- The Washington Times - Tuesday, May 28, 2002

Do hypochondriacs get a bum rap?
The poor patient suffering from hypochondriasis as the disease is called in the Diagnostic and Statistical Manual, or DSM, the bible of the psychiatric profession is the butt of jokes and the bane of some mental health practitioners.
Doctors, and especially psychiatrists, don't express hostility in any overt way heaven forbid but they will admit to frustration in their dealings with patients whose disease, by definition, is extreme anxiety about an illness without any immediately definable physical symptoms.
A number of doctors have a special interest in the condition. They tend to be psychiatrists and psychologists involved in treatment and research in the general field of psychosomatic medicine, which includes a range of categories having to do with the relationship between emotional well-being and a person's physical state.
"In medicine, we see a lot of people who think they are sick and are not, so I ask how could I not be interested?" says Dr. Thomas N. Wise, chairman of the Department of Psychiatry at Inova Fairfax Hospital in Fairfax.
"[Hypochondriasis] clearly has this very pejorative connotation, but in fact, these people really suffer," says Dr. Arthur Barsky, director of psychiatry at Brigham and Women's Hospital in Boston.
"Hypochondriacs often get doctors very upset because we like to think they are taking our advice," agrees Dr. Wise, who calls hypochondriasis "a complicated issue" that is something of an emotional hybrid.
"If there is too much fear, it is hypochondriacal; too little, it is denial. The real world falls along the lines of dimensions, not categories," he says.
Semantics aside, he says "illness fears are very common in our community and throughout the Western world."
That doesn't take away from the stigma attached to what many people perceive as the hypochondriac's unreasonable fears to the point that he or she may be labeled a complainer and a nuisance or, worse, delusionary.
One problem lies in defining and labeling the disease; another arises over treatment especially if a patient refuses to see that he may be mentally and not physically ill.
"People may be convinced that they have cancer and request an MRI so it is not a delusion, but they are worried. It could be a woman whose mother had breast cancer, and her checking for signs ten times a day may be extreme, making her constantly anxious. You can diagnose hypochondria as a 'yes' or 'no,' but when you study it, you find it is made of different factors."
People shouldn't be dismissed as hypochondriacs without understanding the basis of their symptoms, which often include depression, says Dr. Dennis Novack, current president of the American Psychosomatic Society and assistant dean for medical education at Hahnemann University Medical School in Philadelphia. Dr. Novack has run "problem patient" clinics at Brown University and the University of Virginia.
At the clinics, he says, he wasn't so much interested in hypochondriasis as in somatization as a whole the translation of emotional issues into physical symptoms "because we see quite a lot of that in primary care."
In psychiatry, somatization means converting anxiety into physical symptoms and is different from the more strictly defined somatization disorder, which is a mental illness that usually begins before the age of 20, according to the dictionary definition, and is characterized by multiple physical complaints for which no physical causes can be found. It often leads to severe disability.
Hypochondriasis, by comparison, is an excessive preoccupation with one's health, usually focused on a particular problem or set of problems.
Physician training has lagged in this area, Dr. Novack says. "It's studied in medical school, but probably not enough. Fifty percent of depressed people somatize, which means they are worried about aches and pains that aren't really related to a disease. A physician might think it is hypochondriasis when it is actually depression."
The majority in the clinical population that he saw in his clinics included a few people with previously undiagnosed brain tumors, but the majority, he says, came in with symptoms that had them labeled as "problem patients" by referring physicians.
"A variety of emotional and psychosocial problems were the basis of their symptoms," he found. Treatment for many, except the most severely incapacitated, included sympathy from the medical professionals and an explanation of how anxiety and depression cause symptoms.
If people understood somatization better, Dr. Novack concludes, "there wouldn't be a lot of excess workups and dangerous interventions. People have to basically understand that mind and body are one. We haven't yet reached that point."

Professional caregivers have come a long way in recent years in understanding how to treat hypochondriasis and other poorly defined conditions, such as chronic fatigue syndrome and fibromyalgia, that Dr. Barsky says have always been diagnostic puzzles.
"I think what has happened is that basically there was no clearly effective treatment, and no one has known really what to do," he says.
Cognitive therapy is considered the most promising approach. Dr. Barsky and his research team at the hospital are writing a report on a five-year study they conducted, to be called "Cognitive Behavioral Treatment of Hypochondriasis."
"It uses the notion that hypochrondriasis is a particular way of thinking about health and symptoms in medical care," he explains. "It's a process where you talk to people and apprise them about how they think they are sick and give a possible explanation of what is going on in their bodies."
Dr. Wise further describes the method he uses when caring for such people, many of whom have been referred to him by other physicians. Characteristically, hypochondriacs don't respond well to simple reassurance of any kind.
"You directly challenge the hypochondriac's beliefs. You train patients not to think that a gurgling stomach is an ulcer. You challenge them when you hear them say they 'don't think Doctor Smith was telling me the truth,' or 'Doctor Smith wants to spare me the terrible news' or 'is not that smart.'"
He says he leads a patient through a series of logical questions on each of these counts. "It works because you are taking [their condition] and them seriously."
Another of the characteristics of people with hypochondriasis and somatic complaints, says Dr. Steven E. Locke of Harvard Medical School, is their tendency to "amplify" symptoms. They might be annoyed by sounds that other people would ignore and be more sensitive to hot or cold, and their tolerance for pain might be lower.
"They have certain traits that put them at risk for somatization or hypochondriasis because of inborn or acquired tendencies," he says.
When working with patients exhibiting such symptoms, he first rules out depression or an anxiety/depressive disorder and then often talks with them at length to explain the way the nervous system and the body are connected.
"I explain the way they are wired and how these symptoms are not necessarily warning signals," he says. "That lays the foundation for teaching them some specific skills to identify the circumstances that trigger those symptoms and maybe help change the behavior that puts them in that position. They might need to acquire new communication skills or learn meditation techniques to tune down their sensitivity."
Because of science's ongoing investigations into human brain functions, Dr. Locke foresees a time in the next 10 years when he wouldn't be surprised to find that specific areas of the brain account for the persistence of a hypochondriac's symptoms.
Meanwhile, much laughter takes place at the hypochondriac's expense, with the media and publishing world more than willing to capitalize on the condition. Chronicle Books in 1998 published a hardcover pocket book called "The Hypochondriac's Handbook," by Wendy Marston. It's a compendium of alarms in the everyday world that, while accurate factually, is also intended, in the publisher's words, to "make you laugh, which releases endorphins and promotes good health."
Hypochondria, author Marston writes, "is an unkind euphemism for vigilance and deserves much more respect."


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