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The need to be believed

Hypochondriacs suffer from an intractable belief that physical symptoms are a sign of serious illness even when medical evidence indicates otherwise. Hypochondria accounts for at least 5% of all general medicine consultations in the United States. Some people are chronic hypochondriacs, while others regress to it after disappointments in love or work. Divorce, unemployment, breakups and other disturbing life events can trigger somatic complaints and the fantasy of some almighty doctor who can cure them.

James Bloedel/
Source: James Bloedel/

There are two kinds of hypochondriacs. The first type is those who tend to feel all sorts of bodily sensations more intensely than the average person. They attribute fatal diagnoses to everyday sensations like cold hands, indigestion, or a twitching eyelid. The internet feeds the problem because it makes it easy for people to read about symptoms and then imagine having them. The second category of hypochondriacs are somatizers. They have actual symptoms—what Freud called "conversion hysteria." Psychological conflicts are converted into bodily experiences which can range from heart palpitations to paralysis of a limb.

Hypochondriacs demand more tests at a time when physicians are under pressure to curtail unnecessary procedures-- and they move among multiple providers, making it difficult to manage their care. Hypochondriacs can have medical costs 10 times higher than the national average. As a group, hypochondriacs cost billions of dollars a year in unnecessary medical tests and treatments that are many times not borne by the individual, but by all the people whose insurance premiums rise because of these bills. In addition, getting tested for everything all the time does not work because the window of relief is brief.

Doctors are often stymied by hypochondria because patients can be insistent and stubborn in their demand for a cure for their ailment, but the doctor cannot find an organic cause for the symptom. Not only are hypochondriacs not reassured by their visits, they become angry with their physicians for failing to get to the root of their problem and often accuse their doctors of incompetence and not caring about them (Dolores Albarracin, "Narcissism and Object Relations in Hypochondria", Psychoanalytic Review, Volume 102, No. 4, August 2015).

Hypochondriacs, Albarracin argues, are not looking for a cure to their ailment, but rather a witness to their suffering. They are missing an internalized good mother who is concerned for the child's symptoms and expresses empathy for their pain. They go from doctor to doctor desperately seeking an omnipotent professional able to sort out all the disappointments of earlier doctors. But the inevitable disappointment of the idealized doctor results in criticizing his/her incompetence, making the doctor less sympathetic to their pain. Often the patient's perpetual dissatisfaction alienates spouses, friends, and relatives as well, creating a self-fulfilling prophecy.

Doctors often try to refer hypochondriacs for psychotherapy, but find the patient is resistant to the idea that their problem is psychological rather than physical. The patient feels dismissed by an uncaring doctor. There are two things that the physician and/or psychotherapist must understand in order to maximize the chances of helping the hypochondriac or, at least, staying empathic. First, being ill may be a central part of the hypochondriac's identity. To give up being sick may be experienced as losing his sense of self. Second, the hypochondriac needs a witness to his pain or anxiety. He needs affirmation that it is REAL. You must demonstrate that you believe him and understand how pained and frightened he is--but the cause is not organic.