Healing a HYPOCHONDRIAC

It happens to every medical student sooner or later. You get a cough that persists for a while or feel a funny pain in the stomach or notice a tiny lump under the skin. Ordinarily, you would just ignore it — but now, armed with your rapidly growing store of medical knowledge, you can’t help worrying. The cough could mean just a cold, but it could also be a sign of lung cancer. A twinge might be internal bleeding. The lump is probably a lymph node — but is it bigger than it should be? Could it be Hodgkin’s disease?

For doctors in training, nurses and medical journalists, hypochondria is an occupational hazard. The feeling usually passes after a while, leaving only a funny story to tell at a dinner party. But for the tens of thousands who suffer from true hypochondria, it’s no joke. Hypochondriacs live in constant terror that they are dying of some awful disease, or even several awful diseases at once. Doctors can assure them that there’s nothing wrong, but since the cough or the pain is real, the assurances fall on deaf ears. And because no physician or test can offer a 100% guarantee that one doesn’t have cancer or multiple sclerosis or an ulcer, a hypochondriac always has fuel to feed his or her worst fears.

Hypochondriacs don’t harm just themselves; they clog the whole health-care system. Although they account for only about 6% of the patients who visit doctors every year, they tend to burden their physicians with frequent visits that take up inordinate amounts of time. According to one estimate, hypochondria racks up some $20 billion in wasted medical resources in the U.S. alone. And the problem may be getting worse, thanks to the proliferation of medical information on the Internet. “They go on the Web,” says Dr. Arthur Barsky, a psychiatrist at Harvard Medical School and Brigham and Women’s Hospital in Boston, “and learn about new diseases and new presentations of old diseases that they never even knew about before.” Doctors have taken to calling this phenomenon cyberchondria.

Most physicians tend to think of hypochondriacs as nuisances — patients they are just as happy to lose. But a few clinicians, like Barsky and Columbia University neuropsychiatrist Dr. Brian Fallon, have begun to take the condition more seriously. “It’s not correct to say there’s nothing wrong with a hypochondriac,” Fallon asserts. “There is something wrong, but it’s a disorder of thought, not of the body.” And, as he points out, disorders of thought are neither imaginary nor untreatable.

That’s something Fallon realized a little more than a decade ago. He was studying obsessive-compulsive disorder (OCD) when he noticed it had a lot in common with hypochondria. “Both disorders,” he says, “involve intrusive, worrisome thoughts, the need for reassurance and a low tolerance for uncertainty.” Psychiatrists had lately come to think that OCD could be treated with Prozac and similar drugs, and Fallon decided the medications might work for hypochondria as well. With only 57 subjects, the study was too small to be definitive, but it was certainly promising: about 75% of those who got the drug showed significant improvement.

But so did many in the placebo group, which led Fallon to take an even closer look. His conclusion: hypochondriacs may actually represent three different groups whose problems look superficially similar. Those in the first really do have a variant of OCD. Those in the second have a problem more like depression, often triggered by something that makes them feel guilty — an affair, perhaps — or by a loss, like the death of a close relative. And the third group consists of people who somatize — which means they focus an inordinate amount of attention on their bodies. A pain that most people wouldn’t even notice feels like a punch in the nose to those in this group.

In all cases, though, the descent into hypochondria takes the form of a self-reinforcing spiral. You notice a symptom, decide it’s unusual and begin exploring for more. Since we all have minor twinges from time to time, when you go looking for more, you find them. “You build a case in your own mind that something’s wrong,” says Barsky. Even if a doctor assures you it isn’t true, you have the symptoms to prove to yourself that the doctor is mistaken.

The key to treatment is disrupting the cycle. That can be tough, however, since doctors rarely tell hypochondriacs the truth about their disorder. When Fallon tried to recruit study subjects through their doctors, he got nowhere; physicians evidently didn’t want to embarrass or anger their patients by suggesting they might be hypochondriacs.

To avoid stigmatizing their patients, Fallon and Barsky avoid the H word altogether. Fallon calls it “heightened illness concern,” and Barsky doesn’t use any label at all. “The first thing I do,” says Barsky, “is acknowledge the patient’s symptoms and say we have no good explanation for them.” Then he suggests that the patient do some psychological work, which he tells them is often helpful in such situations.

His preferred technique is cognitive behavioral therapy, in which patients are trained to force their attention away from the symptoms. “Just as focusing on a pain makes it seem more significant, ignoring it can make it seem much less,” says Barsky. Patients are also instructed to counter panicky thoughts with self-reassurance, reminding themselves, for example, that stomach pain almost never means stomach cancer. Both cognitive therapy and medication seem to work, and at this point it’s hard to say whether one is better than the other. “Nobody’s done a comparative trial,” says Fallon, “although Barsky and I are working on that.”

Both men agree that their primary-care colleagues aren’t very well attuned to the problem. “Things are improving,” says Barsky, “but there’s not a heck of a lot of education about hypochondria in medical school. We teach doctors that their job is to find disease and weed out those who are physically well. They have no time for hypochondriacs.” It needn’t take as much time as they think, though. “It’s not hard to identify a hypochondriac,” says Fallon, “if you have the right antenna out.” And once a hypochondriac is identified and properly treated, no one is happier than his or her doctor.

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