THE WHYS AND HOWS OF HYPOCHONDRIA : Imagined Illnesses: They’re Enough to Make You Sick

They are the “thick file” patients. One week, they think they have mononucleosis. The next, perhaps after reading a newspaper article, they are just as convinced they have a brain tumor. Often, if one doctor tells them the good news--that nothing is wrong--they will go to another doctor and another, searching for a physician who can find the problem.

There is a name for what ails them. Unfortunately, the real problem is usually the one diagnosis they do not believe: hypochondria.

Hypochondriasis, an abnormal anxiety about one’s health frequently characterized by the false belief of suffering from some disease, can be the root cause of distress in nearly a quarter of all patients, according to some estimates. And this excessive preoccupation with disease persists despite repeated assurances to patients that they are in good health.

Hypochondriacs “have this absolute conviction that the problem is physical, not emotional,” reports Thomas N. Wise, a professor of psychiatry at Georgetown University Medical Center who specializes in the treatment of hypochondria.

Suggest that the trouble is emotional, and the response, according to Wise, is apt to be: “Sure I’m anxious, but you’d be anxious, too, if you had this terrible pain that I know is a brain tumor.”

Hypochondriacs have been the target of jokes for years, though anybody who suffers from the disorder has a hard time sharing in the laughter. The label has such pejorative connotations because many people have the mistaken belief that the distress is not real. In fact, the hypochondriac can experience mental anguish and a wide range of physical symptoms, from chronic fatigue to bodily aches and pains.

Stress is a major component of modern life, and in recent years, physicians have become much more aware of how the mind and body interact, and of the role the mind plays in physical symptoms.

“We have bodies that will cooperate at the drop of a hat to produce symptoms of every style and type,” said Susan Baur, author of “Hypochondria: Woeful Imaginings.” Given the right triggers, she said, “We can numb our entire bodies and have headaches for a month.”

A number of illnesses are considered psychosomatic--disorders of the body that originate in or are exacerbated by a person’s emotions. Sometimes personal or professional concerns cause these illnesses. A man dating two women, for instance, might worry himself into an ulcer. Or, in what psychiatrists call a conversion disorder, a psychological conflict can’t be resolved--and someone who wants to smash his boss gets a paralyzed arm.

What is different about the hypochondriac, though, is that the sufferer is terrified of having a disease and continues to be preoccupied with this fear despite the absence of any clear physical changes or diagnostic confirmation. There may be physical symptoms but no actual loss or distortion of bodily functions.

Physicians define hypochondria as an abnormal and unfounded anxiety about health that often results in imaginary illnesses and melancholic feelings.

But the last thing hypochondriacs want to hear is that it’s all in their head.

“It’s devastating to admit to psychological problems,” said Baur.

Georgetown’s Wise described the case of one patient, a 50-year-old research physician, who believes he has a muscular problem and often experiences unusual cramping and aching in his legs.

“He knows these thoughts are unreasonable, but he still feels he might have a terrible disease whenever he gets a cramp,” Wise said.

Antidepressant medication has helped somewhat, and the physician seeks medical care much less than before. But there are still times, Wise said, when the physician will “go to a meeting, see a paper on muscular dystrophy and start to feel tense.”

Many hypochondriacs are also depressed. But doctors discount the notion that hypochondria is an offshoot of depression. Rather, they see the two disorders as concurrent problems. Treating the depression helps the patient feel a bit better, they say, but it doesn’t treat the hypochondriasis.

Physicians, citing the peculiar and complicated pathology of the disorder, hesitate to talk about cures. Instead, they speak in terms of “managing” the patient’s pain and reducing the hypochondriac’s trips to the doctor’s office.

In many hypochondriacs the dominant emotion is anxiety. Larry D. Empting-Koschorke, director of the Blaustein Pain Treatment Center at Johns Hopkins Hospital and a member of the medical faculty at Johns Hopkins, says most hypochondriacs worry about having or getting a disease, with cancer usually at the top of their list of concerns.

Others may go to numerous physicians for different symptoms--to a neurosurgeon for a headache, a cardiologist for chest pain, an endocrinologist for weight gain. They may see 10 different doctors, each of whom tells them there doesn’t seem to be anything to worry about. But most hypochondriacs, at least initially, won’t accept that.

“They just work through every organ of the body,” Empting-Koschorke said.

Some hypochondriacs develop this trait as children, often as a way of getting attention from parents or friends. But doctors caution that it is “much too simplistic” to trace it all back to a need for attention.

Compounding the problem is the fact that many of the patients are extremely sensitive to--seemingly obsessed with--pain.

“You and I may have aches and pains and go on, but (hypochondriacs) focus on that,” Empting-Koschorke said. “They really fasten on every detail of their bodies and pick up on things we may not pay as much attention to.”

Hypochondriacs come to physicians with a long list of complaints. Some of the most common symptoms are frequent pain almost anywhere in the body, and a striking loss of vigor. The disorder, whose onset can come at any time but is seen most commonly between the ages of 20 and 30, is usually a chronic one, with an ebb and flow of symptoms throughout the person’s life. Doctors who have had experience with hypochondriac patients say one of the biggest challenges can be “organizing” the symptoms.

Part of the problem in diagnosis stems from the fact that symptoms can mean many different things.

“A lot of people don’t know where the pain is,” said Paul T. Costa Jr., chief of the laboratory of personality and cognition at the National Institute on Aging. “They may be having a myocardial infarction and they’re taking Tums for gas. Others really have gas and are presenting themselves to emergency rooms saying they’re having a heart attack.”

The heart, he said, is an area of the body where some of the more classic symptoms of hypochondria get expressed. “And that gets you a lot of attention, especially if you’re a middle-aged male.”

Just by the law of averages, some patients who are considered hypochondriacs do indeed turn out to have a physical disorder. And, according to Empting-Koschorke, between 25% and 40% of those patients judged hypochondriacal will eventually show up as having a disease that will explain their earlier symptoms.

“What we find out five years down the line is that they had the beginnings of multiple sclerosis when they first came in complaining about fuzzy vision,” he said.

Most people with fuzzy vision do not have multiple sclerosis, Empting-Koschorke quickly added. But the fact that there is even a remote possibility is what fuels the hypochondriac’s imagination, and just making the link increases people’s anxiety.

“Now, you know, when you print that,” he said, “you’re going to have all the people with fuzzy vision going to the doctor because they think they have multiple sclerosis.”

Throughout much of its history, the term hypochondria has not projected a disparaging or negative image, according to Baur. The word first surfaced in medical circles as early as AD 1 and was used to describe the location of pain in that region of the body beneath the rib cage. But the term also was linked early on to emotional maladies and hysteria, especially uterine disorders.

By Shakespeare’s time, the word was also used to mean hypersensitive and was often considered a desirable trait, most commonly found in the rich and well educated.

Sigmund Freud, the pioneering psychoanalyst, later classified hypochondria as a neurotic disorder but believed intensive analysis was of little help to the hypochondriac. He wrote about the subject only once, in a 1914 paper on narcissism, and treated a few cases with hypnosis, with mixed success.

Today’s psychiatrists generally agree with Freud that intense, long-term psychoanalysis is not effective in treating hypochondria. They are more optimistic about other treatment methods, but they do acknowledge that treating the hypochondriac can prove trying to even the best doctor-patient relationships.

The treatment approach varies, according to Costa, depending on the personality and history of the hypochondriac patient. Group therapy, behavior modification and drugs, typically tricyclic antidepressants, are common treatments. But doctors, in an effort to “manage” the patient’s anxiety and pain, also rely on progressive relaxation techniques and biofeedback.

The course of treatment can be stormy. Patients with the disorder often think they are not getting proper care or that their doctors are deliberately withholding information. And physicians, who want to help and feel helpful, can end up feeling angry and frustrated instead.

“Hypochondria is really the perfect adversary for the doctor,” said Baur. “If you don’t like a doctor, send him a hypochondriac.”