by Marc D. Feldman, M.D.
"Hypochondriac" is one of those psychiatric terms that have insinuated themselves into everyday parlance. And we all know at least one person who qualifies for the title.
In hypochondriasis (the formal term), an individual is preoccupied not only with symptoms that lack a medical basis but with the conviction that the symptoms point to a serious disease lurking in the background.
Most of us can accept a few fleeting pains as one of the vagaries of the human body. For others, however, symptoms such as these become ominous portents of serious medical illness. It is this belief that is at the core of hypochondriasis. Even illustrious figures such as Charles Darwin and piano virtuoso Glenn Gould have fallen prey to this mental disorder.
Today, family doctors and internists encounter hypochondriasis in up to 9% of their patients, with its severity ranging from a relatively mild state of worry to an intense, nearly delusional belief that one is terminally ill. The most common fears hypochondriacal patients have are of cancer or heart disease; the most common symptoms are headaches, back pain, and dizziness.
In their quest for reassurance about their physical condition, patients sometimes alienate family and friends. One woman, for instance, demanded reassurance of her good health from her husband more than 30 times a day.
Hypochondriasis tends to strike in early adulthood. The people at greatest risk are those who have had a serious illness in childhood, grew up in households dominated by parents' "health hysteria," are facing high levels of stress, have coexisting depression and anxiety, or have recently experienced the death of a loved one.
Why Me?
Traditional thinking has maintained that patients with hypochondriasis are expressing their inner conflicts via their illness obsessions. After all, it's more acceptable in our society to be sick than crazy. Other theories hold that genetics plays a role or that hypochondriacal patients have brains that are far too attuned to physical sensations (the so-called "noisy body" theory).
The Costs of Being "Sick"
Any time that hypochondriasis is diagnosed, the health professional is implicitly stating that he or she has ruled out a genuine medical basis for the symptoms. But some diseases, such as multiple sclerosis and lupus, can be notoriously difficult to diagnose in the early stages.
When has "enough" testing been performed? For the hypochondriacal patient, the answer is "Never."
The dilemma is intensified by the ready availability of many thousands of lab tests, X-rays, radionuclide scans, and the like. The nonessential treatments administered to hypochondriacal patients cost the health care system $20 to $30 billion per year.
Treatment For A Hypochondriac
Treatment for hypochondriasis is a puzzle. Part of the difficulty stems from the fact that these patients almost always lack motivation to lessen their medical vigilance. Thus, at the same time that they enlist help from medical professionals, they reject the conclusion that all is well; rarely is reassurance alone enough for them to let down their guard.
Doctor-shopping—that is, transferring care to a new and "more understanding" physician, followed by another, and another—is the rule in these situations. Although they'd be loath to admit it, that tendency of patients to move on is a relief for many physicians. The doctors and patients both feel badgered in a game they can't possibly win.
Psychiatric medications, especially serotonin uptake inhibitors, can be helpful in some cases of hypochondriasis. Psychotherapy sessions, when the patient is willing to commit to them, usually focus on careful explanations about the innocuousness of the physical complaints. At the same time, the patient's attention is redirected away from medical concerns, and his or her fears and beliefs about illness are gradually explored.
Behavior therapy can be helpful in some cases, taking a variety of forms. In a 1988 study, the behavior-therapy techniques included:
- exposure (e.g., having a patient frightened of a heart attack sit for long periods in a cardiology waiting room);
- satiation (e.g., having the patient repeatedly write down his or her fears in detail);
- paradox (e.g., having the patient strenuously exercise as if to try to "bring on" the baseless heart attack he or she fears so intensely);
- banning of reassurance (e.g., teaching relatives to withhold sympathy and forbidding the patient from undergoing further exams and tests). This last option is extreme, and should be used only when the patient clearly has a mental, rather than physical disorder.
Alternative techniques—such as self-hypnosis, yoga, aerobic exercise, and transcendental meditation—can increase some hypochondriacal patients' feelings of well-being. Distraction from physical sensations, perhaps through increased social activities or volunteer work, can help disrupt the focus on self-perceived ailments.
Patients who have had a sudden onset of their hypochondriasis—perhaps due to intense but short-lived stressors—have the best prognosis. Depressed hypochondriacal patients may also do well; treatment of the underlying depression may remedy the problem.
Still other patients seem to get over their hypochondriasis spontaneously. Encountering undeniable illness in another person can also trigger the realization that the worries have been out of proportion, even shameful by comparison.
There is no sure-fire cure. For far too many patients with hypochondriasis, the preoccupation with illness becomes a way of life—a cuddly, warm blanket they refuse to give up.
Equally unfortunate is the fact that for too many lazy or arrogant health care providers, the diagnosis is easy to use when the expertise needed to find a what's wrong with a patient isn't available.
Two things are certain, hypochondriasis does exist, as do unexplained physical symptoms. Differentiating whether or not a person is a hypochondriac or has another illness, is a challenge that creates a dilemma that will most certainly continue for a long time.
References
Abramowitz JS. Hypochondriasis: conceptualization, treatment, and relationship to obsessive compulsive disorder. Ann Clin Psychiatry 2005; 17:211-217
Feldman MD, Feldman JM. Stranger Than Fiction: When Our Minds Betray Us. Washington, DC, American Psychiatric Press, Inc., 1998
Harding KJ, Skritskaya N, Doherty E, et al. Advances in understanding illness anxiety. Curr Psychiatry Rep 2008; 10:311-317
About the Author:
Marc D. Feldman, M.D. is the author of "Playing Sick? Untangling the Web of Munchausen Syndrome, Munchausen by Proxy, Malingering, and Factitious Disorder" (2004) and co-author of "Stranger Than Fiction: When Our Minds Betray Us" (1998).