Hypochondria: The Impossible Illness
For millions, a cough is not merely a cough; it’s a drumroll of death, and no amount of diagnostic assurance can convince them otherwise. But the crosstalk between mind and body is such that we may all have a bit of the hypochondriac within.
By January 1, 2010 - last reviewed on June 9, 2016published
I am Dying
That pain on the left side of my stomach still hasn't gone away. It's been there for eight or nine months now. The ultrasound came up negative. So did the CT scan, the MRI and the colonoscopy.
"It's probably nothing," said one doctor.
"You likely pulled a muscle," said another.
"I'd ignore it," advised a third.
They are wrong. I know they are wrong. So, with nowhere else to turn, I seek out reassurance. "What do you think my stomach pain is?" I ask. "Do you think I'm OK?"
Eyes roll. "You're fine," my father says. "You're fine," my mother says. "You're fine," my sister-in-law says.
"You're 37 years old. You run marathons. You play basketball every Monday. You've never even broken a bone," my wife says. "You're fine."
I don't believe them. I can't believe them. I refuse to believe them. I wish I could believe them.
This is what it is to be a hypochondriac—what it is to live a life too often based upon the raw, carnal fear of inevitable, forthcoming, around-the-bend death. Though I was only recently diagnosed with the disorder, it has plagued me for more than a decade. Over the past 10 years, I have been convinced that I am dying of (in no particular order): brain cancer, stomach cancer, pancreatic cancer, testicular cancer, lung cancer, neck cancer, Lyme disease. When one ailment is dismissed by doctors, I inevitably rush to the Internet to learn why they are wrong. What? I don't have colon cancer? Then it must be....
A full-throttle hypochondriac like me convinces himself—beyond reassurance, beyond comfort, beyond anything—that a cut is never merely a cut, that a cough is never merely a cough. He doesn't merely think he feels the pain. He literally feels the pain.
On cue, I was overcome by dread. Actually, a blackness. I didn't want to talk to anyone. I didn't want to think. Or eat. I was dying. I knew I was dying.
My lowest moment came two summers ago, when—in the midst of an otherwise uneventful trip to Florida to see the in-laws—I was overcome by despair about the Lou Gehrig's disease eating away at my body. What brought it on? I'm not certain. Stress, perhaps. Or anxiety. My arms were heavy, my breathing was strained. I locked myself in a bedroom and told my wife to handle our two children without me. Finally, she insisted I get help. "This isn't going well," she said. "You need to talk to someone."
I immediately contacted a therapist, who convinced me of my irrationality. But now there's this pain in my stomach.
This damned pain ... the greeks invented the term to describe ailments caused by movement of the upper region of the abdomen—from hypo (below) and chondros (breast bone cartilage). By the late 19th century, however, hypochondriasis had come to mean "illness without a specific cause."
In the year 2010, hypochondriasis is as covert and confounding as ever. Regarded as a mental disorder in the Diagnostic and Statistical Manual (DSM) and categorized as a somatoform disorder, it is defined as "preoccupation with fears of having, or the idea that one has, a serious disease, based on a misinterpretation of bodily symptoms. This preoccupation must have been present for at least six months and persists despite adequate medical reassurance."
It is estimated that one of twenty Americans who visit doctors suffer from the disorder, though all figures are frustratingly inconclusive: One can be a lifelong hypochondriac and never know it, just as one can be convinced one is a hypochondriac and, in fact, be physically ill.
Indeed, hypochondriasis is the Big Foot of disorders—studied, discussed, but persistently elusive. Some people who are hypochondriacs might classify themselves as merely physically sick. "It's very hard to quantify," says Peter T. Swanljung, medical director of the General Adults Unit at Friends Hospital in Philadelphia. Part of the problem is that hypochondriasis exists on a broad spectrum. The worst-case hypochondriacs can delve into the deepest depths of depression—lengthy, unwieldy funks evoked by self-diagnosis and fear of the unknown. Consequently, somewhere in Tulsa, a man is worried that the cut on his foot is a flesh-eating virus. He frets and frets and frets for a week, then gradually forgets about it. A month later, he fears that the spot on his arm is a deadly goose virus. It fades, too.
Despite official recognition in the DSM, those with hypochondriasis are often treated with the respect and seriousness of a Scott Baio film festival. "It's an obsession, and oftentimes people don't want to listen to someone's obsessions," says Gail Martz-Nelson, a Denver psychologist specializing in anxiety disorders. "'I'm terrified I have HIV, I'm terrified I have cancer, I'm terrified I have lymphoma.' People hear that and dismiss it or laugh it off. But being a hypochondriac can be crippling. It's not a joke."
Generally speaking, hypochondriacs aren't merely hypochondriacs. Most struggle with anxiety or depression—or both, says Swanljung. "When someone is anxious about having an illness, the anxiety level goes up, the stress level goes up," he says. "That can lead to headaches, to stomach and digestive problems. Anxiety definitely can cause pain, and if you're a hypochondriac you react to that pain in a unique way."
No amount of reassurance helps.
"The brain is so powerful that it really can convince itself of illness," says Caroline Goldmacher-Kern, a New York-based psychotherapist who specializes in anxiety disorders. "You know something is wrong because you believe what you're thinking, and what you're thinking is what you perceive to be feeling. So you can have five people tell you it's all in your mind and that's not good enough."
But in fact, all illnesses are psychosomatic, contends Suzanne Koven, an internist at Massachusetts General Hospital. "All illnesses involve both mind and body," which suggests that one way conditions differ is in the relative contributions of psyche and soma. Koven points out that "the simplest sore throat brings a tide of emotion—sometimes fear (What if I miss too much work? Will I lose my job?), sometimes guilt (Will anyone catch this from me?), sometimes anger (Who did I catch this from?). And conversely, emotions often communicate in the language of the body: a tension headache, for example, or stress-induced upset stomach.
Although hypochondria is formally regarded as a mental disorder, Koven, who sees hypochondriacs every day in her medical practice, has a slightly more expansive view. "We all walk that side of the street a bit. None of us are disembodied; we all have personalities and fears and hopes. It's a matter of degree." One distinguishing factor: Hypochondriacs "get something subconsciously from the illness role," she suggests.
The causes of hypochondriasis seem no more concrete than the symptoms. Some argue that, given the larger axis of anxiety and depression, the condition is largely genetic. Others believe it's learned. "A child is raised by a mother who always fears her kids are sick," says Brian A. Fallon, director of the Center for Neuroinflammatory Disorders and Biobehavioral Medicine at Columbia University. "Then the child becomes an adult and worries irrationally about health issues." Stress is often a catalyst, as is personal tragedy—such as the death of a loved one.
As a boy growing up in Mahopac, New York, I was reared by parents who rarely fretted about my health. I've never lost a loved one who was younger than age 80, and my greatest personal injury was a dislocated shoulder 10 years ago (painful, but certainly not tragic). As for stress, well, I cover sports for a living. Hardly flying jets into enemy territory.
The one thing I did have, however, was Grandpa Curt, an ornery, brooding man whose night table was topped with a cornucopia of pill bottles and whose hands routinely trembled as if his fingers housed jumping beans. When we visited my grandparents in their Manhattan apartment, I would tiptoe around Grandpa, fearful of brushing against him and drawing his ire.
"He went to the doctor at least once per week," my mother recently recalled. "He'd call the doctors all the time, and after a while they didn't want to take his phone calls. He was never terribly sick, but he always thought he was."
So can I blame this on genes? "That'd be hard to say," says Fallon. "There are so many factors."
If the disorder remains mysterious and understudied, treatments do not. As researchers from the University of Groningen reported in late 2008, cognitive therapy can be "effective in decreasing hypochondriacal complaints, depressive complaints, and trait anxiety." The study cemented the role of what is now the most widely regarded method for tackling the disorder.
"I believe in a cognitive technique called exposure with response prevention," says Martz-Nelson. "You take an obsession and confront it directly. Let's say someone has an irrational fear that he has HIV. That person moves toward the fear, maybe spending time around somebody who has HIV, maybe going to a medical facility. The goal is to do something you've been avoiding."
Initially the process increases anxiety levels. "But over time," she says, "it will settle down and stop meaning so much. You've confronted your fear up close, and you see it for what it truly is: merely a fear, not a reality."
A growing number of doctors are also viewing hypochondriasis as something that can be treated via various antidepressant drugs. "In the right cases, medication can certainly help," says Goldmacher-Kern. "Just as anxiety can be treated with medication, hypochondriasis can, too. If it works, fantastic." The trouble is, it doesn't always work.
Eleven years ago, when he was still a medical resident at Columbia University, Fallon was asked to help a man who was convinced, despite medical results to the contrary, that he was saddled with a brain tumor. "He tried Prozac, and it made a dramatic change," Fallon says. "He went from irritable and hostile to grateful and happy that something was helping him. I thought, 'Wow, this is fascinating.' Because at that point so little was known."
The use of Prozac and similar medications is now under formal study. Columbia's Fallon and Arthur Barsky, a professor of psychiatry at Harvard Medical School, are conducting the largest trial ever undertaken of the disorder. They are enrolling 264 hypochondriacs in a randomized, placebo-controlled clinical trial comparing cognitive behavioral therapy, Prozac, and a combination of the two. They suspect that CBT and the drug will be equally effective, but that combination therapy will be even more effective for "this major public health disorder." "I don't know what to expect," says Fallon. "But it will be very interesting."
Two days after speaking with Fallon, I find myself sitting across from a therapist specializing in cognitive therapy. It is our first session, and as I tell him about my health issues, and my troubled mental state, and my grandfather, and my weaknesses, he nods knowingly. I feel naked. Embarrassed. At times, stupid. I am a healthy man with a great family, a great job, a great life.
"What am I doing here?" I ask, dumbly. "What in the world am I doing here?"
"You're getting help," he says, nodding. "And you're trying to end the pain."
Tears stream down my cheeks.
Yes, indeed, I am. —Jeff Pearlman
The Struggle to Understand Hypochondria
According to Columbia’s Brian Fallon, there are three types of hypochondria. A person with the obsessional-anxious type repeatedly worries, repeatedly asks for assurance, and cannot get out of his mind that something serious may have been missed by the doctor. When we think of a hypochondriac, this is the person we think of, who goes to the doctor over and over again.
The depressive hypochondriac enters the doctor’s office with tears in her eyes, insists she’s dying and that there’s no point even getting tested. Or she might avoid going to the doctor to avoid confirmation of her fears. She might be driven by the guilt of having had an affair and the fear of having contracted HIV. Depressive hypochondria can evolve into a serious delusional type in which the person is convinced of the disorder and has no insight into the irrationality of her fears. She is at risk for suicide.
The somatoform type of hypochondriac has many physical symptoms and assumes there’s a serious underlying cause but doesn’t necessarily jump to catastrophic conclusions. He just wants the doctor to figure out the cause of the persistent pain and how to get rid of it. Such patients resemble those with somatoform disorder, but worry that there’s a significant illness.
Current ways of categorizing somatoform disorders are problematic. They don’t capture the large number of primary-care patients—about 25 percent—with unexplained medical symptoms.
People with hypochondria resemble those with OCD: They worry excessively and feel compelled to do something, like visit the doctor over and over. On the other hand, the inability to explain multiple symptoms may be related to medicine’s inadequate understanding of conditions like fibromyalgia. The disorders might be linked by excessive production of pro-inflammatory cytokines.
It may be that the mechanism controlling normal immune response is dysregulated and cytokine production is not turned off, leading to ongoing symptoms of fatigue and malaise. “As we learn more about the relationship between the brain, the immune system, and the endocrine system,” says Fallon, “a new view will emerge of patients with multiple unexplained symptoms.”