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A hypochondriac is someone who, experiencing certain symptoms, immediately imagines that he/she is suffering from the most serious condition that could explain those symptoms. We call such people health worriers. The health worriers we see in our clinic tend to worry that they may have a disease that is not evident right now, but might be lurking unseen, and is likely to be fatal. There aren’t very many such diseases. Some of these patients concentrate on the possibility of being infected with AIDS. They test themselves for the illness over and over again, but are not reassured by a series of negative tests. Some worry about neurological diseases, such as multiple sclerosis, or Lou Gehrig’s disease. The heart is always felt to be a critical organ, and some patients are afraid that they are on the verge of having a heart attack. Actually, they are more likely to think they have just had a heart attack that has been missed by the examining physician. Some people fear they may be having “little strokes,” which are premonitory for a really big stroke. Some people worry about hypertension or diabetes, mostly because they think these diseases, which are serious, are still more serious than they really are. Some people have a “favorite” disease they worry about because that particular disease runs in their family. Still, the most common fear these patients have is of cancer. Brain tumors and pancreatic cancers predominate, probably because they are more likely to be fatal. Also, pancreatic cancers are notorious for generating little in the way of symptoms until the condition is too far advanced to be cured; so, anyone, including them, might be suffering from pancreatic cancer. Since one symptom of a brain tumor is headaches, they surmise that their headaches might come from a brain tumor. Other than their fears, there is little to set these patients apart from everyone else. They are just as smart as everyone else. Some are physicians, themselves. I remember off-hand, a cardiologist, a psychiatrist, a couple of internists and a pediatrician. Anyone can be a health worrier.
It is not clear just what a patient afraid of cancer is really afraid of. Some people say they are afraid of dying, that is, the process of dying. Some people are afraid of being dead. Their real fears are hard to elicit, but may range from mutilation, abandonment, and helplessness to other such existential fears.
A middle-aged man woke up every morning distressed, wondering if he was well. He would lie in bed, trying to feel whether or not he was all right. In particular, he worried about prostate cancer. He paid attention to any strange sensations that came from his lower abdomen and wondered whether they were a sign of prostate cancer. During the rest of the day, he was troubled every once in a while by the thought of getting this condition. His father had died of the disease.
With cognitive-behavioral treatment he improved, but still had occasional thoughts of prostate cancer, and what getting it would mean to his life. And then, a few years later, he developed prostate cancer!
He handled this diagnosis pretty much as anyone would. He contacted different doctors for their advice about treatment. He had the choice of surgery, or radiation, and having decided on surgery, he had to choose between conventional surgery and a newer laparoscopy kind of operation. When the time came, he prepared for the procedure and went through it and through the succeeding hospitalization without any more anxiety than anyone else would have felt. He managed the after-care comfortably. A few months later, it became apparent that he had stopped worrying about prostate cancer! He did not know why. He worried only on those follow-up visits when he took tests to indicate whether or not the cancer had spread. Two years later he was still not thinking about the cancer, even though he knew it might return.
There are two possible explanations: Exposure therapy is based on the idea that a frightened person who is not truly in danger will become unafraid if exposed to the frightening situation over and over again. Someone afraid of driving will become comfortable driving after spending enough time on the road. That may be as little as one hour a day, but for a considerable number of days. Similarly, someone who is phobic for shopping centers will become comfortable shopping in such places if he/she spends a couple of hours a day in that place and repeats that experience every few days over a week or so. It takes a certain amount of time for someone to become used to an unfamiliar and dreaded situation. Someone who has cancer, however, is exposing himself constantly to the idea of the illness. It is usually true, therefore, that the thought of the cancer recedes into the background. Such a person thinks mostly about other things, except when the cancer returns, or when the thought of cancer is brought up again by testing, or by the return of the cancer. If such a person is inclined to worry he/she will worry about something new, a different cancer, perhaps, or something completely different, such as radiation.
Knowing this man, however, I realized that the reason he stopped worrying is that the experience of having cancer was different from what he had anticipated. He imagined abandonment and helplessness. Nothing of the kind happened. The reality of cancer was not as bad as the fantasy of cancer. It is these other underlying fears that drive health anxiety. (c) Fredric Neuman 2012
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