Have you ever spent a sleepless night convinced that the inexplicable pain in your leg was due to rapidly growing tumor? In most cases, a visit to the doctor and tests, with negative results, will allay fears of serious illness. But for people with hypochondriasis, reassurance is almost never enough to ease their medical concerns.
Hypochondriasis is a bona fide psychiatric disorder with potentially serious consequences. Even if a medical problem has been reasonably ruled out, a person with hypochondriasis will continue to fervently seek healthcare, and support from friends and family. Contrary to old beliefs, people with this disorder are not always inventing their complaints, but may be less able to cope with aches and pains than others. This heightened awareness can, in some cases, be traced back early relationships with caregivers.
Below, Dr. Scott Stuart, an associate professor of psychiatry and psychology at the University of Iowa, discusses the challenges inherent in diagnosing hypochondriasis and how a solid doctor-patient relationship can help ease people's health anxieties.
What is hypochondriasis?
Hypochondriasis is simply an excessive concern about one’s health. Distinguishing between someone who has a normal concern for a medical issue or their health and someone who actually has this disorder has been debated for quite some time. “I think there is a difference in terms of the anxiety that's associated with the individual's health problems, or perceived health problems,” says Stuart.
For example, if someone has had a relative who had cancer, they may be a little bit more vigilant about making sure that they don't face the same diagnosis. But people with hypochondriasis worry so much about their health that their functioning is impaired. Their health worries prevent them from engaging in pleasurable activities and functioning as well as they might at work. Their health anxiety might affect their sleep and relationships with friends and family members.
Do people with this condition tend to focus on particular problems?
Most people complain pretty consistently, over a long period of time, about the same kinds of things. A classic hypochondriacal patient would have multiple complaints in different areas, so they might complain of persistent diarrhea, stomach problems, joint pain and aches all over their body. They might also have persistent headaches, and neurological symptoms such as numbness and tingling
As a result, people go to a number of different doctors seeking a diagnosis, and wanting treatment as well.
How is hypochondriasis diagnosed?
The understanding of hypochondriasis has really changed over the last 20 to 30 years. Psychiatrists used to diagnose it primarily based on the number of physical complaints that people had. So it was required that people have a certain number of neurological complaints, or gastrointestinal complaints.
Now doctors understand hypochondriasis much more in terms of the way in which people go about seeking reassurance for physical problems. It's about how frequently people seek care, so you could have somebody with just two complaints for instance, but if they persisted in complaining or seeking reassurance about those problems to the degree that it impaired their functioning.
Is it difficult to diagnose hypochondriasis when symptoms are hard to confirm?
Many people who are diagnosed with hypochondriasis actually do have physical symptoms that are very real and have medical causes, even though, classically speaking, the diagnosis requires that there is no medical cause that explains their complaints.
As an example, headaches are very tricky because physicians still don't know much about the physiology of headaches. So a doctor could easily do a medical work-up and not find a specific physical reason for a person's headaches, but that doesn't make the headaches any less real.
In situations such as this, when a medical diagnosis does not have a clear physiological cause, a diagnosis of hypochondriasis is based on the patient's ability to accept and work with their physical diagnosis, or on their persistent healthcare-seeking behavior.
A different example illustrating this concept would be somebody who is diagnosed with diabetes. Most diabetics cope with the illness pretty well. But a diabetic patient with hypochondriasis may have tremendous difficulty coping. They frequently go to doctors in order to make sure that they aren't having any other complications or to have their insulin adjusted just slightly, even when there is no medical reason to do so. They use the medical system in ways that most people would consider to be excessive.
Is hypochondriasis under-diagnosed?
Most physicians generally feel that hypochondriasis is under-diagnosed. Today’s medical care has an emphasis on acute care, and tends to be symptom focused. For example, if somebody comes in complaining of severe back pain, a typical physician's response would be to order some tests and to give the patient a prescription for the pain. The doctor would only rarely, however, ask more holistic questions like “Are there other life events that could explain why this back pain is bothering you more now than it might at other times?”
Are there any characteristics that hypochondriacs usually share?
It appears that women are more likely than men to have it. Some people have suggested, however, that this is because there is more of an emphasis on reproductive system complaints, which are far more common in women. In addition, women go to physicians more frequently and are more likely to be diagnosed for that reason.
Hypochondriasis is also more common in people who have had legitimate serious childhood illnesses. Also, people with depression or anxiety disorders, but particularly depression, seem to have higher rates of hypochondriasis.
Can hypochondriasis affect people's relationships?
One of the most consistent findings from studies is that hypochondriasis puts stress on people's relationships. It turns out, not surprisingly, that people with hypochondriasis tend to ask other people for a great deal of care. And they do so very persistently over time. After a while, they generally wear out the people they're asking for care.
This behavior is often a reflection of the way in which these patients interacted with their parents when they were growing up. If one's parents are able to encourage independence, and are supportive as they're doing that, people generally grow up relatively secure. Those are the kinds of people who are able to enter into very productive and fulfilling relationships, especially intimate relationships.
On the other hand, if one has parents who encourage dependence on them, that's the way an individual will begin to view the world as a whole. People who grow up in that kind of environment generally are of the opinion that they can't really meet all their needs, including their physical needs.
How can the condition affect people's ability to function?
The first thing to consider is how much people are actually disabled by many kinds of chronic pain. Chronic back pain, for instance, is one of the leading causes of missed days at work. People with hypochondriasis oftentimes experience a great deal of pain, so it tremendously affects their ability to function well at work, at home, in their social relationships or fulfill any other obligations that they might have.
Pain is difficult thing to measure because there is no objective way to rate it. One person's bad headache might be insignificant to somebody else. People with hypochondriasis tend to over-exaggerate the severity of their pain, and they tend subsequently to be more impaired as a result.
How often is hypochondriac missed when there is a physical cause to a person’s ailment?
It turns out that there is a fairly high rate of mistakenly diagnosing a person with the disorder. “I think that's one of the things that makes physicians a little reticent about diagnosing hypochondriasis;” says Stuart, “there is always a fear that something might have been missed.” Needless to say, hypochondriacal patients argue the same point in justifying their use of the medical system.
How important is a good doctor-patient relationship?
There is very good evidence that having an empathic, caring healthcare provider does a great deal to help people with hypochondriasis. It doesn't really cure the illness or change their behavior a whole lot, but it helps create a sense of reassurance for the patient.
A good doctor-patient relationship tends to lead patients to work with only one physician rather than doctor shop. That dramatically reduces the risk of unnecessary medical procedures that might be done because the treating physician is very familiar with the patient. It will also reduce the chance that people will receive different kinds of medicines from different physicians. Those medicines may interact and may have side effects.
What kind of treatment is available?
In terms of counseling patients, cognitive behavioral therapy has been tested and seems to work for limited symptoms, such as irritable bowel syndrome and headaches. But it's not been tested with patients who come in with a whole spectrum of complaints.
The approach that a counselor would take in cognitive behavioral therapy is helping the patient reinterpret what their physical symptoms mean, so they no longer think that the symptoms mean that they are ill.
Experts are studying some different kinds of approaches in counseling. One approach focuses on the way in which people ask for reassurance. It is aimed at helping them to appreciate that their persistent complaints about their medical problems are not serving them very well. In fact, it is often those persistent complaints that have damaged the patient's interpersonal relationships.
Antidepressants do not seem to be helpful for hypochondriasis by itself. But since many people with hypochondriasis do have depression as well, medication can be quite helpful for that.
Why is there a stigma attached to hypochondriasis?
“There is still a stigma to any kind of mental illness,” says Stuart, “but I believe that it is greater with hypochondriasis because the association that most people make is that patients diagnosed with hypochondriasis are faking it.” As a result, almost every patient will desperately try to avoid being diagnosed as a hypochondriac.
Unfortunately, that stigma is also very pervasive across physicians as well. Most physicians don't appreciate that hypochondriasis is actually a legitimate medical problem, and that it reflects the patient's difficulty in asking for help and engaging their social support system well.
What advice do you have for friends or family?
Friends and family can have a big impact by urging the patient stick with a single healthcare provider. Excessive medical consults and doctor shopping should be discouraged. Being firm but consistent in support can also be of great help.
©2007 Healthology, Inc.