Hypochondriacs Have Real Disease: 'Health Anxiety'
June 11, 2004
The Seattle Times
SEATTLE - Doctors' waiting rooms are full of them. The fellow with a dry cough who is convinced it's SARS. The woman who thinks her new freckle is melanoma. The patient who is sure his headache is a telltale sign of brain cancer.
Immune to assurances otherwise, they vex physicians, rack up health-care costs with unnecessary tests and exasperate those closest to them with their incessant aches and pains.
In fact, they do have a medical condition - just not the ones they think they have.
Physicians used to call them hypochondriacs, but the term has taken on the negative connotations of whiners and malingerers.
"No smart doctor says to a patient, 'I think you are a hypochondriac,'" says Dr. Wayne Katon, a professor of psychiatry and behavioral sciences at the University of Washington School of Medicine. "That's a quick way to lose patients."
Now such patients - about 4 percent to 9 percent of people who visit a doctor's office each year - are seen as having something akin to an anxiety disorder. In the way that some people are driven to distraction by fear of planes or spiders or crowded spaces, those with health anxiety - the favored label - interpret every physical symptom as a sign of impending doom.
"A headache is never just a headache," says Dr. Greg Simon, a psychiatrist at Group Health Cooperative. A stomach twinge can only mean bowel cancer. A muscle pain portends Lou Gehrig's disease, or perhaps dengue fever.
Treating these patients has long been a struggle. While the fellow fearing dengue fever may think a blood test is in order, the physician concludes he needs his head examined. But reframing the disorder as one of undue anxiety rather than imagined symptoms has opened up new treatment strategies that can help the worried well get on with their lives.
The average person experiences about two to three inexplicable twinges, pains or aches or other odd symptoms every day, says Dr. John Wynn, a psychiatrist who specializes in cancer patients at Swedish Medical Center. Most of us don't think much about them and they go away.
But for Melissa Woyechowsky, no bump, itch or twitch went without notice. Her glands felt swollen so she immediately concluded she had HIV, even though she tested negative repeatedly and had no reason to think she'd been exposed. Any bump on her skin was thought to be skin cancer. Her feet felt numb and tingly so she went online to search for an explanation. She became convinced she had a neurological condition like multiple sclerosis. She began to fret.
The doctor's clean bill of health didn't reassure her for long. "On the way home I'd start to thinking, they must have missed something," she says.
Newly married and in her 20s, she became a full-time worrier who rarely left the house. Her husband grew so exasperated with her it almost ended their marriage.
"Doctors didn't know what to do with me - they said, 'There's nothing wrong with you, why are you wasting my time? I have patients who are really sick,'" she recalls.
Finally, while late-night symptom surfing on the Web, she discovered a new condition: health anxiety. "I realized it was the one thing for which I had every single symptom."
A psychiatrist prescribed Prozac, which she credits with muffling her blaring health fears. Now 35 and living with her husband in the California desert town of Twentynine Palms, she hasn't obsessed about her health in five years.
But Health Anxiety Support, the online message board she started when she was first diagnosed, still hums with Cassandras bouncing their health worries off each other and searching for reassurance. It offers a window into the strange and specific fears of hypochondriacs.
One member worries about a "clicking sensation" in her joints. Another has prickly feet and wonders if it's a sign of diabetes. A posting asks if taste buds are supposed to be white or could it perhaps be a sign of leukoplakia.
For people prone to health anxiety, such minor physical sensations or observations can kick off a vicious cycle. They zero in on a symptom and start obsessing. The more anxious they get, the more glaring the symptom. When you stare at your tongue in the mirror, it does begin to look stranger and stranger.
The irony is it's the patient's ramped-up anxiety that likely causes a lot of the physical symptoms, ranging from headaches, to belly aches, to back pain, to muscle soreness, to sleepless nights.
"Anxiety turns up the volume on body sensations," says Simon, who's also a mental-health researcher at Group Health's Center for Health Studies. "A patient of mine described the process as being like when the oil light comes on in your car and suddenly you can smell things you never smelled before."
Health anxiety often develops in young adulthood, and usually in people who have another diagnosable mental disorder - often depression, generalized anxiety disorder or obsessive-compulsive disorder.
No one really knows what triggers it, but some cases seem to be related to a traumatic health-related event, such as a loved one dying suddenly. Some experts speculate it might be tied to a low threshold for physical pain.
"At its essence, anxiety is the endless search for certainty you can't find," Simon says. "And with health fears, it's true, you can never be certain they won't actually happen."
This quest can become an obsession that overtakes a patient's life. "It certainly does keep me from doing the things I want to do, in that it makes it very difficult to think about a positive future. If I'm going to be a bedridden invalid with dementia, why the heck am I doing X or Y," says James Bayliss, a member of Health Anxiety Support.
Hypochondriacs and even garden-variety worrywarts fighting to suppress their health-related fears have their work cut out for them these days.
Vague pharmaceutical commercials provide rich fodder for worries: Is your good cholesterol too low or bad cholesterol too high? Could your heartburn really be gastro esophageal reflux disease? Do you "gotta go, gotta go, gotta go right now?"
Web sites have popped up for every disease imaginable, and 80 percent of Internet users report searching for health information online.
It's enough to send even the healthiest and most level-headed among us scurrying to the doctor's office.
Health-information overload doesn't create hypochondriacs - but it can give them more things to worry about. "For some, it can be taken as, here are all the new ways you can die," says Craig Sawchuk, a clinical psychologist at the University Of Washington.
For this very reason, a temporary form of hypochondria, called medical-student syndrome, is considered a standard phase of doctor training. "They're under high levels of stress and sleep deprivation and they're immersed in reading about symptoms and pathology and they say, 'Oh God, I'm feeling just that way,'" Sawchuk says.
Shannon Simon, a second-year medical student at University of Washington, admits to having made rather outlandish interpretations of her own bodily symptoms.
A healthy, active 23-year-old, Shannon Simon took her blood pressure and found it to be a little bit high. Her first reaction: "I automatically thought I had an adrenaline-secreting tumor or kidney damage." When she woke up with a sore neck: "I thought, uh-oh, that could be meningitis."
Unlike a true hypochondriac, however, her sense of logic ruled. Turns out the elevated blood pressure wasn't surprising considering the stress she was under, and the stiff neck was more readily explained by her lifting too-heavy weights at the gym.
So what's a time-strapped doctor to do when faced with chronic hypochondriacs?
Dismissing their symptoms will only make matters worse, experts say, and will likely send them doctor-shopping.
"You always have to respect the patient's experience - you can't argue with someone who has a sensation," says Wynn.
Psychotherapy techniques and antidepressants used to treat other anxiety disorders can help quiet patients' health fears about their sensations, that is if you can get them to agree to therapy rather than a biopsy.
In a landmark study in the Journal of the American Medical Association last March, Dr. Arthur Barsky at Brigham and Women's Hospital in Boston found cognitive therapy to be surprisingly effective in helping patients dampen their overreaction to every ache and twinge.
Therapists taught patients to consider more likely explanations for their symptoms and trained them to stop habits that further fueled their anxiety, such as continually taking their pulse or researching their symptoms online.
Of patients who attended the study's six therapy sessions, half paid significantly less attention to their symptoms and were better able to perform daily activities without fretting about their health.
The downside was that a quarter of patients quit the study because the treatment didn't fit with their interpretation that their symptoms were "real."
Still, the results were considered a major success among psychiatrists because hypochondria is considered just that difficult to treat.
Other studies have also found two antidepressants, Prozac and Luvox, may help patients keep chronic, overwhelming health fears in check.
"Treatment is still very limited by the fact that a lot of hypochondriacs wouldn't be caught dead going to a psychiatrist," Katon says. "They say, 'Gee, my belly hurts or my back hurts,' and they are mystified or insulted when a doctor begins asking about stress in their life."
Sometimes, he says, when the one disease a patient doesn't think he has is health anxiety, all a doctor can do is run interference to protect the patient from unnecessary medications, tests, or even surgery, and to take their symptoms as seriously as anyone else's. After all, hypochondriacs get sick, too.