How Do You Know If You're Really Sick?

How can you know if you are really sick? Like life-threatening, need-to-get-help-right-away sort of sick.

In my Emergency Department, life-threatening illness is often spotted as easily as pornography and poor fashion sense—we know it when we see it. But for most people, in most situations, sorting out true illness can be difficult. Many healthy folks seek care for nothing because they are anxious about disease, while some very unwell people stick it out at home, in full-on denial or stoically convinced that they can will themselves better.

What’s the difference between a mind that causes illness and one that can detect sickness early? This would seem to be an important question not only for the field of medicine, but also for every single living and thinking “patient” in the world.

Auras and Premonitions

Do we, as humans, have a muted and under-recognized sense of our own sickness? With better recognition skills, could people serve as their own triage nurses? Phone advice lines are great, but wouldn’t it be nice if our patients had a reliable sense of sickness—an epiphany of medical impairment? Well, let’s consider some examples, starting with the “aura”:

The aura that “precedes the headache of migraine is very mysterious… there is a process of intense activity which seems to spread, like the ripples in a pond into which a stone is thrown.” So wrote British neurologist Sir William Gowers in 1906 [1]. He continues “… the most frequent among the many forms is that of a small star near the fixing point; it enlarges towards one side, its rays expanding into zigzags.”

Source: Foundry/Pixabay

Auras, as we know, are also common in people with migraines and epilepsy and come in a wide variety of forms—a kaleidoscope of lights, the smell of burnt toast, the sound of a public address announcer booming—and may occur seconds to hours before the onset of a headache or seizure. For a patient with epilepsy or a migraineur, the aura is an extremely reliable indicator of impending symptoms (far more accurate than routinely available clinical evaluation or testing.) Absent fancy tests like continuous functional MRI or EEG monitoring, most would consider auras the gold standard of disease prediction.

Yet we don’t really understand where auras come from. We assume of course that they are associated with excitation or injury of specific cortical areas preceding the onset of more generalized processes but have not been able to actually capture the pathology and neural circuitry of this process.

Is it possible then that auras are a prominent manifestation of an innate mental ability to detect illness that represents a more global function: a synthesis of inputs that triggers a sense and premonition of impending illness or death?

Consider some other health-related premonitions. A colleague tells a story of an aunt who suffered for months with headaches and dizziness, of unknown etiology. After many visits to her doctor and failed treatments, she became convinced that she was going to die. So convinced, in fact, that she began preparing and freezing dozens of meals, so that her husband would eat well after she passed. Ultimately, her cerebral aneurysm was diagnosed just shortly prior to rupture. She did not die but was right on about being on the verge of it.

While not a rich topic in the literature, there is some evidence supporting a premonition of death as a real entity. For example, it is not uncommon for pregnant women who miscarry or otherwise lose their pregnancy to report experiencing a premonition beforehand. For example, in a survey study of women who suffered a stillbirth in the second trimester or later, 64 percent reported some premonition that their child was unwell [2].

And there are a handful of case reports of other kinds of apparent premonitions sprinkled through the literature. Joseph Ngeh, in a 2003 letter to the Journal of the American Geriatrics Society, describes one such premonition in the in-hospital death of an elderly patient [3]:

“The patient’s family had arrived by then. Although distraught, they showed no surprise at hearing about the patient’s sudden death. During our conversation, I sensed that they had expected this to happen. Remarkably, the daughter-in-law volunteered that, when they visited the patient at 9 p.m. earlier that night, a mere 6 hours before the patient’s first cardiopulmonary arrest, the patient had held her hand and mentioned that he would ‘die tonight.’”

Premonitions of death are also common in trauma patients; in a 2009 survey-based study by Miglietta and colleagues of 302 members of the Eastern Association for the Surgery of Trauma, ninety-five percent of respondents reported encountering patients who expressed such a premonition and fifty percent agreed that patients expressing such premonitions had a higher mortality rate [4]. Fifty-seven percent also agreed with the belief that patient willpower affects outcome while forty-four percent were on board with the notion that patients have an innate ability to sense their ultimate outcome after injury.

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Now, such “evidence” must be considered in light of its limitations. Recall bias is an obvious limitation—there are surely many pregnant women and trauma patients who thrive or recover despite premonitions to the contrary. We must also distinguish the premonition of death from the ancient Chinese phenomenon of Hui Guang Fan Zhao, also called Lazarus premonition. This refers to a scenario that screenwriters have made liberal use of for decades—the transient revival of the dying person before death. This situation is clearly different, as it is not so much a premonition as it is the recognition of a process, like a song in its last chorus, that is nearly complete.

And, of course, absent a biological explanation, it’s impossible to prove that humans have an innate sense of sickness. I would argue, though, that we should not be overly skeptical. We accept the fact that animals may intuit when they or others are ill—remember Oscar the cat (featured in the New England Journal of Medicine in 2007) who correctly foretold the deaths of over 50 patients in a nursing home—curling up with them within hours of their death [5]? We also accept that certain animals, and my dear departed black lab was one of these, will innately put themselves out to pasture near the time of their death (in the case of my lab, this did not work, as my wife kept carrying her back inside from the bushes).

So it seems biologically and intuitively plausible that we humans have an innate aurascope that can sense true illness. And if it exists, there may be ways to cultivate and enhance it.