Iowa Alumni Magazine | June 2008 | Features

A Sick Fantasy

By Kathryn Howe
As if a crippling fear of death weren't enough, hypochondriacs endure embarrassing social stigma. A UI professor emeritus throws some light on a misunderstood mental illness.

I was scared. The mole on my upper left thigh appeared dark, discolored, and jagged—all surefire signs of melanoma. I lay awake at night wondering which friends could deliver an inspirational eulogy at my funeral and what songs I'd want played, a mix of somber and silly, like "I'll Fly Away" and "Girls Just Wanna Have Fun."

I must be a hypochondriac, right? Not exactly. You see, I went to the doctor, and a biopsy proved that I was not, in fact, dying of skin cancer. I had the mole removed and that was that. I haven't thought about it since.

Not so for the genuine hypochondriac. Where medical expertise and tests allayed my worries, the hypochondriac finds no such relief. Instead, her mind stays locked in a vicious, never-ending cycle of fear and despair, convincing her that aches and pains and odd-looking moles undoubtedly mean serious illness—no matter what reassurance a white coat or lab result can provide.

To some extent, we all have a degree of health anxiety. Constant coverage of every new, ominous illness, from West Nile virus to bird flu, makes the world seem a scary place. But for the hypochondriac, every chest pain signals heart disease, every headache a brain tumor. While these Woody Allens of the world are often fodder for jokes, hypochondria actually isn't funny. It's a real psychiatric disorder that inflicts an estimated five percent of the population with irrational, debilitating thoughts of health catastrophe. The wealth of medical information available on the Internet has only fueled the phobia, creating a generation of modern-day "cyberchondriacs" who feverishly troll the Web to validate their latest self-diagnosis.

"This narrowly focused fear of death robs life of much of its pleasure and satisfaction," says University of Iowa professor emeritus Russell Noyes, who has studied hypochondria for two decades, working to decode the complexities of this illness, encourage compassion for patients, and help medical professionals better treat their repeat customers. Noyes, who gave a presentation on campus earlier this year that traced the history of the disorder from the 17th century, notes that a hypochondriac's all-consuming anxieties draw him inward to the exclusion of other activities and people—and to the detriment of professional and personal relationships. Says Noyes: "It's certainly a source of suffering and impairment."

True stories from a WebMD message board for hypochondriacs illustrate the torment.

Eighteen-year-old Cayla confesses she's been scared of dying since she was seven years old. "My number one fear is AIDS. I've been tested for it a lot and it has always come up negative. Now, yet again, my fear is worse than ever," she says. "No matter what I do, my anxiety NEVER goes away. Please help me."

Another poster details his battle with anxiety attacks, the multiple ambulance trips to the hospital, the frustration that what he feels is "all in my head": "I have had blood tests, EKGs, MRI scans, and X-rays, and the results are the same: nothing wrong with me." Many other people describe panic attacks and anxiety so intense that their pounding hearts feel as if they could leap out of their chests.

Despite such pain, hypochondriacs usually face social stigma. Unsympathetic critics contend they're "making up" their illnesses. They're quacks, nuisances, frauds, and they need to get over it. Such judgment comes not only from the general public, but, often, from general practitioners. Modern medicine emphasizes acute care based on physical symptoms. When a hypochondriac buzzes like a pesky fly around the doctor's office, demanding unnecessary medical tests, sympathy isn't always the first emotion that surfaces among healthcare professionals.

Thanks to researchers like Noyes, though, more doctors are making an effort to approach hypochondria with care and concern. They're increasingly likely to regard it as a significant medical condition that they can address with a combination of pharmaceutical and psychological therapy.

Although the American Psychiatric Association didn't officially add hypochondria to its list of mental disorders until 1968, the illness has plagued people throughout history. Lord Byron, Charles Darwin, Tennessee Williams, 38BA, and Howard Hughes all suffered from hypochondria. During his UI presentation, "The Transformation of Hypochondriasis: 1680 to 1880," Noyes examined the medical advances and social factors involved in the evolution of hypochondria from a major physical disease of the body to a disorder of the brain, and, finally, the mind.

The Greeks first considered hypochondria an affliction of abdominal organs called the "hypochonders." Until the 17th century, physicians associated hypochondria with a temperamental disturbance known as melancholia, thought to be caused by a buildup of black bile in the liver. When the pioneering English physician Thomas Sydenham identified the condition in 1681, hypochondriasis—along with hysteria—accounted for half of all the chronic diseases he treated.

Soon, though, physicians began to suggest that the brain was most likely the source of hypochondriacal fears. By the 18th century, hypochondria was considered a "fashionable disturbance" of the upper class. By this time, doctors were increasingly identifying diseases by their physical, organic manifestations, of which hypochondriacs had none. So, hypochondria began to be viewed as a weakness or moral failing. The 19th century saw it increasingly defined as a mental problem. Present-day descriptions originate with a 1928 definition of hypochondriasis as "a preoccupation with a real or supposititious physical or mental disorder."

Contrary to common belief, hypochondriacs don't just imagine illness; their symptoms are quite real. Thought to have ultra-sensitive nervous systems that make them more aware of pain, they experience troubling sensations, such as a nagging cough or a sore back. Most people wouldn't give such everyday twinges a second thought, but the hypochondriac unrealistically equates health with the absence of pain. Experts don't know why one person is able to ignore common bodily nuisances while the hypochondriac cannot, but they believe that hypochondria is, in some sense, a physiological disorder. Up to two-thirds of hypochondriacs also suffer from other psychiatric problems, including major depression, obsessive compulsive tendencies, and panic and anxiety disorders.

Hypochondria appears to affect men and women equally and often begins in young adulthood. Experiencing a serious illness in childhood or the illness or death of a loved one increases the likelihood that a person will develop hypochondria. Noyes, who also theorizes that hypochondriacs' poor interpersonal relationships prompt them to seek medical attention, recalls a young man whose father died an agonizing death from spine cancer. Noyes' patient believed he would suffer the same fate as his parent. "He couldn't sleep; he couldn't work," Noyes says. "His mind turned in on himself."

Hypochondria often strains the doctor-patient relationship. In their relentless pursuit of a diagnosis, some hypochondriacs doctor-hop. Others keep their terror a secret, avoiding doctors because they fear disdain—or confirmation of a dreaded illness. Doctors can become irritated when problematic patients repeatedly take up their time and waste medical resources. (It's estimated that the five percent of the population affected by hypochondria creates a multibillion dollar burden on the healthcare system.) So it's no wonder doctors get frustrated when these patients refuse to accept reassurance. Patients are equally frustrated, citing unprofessionalism and disregard for their pain and suffering.

"I want to make my patients feel better when they are ill, and it's discouraging when I'm unable to help them," admits Alison Abreu, 98MD, 03R, a UIHC psychiatry and family medicine physician. "It's very satisfying when you can identify the source of their symptoms and recommend a solution. With hypochondria, this process doesn't occur. I believe it's even more frustrating for my patients when I don't have a cure for their condition. Healthcare providers are also under pressure to see more patients. Working with someone with hypochondria takes more time—in examination, testing, and also time spent reassuring that patient."

Diagnosis proves especially tricky. With a diagnosis of hypochondria—defined by the American Psychiatric Association as a preoccupation that interferes with daily life and persists for more than six months despite evidence of a clean bill of health—a physician risks offending her patient and inviting a lawsuit. Noyes recommends that doctors acknowledge and legitimize the patient's symptoms and explain that some people experience bodily sensations on a higher level—and even though an underlying physical cause can't be found, that patient might benefit from a psychological treatment approach to reduce their worries. Says Abreu: "I try to convey that I believe they are in pain or uncomfortable, even if I can't find a reason for it. I also explain that even if I cannot find a cause or cure, I will continue to work with them and provide guidance and advice about how to manage their symptoms."

Noyes also advises medical professionals to skip the "H" word and describe the patient's situation as "heightened health anxiety." Treatment features cognitive behavioral therapy along with antidepressant medication, which often alleviates a first-line psychiatric problem such as an anxiety disorder—and, along with it, symptoms of hypochondria. A positive, stable relationship with a responsive healthcare provider goes a long way to a hypochondriac's recovery, and chat rooms such as the Health Anxiety Support board offer an important outlet for people who often feel isolated and alone.

As I waited on the examination table, clothed in drafty hospital gown and scary mole, I certainly felt lonely. I worried that the doctor might make fun of me. If not a hypochondriac, I was definitely an educated health consumer. My questions would give me away—I'd been researching, fretting.

"I thought maybe this might be a melanoma," I offered, embarrassed.

"I don't think so," my doctor said kindly, as she inspected the spot with a gloved hand. "But we'll get this off for you, and, in the meantime, try not to give it another thought."

That was easier said than done, but my mind was finally put to rest when the biopsy revealed my mole was nothing more than a tangled web of capillaries.

My health scare ended with a tiny scar that's now barely visible. For a true hypochondriac, the nightmare would've only just begun.