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Haraldsplass Diakonale Sykehus

Clinic for hypochondriacs

Hypochondria

HYPOCHONDRIA
By Professor Ingvard Wilhelmsen, MD, Ph.D

What is hypochondria?
A person with hypochondria is preoccupied with physical health and body. The diagnosis is used when a person during at least 6 months believes, fears or is convinced that he has a serious disease despite medical reassurance. This fear of disease or preoccupation with symptoms is unpleasant, interferes with the patient's daily life in a negative way and leads to medical examinations and/or treatment. The patient can only temporarily accept assurance that there is no physical explanation to his symptoms.

Is hypochondria a medical diagnosis?
In common language hypochondriac indicates a person who «thinks he is ill» or merely «imagines that he has symptoms». However, hypochondria, or excessive health anxiety, is as serious as any other medical diagnosis. It has always been a part of the official medical diagnostic systems, and still is. Hypochondria must be "positively diagnosed", i.e. it is not enough to exclude physical disease, the exaggerated health anxiety must also be found. Hypochondria is as common in men as in women, and can be found in all age groups and social classes.

What are typical symptoms in hypochondria?
The physical symptoms are always real, but might be "normal" physical signs (like headache, belly pain, dizziness, fatigue etc). which are misinterpreted as more dangerous than they really are. The physical symptoms may change or can be stable over time, they can be vague or quite specific. In a person with excessive health worries the anxiety-symptoms (palpitations, breathing difficulties, chest pain, nausea, dizziness etc.) are easily misinterpreted. This establishes a vicious circle: symptoms are experienced and misinterpreted, anxiety increases, symptoms become stronger, this is even more frightening and so on. It is very tiring and exhausting to be scared, and this feeling of exhaustion is by many patients taken as a sign of serious disease.

Can hypochondria be treated?
Yes, but the tendency to have exaggerated health anxiety might not completely vanish (after all it is normal to fear cancer). However, the patient with hypochondria can realize that he has anxiety, and not a serious physical disease, and gradually reduce his anxiety. The patient is not healed when he realizes that he has health anxiety (just as a person can still be afraid of flying even though he knows it), but it is an important first step. When hypochondria begins in conjunction with a major life event (f. inst. your are 40 years old and somebody close to you dies) treatment takes shorter time than if you have always been cautions, anxious and afraid of physical disease.

How is hypochondria treated?
At Haraldsplass Deaconal Hospital in Bergen we use cognitive-behavioural treatment. In the first consultation the patient explains his symptoms, and we make an evaluation whether he has been examined good enough. Of course we never discuss whether the patient has his symptoms or not. Symptoms (like pain, nausea, numbness etc.) are always subjective, and hence "accepted". However, we do discuss how to interpret the symptoms. What do they mean? Most patients believe that something serious must be present. They cannot imagine that symptoms like they have can be caused by f. inst. anxiety.

During the treatment the patient registers the thoughts that go through his mind when he notices his physical symptoms. Hypochondriacs choose the most serious, but often least probable, explanation. Headache is not migraine or stress but brain tumour, chest pain is not caused by tense muscles but is serious heart attack and so on. These thoughts are then discussed and alternative explanations are tested out. Often patients with hypochondria have beliefs like: It is normal to feel completely
well all the time - A physical symptom is a sign that something serious is wrong in my body - You can be 100% sure that you are completely well - Doctors often misdiagnose cancer. Moralism, aggression (you are sick!) or reassurance (new tests) do not help hypochondriacs. They have little secondary gain and often intensely want to get better. The problem is that they don't know how. So, what helps? One of my main questions to the patient is this: What is your project? What are you up to, what are you doing? Most people are not aware of their project, but it is important to identify it. When this is done, you can evaluate it, reflect on it and even change it. Thoughts and behaviour, which might seem irrational, are usually quite logical and understandable in light of
the project. Typical projects in hypochondria are not to die now (later might be OK) or to get rid of uncertainty (I must be 100% certain that I don't have cancer or heart disease). The problem with controlling death is that you don't know how and when you are going to die. So, what will you focus on? The heart, cancer, a car accident.... If you try to control something, which is in principle uncontrollable, you are bound to run into big problems. It is doomed to fail, and extremely tiring and energy consuming. Another problem is that focusing on chest pain or vague symptoms of imagined cancer tend to increase the symptom load. People often have good arguments in favour of living (being a mother with small children etc.). It is legal to want to live, but it is not legitimate to demand it. How about being 100% certain? Is that possible? Only one thing is 100% certain in this life: one day we are going to die. All other decisions must be taken when still in doubt. You might as well learn how to. About 30% of us get cancer during our lifetime (70% do not, and die of something else). Of patients with real cancer, 50% survive. What is the most important factor deciding whether a person with cancer will live or die? Many people think it is the timing of the diagnosis. The sooner the better. However, there is one factor, which overrules everything else. It is not the will to live, checking the body, detecting the cancer early etc., but what type of cancer you get. If you get the wrong kind of leukaemia it doesn't help being a hypochondriac or desperately wanting to live, you will die anyway. On the other hand, if you get a cancer type, which seldom spreads, there is no need to diagnose it early. You will survive anyway. So, the main factor in cancer survival is taken out of our hands. If your project is trying to control something, which is uncontrollable (like death, the future, which diseases you will get, other peoples thoughts and emotions), you can choose to reject it. You can put it aside, and find a project, which is not doomed to fail and is more compatible with living a good life. Such projects are: tolerate uncertainty; spend your energy on living and not on not dying etc. After you have found your new project, you will have to spend time and energy on meaning it. One of the best ways of changing, and meaning something new, is to behave as if you mean it. Our program includes homework assignments which might be behavioural (less checking of the body, activation etc.) or cognitive work (registration of situations, thoughts, feelings and behaviour). Some people feel it is unsafe to leave their worries behind. If you don't worry anything can happen? Is this new? Couldn't it happen when you worried? Does worrying prevent bad things from happening? If they do, how? If you are concerned with worries, which can lead to actions that in fact prevent problems or disasters, then it is OK. This includes travel preparations, reading before exams etc. However, if you catastrofize about events which might never happen or are uncontrollable (concerning your kids, your job, your house, your health and so on), you don't really know which disaster to choose. Then the best option might be to live as happily as you can, knowing that anything can happen, but waiting until the problem becomes real. It is interesting that few people seek psychotherapy because of real problems. I ask my patients to consider the difference between real problems (which are here) and imagined problems (which are in their fantasies). Real problems can be tough, but are limited by reality, time and space. Imagined problems are only limited by your fantasy (and by the way, all hypochondriacs are creative human beings! - they wouldn't be hypochondriacs if they weren't). You will have to face real problems, and people do. They start coping, seeking solutions etc. If the problem is imagined you cannot cope. The problem is vast, but not here. My suggestion is: do not take on too many imagined problems. Contrary to real problems the imagined ones are easily dismissed! May be the best preparation of a real disaster is to live a good life until it happens. Make sure you are not too exhausted and depressed when bad things happen. Real challenges take all you have got, so you had better save your energy for the real things. It is fascinating to see how fast a person can change when they realize that their project is doomed to fail and in a sense meaningless. It did not help to pursue it with dedication and lots of energy. It even made things worse. When people dare to live, become mortal, decide to trust their heart etc., they experience a new freedom. Instead of constantly checking whether they are healthy, avoiding exercise, travelling etc., they are now free to choose differently. Most people who get real, serious diseases notice it. They don't have to pay attention all the time. If you suffer from hypochondria there is hope. I will suggest that you talk this over with your GP, who might be able to refer you to a cognitive therapist. Usually patients are referred to us from a General Practitioner but also from other hospitals. Some patients contact us directly and are advised by mail.

Email: Ingvard.Wilhelmsen@med.uib.no