would. I hadn’t found a way to dissuade him from his dangerous habits.

But Frank surprised me. He scheduled an office visit for the following week -- and actually showed up. He looked worried, and said he wanted my help.

“It wasn’t my heart this time, but now I feel like I’m a walking time bomb.”

Clearly jolted by the second hospital visit, Frank’s attitude toward his health began to improve. Whether it was his heart that afflicted him, he saw that his life was being punctuated by repeated scary visits to the ER. He finally realized he had to do something to stop this.

I prescribed Wellbutrin, an antidepressant that can reduce cravings for cigarettes, and Frank began to take it. He also accepted a pill for his diabetes and another for his high blood pressure. He requested a diet pill as well, but I declined, explaining that I wanted to try to control his blood pressure before considering a stimulant. In the meantime, he began to exercise.

When he saw me next, a month after his second visit to the ER, he had lost 30 pounds, was smoking only four cigarettes a day, and was compliant with his blood pressure and diabetes medications.

On this visit, he admitted that part of the reason he had ignored his deteriorating health was his embarrassment over his weight. All his male friends of similar age were in much better shape; they exercised and watched their diets. Among them, he was “fat Frank” -- and this made him feel so humiliated and depressed that he lacked the emotional strength to deal with his physical problems.

When he finally realized that he had to change, he managed to follow a fairly vigorous schedule of walking and swimming.

He still had the occasional heavy meal, but with the help of Wellbutrin, he kept away from cigarettes. I suspected this drug was also treating Frank’s depression (it was an antidepressant, after all), though it was possible that the hormonal changes associated with regular exercise were helping improve his mood too.

Frank’s cycle of worry and denial is common among men with a poor self-image and untreated depression. Many fail to respond to the warning signs, no matter how serious. Luckily, in Frank’s case, the second shock of the ER was enough.

For some of my patients, this kind of trigger leads to a healthier life than they’ve ever had. For others, the pull of denial is so strong or the onset of disease so sudden that by the time they see the light, it’s too late.

Dr. Marc Siegel is an associate professor of medicine at New York University’s School of Medicine and the author of the new book “False Alarm: The Truth About the Epidemic of Fear.”