Monday, January 27, 2003
Copyright © Las Vegas Review-Journal

HYPOCHONDRIASIS: Ill Feelings

A real psychological disorder can be at work when patients become obsessed with their health

Illustration by Anton.

Dr. Douglas Farrago, a family practice physician in Auburn, Maine, calls it the Shawshank Syndrome.

You won't find it in any medical textbook -- see, instead, Stephen King's prison-escape story -- but Farrago says it's a very real psychological malady that afflicts doctors whenever they enter an examination room to see a patient who's a raging hypochondriac.

At such times, admits Farrago -- who's also editor and founder of the Placebo Journal, a humor magazine for and by doctors -- "I'm actually envisioning myself pulling down the (wall) poster I have and digging my way out with a tongue depressor."

Hypochondria usually serves mostly as fodder for sitcoms and jokes. But it's a real condition, both for the patients who have it and the doctors who treat them.

What most laymen know as hypochondria actually is a clinical condition called hypochondriasis.

According to the Diagnostic and Statistical Manual of Mental Disorders IV, the current bible of psychological disorders, hypochondriasis is marked by a fear of having a serious disease "based on the person's misinterpretation of bodily symptoms."

This fear continues even after medical evaluation to the contrary, lasts at least six months and impairs the function of daily life, the manual says.

Key to the diagnosis, says Dr. Gregory Brown, a psychiatrist and assistant clinical professor in the University of Nevada School of Medicine's department of psychiatry, is that the person obsesses about his or her health even when there's "not really a severe enough medical explanation" to warrant it.

Hypochondriasis is among a class of conditions called somatization disorders, Brown notes. "It's a term that refers to psychological or psychiatric effects playing out in the form of physical symptoms."

"There's a common perception that since there's not a physiological cause it's, quote, all in your head, unquote," he continues. "And, in a sense, it is.

"But even if it's just in your head, it's just as real to you as if there were a physiological cause. If you have a pain and there's no physiological cause, you still hurt, and that makes it more frustrating for the person experiencing it and the physicians trying to treat it."

The doctor keeps coming up with nothing, Brown says. "And, of course, the person still hurts or still feels unhealthy, so they're going to keep coming back, hoping for answers."

Dr. James Lenhart, chairman of the University of Nevada School of Medicine's family medicine department, says some hypochondriacal patients "have a history of neglect or abuse or some other dynamic in their life in which they feel nobody cares or nobody pays attention or nobody loves me and, if I can get my doctor to do that, I've achieved a great thing.

"And, of course, our model is that (doctors are) supposed to care. So the motivation is getting somebody to address those concerns."

Some, Farrago says, "just have really bad lives and want you to come and fix them."

Dr. Michael Stein, an assistant professor of internal medicine at the University of Nevada School of Medicine, says patients with substance abuse problems or "underlying depression or anxiety are more likely to present with hypochondriasis."

Lenhart says patients with hypochondriasis typically show up at the doctor's office with a "laundry list" of complaints.

"They sit down and pull out their list of concerns today, and it's anywhere from four or five problems to 10 or 12 and they want to talk about all of them," he says.

"They're certainly not hysterical. But they are very concerned that maybe all of them are interconnected."

Such patients tend to be "fairly vague about the symptoms," Lenhart adds, often to the point that "they lead you in no specific direction."

Then, when the patient's symptoms don't match findings from physical exams or screenings, Stein says, "we start thinking maybe there's some psychiatric disorder that could be causing this type of problem."

Whatever its origins and however it manifests itself, hypochondriasis is a tricky condition for doctors who must divine the patient's more hypochondriacal complaints from symptoms that could signal true illness.

"Think of it this way: There are a lot of patients who come in who are like little kids blowing little bubbles out of a pipe. Those are complaints," Farrago says. "My job is to pop every one of them and find the ones I can fix."

Patients with hypochondriasis are "the most challenging patients that we will see," Stein says, "because you don't want to miss something that could potentially cause them problems down the road."

They're also the most frustrating for doctors to deal with because they can "monopolize your time with all of their complaints, and you never get to see the 80 percent of people who need you," Farrago says.

Farrago notes he's even seen patients with "cyberchondria," who have seen dubious health information on the Internet and "want to come in and debate with me."

Brown says hypochondriacs usually don't seek psychiatric help "because, at this point in their minds this is not psychiatric, this is physical -- this hurts or that hurts or whatever."

However, he continues, because "a lot of people who have a lot of physical complaints of various sorts will also have other signs of depression," treating the underlying depression sometimes will alleviate the symptoms of hypochondriasis.

But the most effective treatment, according to Brown, is for the patient to agree to see the doctor only for more frequent, shorter and more focused visits, versus the less-frequent, longer, more meandering visits they've become accustomed to.

"So they come in every week and spend only five or 10 minutes a visit, not a half-hour or an hour," Brown says. "That way, the person doesn't feel they aren't being cared for."

Such a change often will result in a reduction of the patient's complaints, Brown says.

Similarly, Lenhart has found it useful to "make a contract with the patient that they will address their most pressing issue that day -- and give it 10 or 15 minutes and no more -- and come back next week and we'll get to problem No. 2."

Stein says the best way for doctors to help patients with hypochondriasis is "by developing a long-term relationship with them, and by listening to the patients and hearing what their concerns are, and by doing the physical exam to show that we are listening and that we are concerned by their complaints."