"Is it allright if--" the patient, perched upon the examination table, cut easily into the doctor's attempt to apologize for our presence: "Absolutely! Come on in," he grins at us from behind huge wrap-around shades, "I'm used to it by now."
As the doctor examines some paperwork in preparation for the examination, the patient welcomes us, a small throng of summer students, into the examination room, and asks us, "So, have you ever seen what I have?"
None of us had even heard of blepharospasms before that day, so we told him we had not.
The patient then proceeded to remove one pair of shades, only to reveal a second pair of smaller sunglasses, which he also removed.
As he removed the second pair of sunglasses, we saw his eyes beging to shut spasmodically--violent continuous convulsions localized and centered upon his eyes, which he soon masked again after a few seconds that put us all--except perhaps the patient, who was by now quite used to this--into a state of extreme discomfort.
The patient explained to us that his problems began with a twitch in one eye, progressing and precipitating ultimately into his current condition. When he is concentrating--when working at the steel mill (on rails hundreds of feet in the air, he adds with emphasis) or when reading--he can control and temporarily stop the spasms. But if his concentration lapses (even for a moment, he impresses) the spasms return immediately. He explained the multiple layers of sunglasses--the spasms are illicited particularly in the presence of light. He experiences no problems at night.
He has been receiving injections of botox--a muscle-weakening toxin treatment effective on 98% of belpharospasm patients. Injections of even extremely high doses of botox type 1 have had little effect upon him; neither have more recent injections of botox type 2, even though he is not immune to either toxin.
A short examination that indicated a slight decrease in muscle strength (extremely slight--this man had the most highly developed muscles protruding in large bulges above his eyebrows that I had ever seen). The doctor told the man with the eye spasms that in a month they would up the botox treatment dosage one more time, but that drastic improvement was unlikely to result.
The patient had just one question for the doctor: "if these treatments work for 98% of people with this problem, and I'm not immune to these treatments, why aren't they working on me?"
Just then another doctor, the one presiding over the clinic that day, came into the room, and immediately adopted a drastically different tone with the patient, emphasizing the increased weakness as an improvement and trying to convince him of the potential for further improvement. He told the man that his condition was unique, not typical of blepharospasms, which was why he was not responding the same way to botox treatements, but the doctor did not elaborate.
When the patient had left, the presiding doctor explained to us that this man was probably suffering from a psychogenic disease (from the greek, a disease born of the mind) and that his disease in fact probably had deep psychological roots.
Once again, I was struck by the relative impotence of a system in which psychiatry and medicine are segragated and sometimes even opposed to deal with such patients.