Solving a Mystery in Medicine
“When you look at me, you can’t see that anything is wrong,” says Oddvar Aamdal, and that’s so. Lean and fit at 64, dressed for the brisk Norwegian fall in corduroys and a pressed flannel shirt, he looks every inch the healthy, mile-and-a-half-per-day jogger that he is.
Still, though nothing’s “wrong” inside, Aamdal is a sick, sick man. He is a hypochondriac--such a bad one that he brought his high-flying career crashing down and nearly wrecked his marriage.
“Inside, I was dizzy,” says Aamdal, who collapsed at his financial consultant’s job in 1981 and spent the next 16 years suffering every symptom in the Index Medicus.
“My head was swimming,” he recalled. “I was sure I had a brain tumor. They investigated this. Nothing. Then I started on my stomach and again it was nothing. Every part of my body has been tested. I even had a health anxiety for my car. Yes, yes, you can laugh, but I always thought it would stop running.”
Practically all doctors run across an Aamdal at some point in their careers: The patient who describes precise symptoms for which there is no cause; the patient who complains of pain when nothing is wrong; the patient who, when told he doesn’t have cancer--or a migraine or a slipped disc or whatever--concludes the doctor is incompetent and flounces off to another one.
“Of course, this drives doctors batty,” says Dr. Henry Altenberg, a Maine psychiatrist specializing in psychosomatic illness.
To say nothing of driving up needless costs for the health care system. “Getting a diagnosis is expensive, getting treatment is expensive, and nothing works for these people,” says Altenberg. “Even if the patient gets to a psychotherapist, psychotherapists get nowhere with hypochondriacs. They’re very difficult to treat.”
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Don’t tell that to Dr. Ingvard Wilhelmsen, a gastroenterologist and psychiatrist here on Norway’s west coast. By most standards, Wilhelmsen is a glutton for punishment: He avidly seeks out the very patients most doctors want to avoid. He runs what is believed to be the world’s first clinic for hypochondriacs.
Something of a media figure in Norway, he has a new book out this fall, in Norwegian, about his discoveries, and he lectures part-time at this nation’s medical schools.
“I cannot explain what has happened to me, but something has happened” since coming to Wilhelmsen, says Aamdal, who was referred to the clinic in the spring. “Six months ago, I couldn’t have sat here, talking to you like this. I wouldn’t have been able to concentrate. I would have been too worried that I was about to collapse.”
Wilhelmsen, who opened his peculiar practice in 1995, has treated about 170 otherwise well hypochondriacs, so far, and insists that the conventional wisdom is wrong: The obsessive, neurotic Felix Ungers of the world can be ridden of their conviction that the end is near.
And it can be done, Wilhelmsen adds, without prescribing Prozac or any of the related psychotropic drugs that have become so widely used for various ailments in America in recent years. Prozac and other medications like it are just now being tried for the treatment of hypochondria. While some psychotherapists in the United States are specializing in hypochondria, the disorder is most likely to go untreated.
“This is a group of patients who have never really had good treatment,” says Wilhelmsen, 48. “But if hypochondria were more acceptable, it would save money for the patients themselves and for society.”
Compare Wilhelmsen’s labors with the way hypochondriacs are usually treated in America: When they’re not being made figures of fun, they are either shunned by busy doctors or subjected to endless tests and operations by physicians whose earnings are linked to the number of procedures they perform.
“There’s a dreadful symbiosis between these people and physicians,” says Barry Blackwell, a psychiatrist at the University of Wisconsin’s medical school who is writing a book on what he calls “the worried well.”
“These people lose all their disposable organs,” says Blackwell. “They lose their tonsils. They lose their appendixes. They lose their uteri. They lose their gall bladders. American medicine, in the past, has been one big candy store for hypochondriacs to roam at will.”
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Here in Norway, Wilhelmsen sees hypochondriacs four days a week at his clinic. On the fifth day, he reverts to his practice as a gastroenterologist, examining patients with real ulcers and other digestive disorders. Working with the gut in this way, he has discovered, serves as a useful beard behind which to hide his psychiatrist self. “The kind of patient that I like tends not to come to psychiatrists,” he says.
There are other tricks to deal with hypochondriacs, Wilhelmsen says. First of all, don’t test them--they’ve already been tested dozens of times. New tests only whip up their fear that the doctor knows they have “something,” and is holding back the bad news.
Second: Don’t pooh-pooh them when they report that they are gasping for breath, dying of thirst, flattened by headaches or suffering any other seemingly nonexistent misery. “I accept all symptoms,” says Wilhelmsen. “That’s one of my basic points. I always believe they feel what they say they feel.”
When 31-year-old Inger Johanne Fyllingen hit the peak of her hypochondria, she not only thought she was dying of cancer and having heart attacks, but feared her three children were about to succumb as well. “I started going to the doctor and saying, ‘You’ve got to X-ray my head, my stomach, my lungs, my breasts.’ I went to at least 10 specialists.”
Before long, Fyllingen now admits, she was refusing to hire baby sitters, to let her children go out to play, to let anyone--even her husband--drive the kids unless she was also in the car.
Working the evening shift as a hotel housekeeper, she would call home several times nightly, reminding her long-suffering husband that it was time to feed the children, to bathe them, to put them to bed. Fyllingen started wishing she had never had children. But that didn’t stop her from quitting her job, so she could sit at home and worry about them even more.
“This thing was ruling my life,” she says. “I didn’t have five minutes to think normally.”
Finally, Fyllingen’s doctor told her there weren’t any more tests he could give her and he was sending her to a new hypochondria clinic in town.
Fyllingen says she went willingly enough.
“I trusted [Wilhelmsen] because he is a doctor,” she says. “He isn’t just a psychologist.”
Wilhelmsen’s treatment is based on cognitive therapy--an alternative to classical psychoanalysis, which he used years ago on ulcer patients, before it was discovered that ulcers are an infectious disease. He admits now that cognitive therapy seemed to make his ulcer patients worse, but says it works wonders for hypochondriacs.
At the clinic, Wilhelmsen set to work first on Fyllingen’s conviction that she had lung cancer. Why did she think so? Because she smoked, she told him, and she was always gasping for air. She had pains in her lungs. Her father had recently died of cancer.
Wilhelmsen asked her where the pains were, and she told him in detail. “When I was done talking, he told me lung cancer has completely different symptoms,” says Fyllingen. “My pain just went poof.”
Resolving Fyllingen’s case took about a year and a half, though Wilhelmsen says the typical hypochondriac stays in treatment for about six months. Some never get better. And occasionally, Wilhelmsen even discovers “hypochondriacs” who are really sick. They are referred onward, often to pain clinics.
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American health care analysts who have heard about Wilhelmsen’s practice are intrigued by his work and about the Norwegian context, in which a rich country’s state-led health care system is willing to let a specialist lavish time and attention on patients who are well.
If there were an American counterpart to Wilhelmsen, could it save the U.S. system money?
Blackwell thinks so, at least in theory. He cites a phenomenon that analysts call the “medical off-set,” which describes the big savings that result when a doctor can identify and treat the psychological component of a disease early.
The problem, Blackwell says, is that in America, “primary care practitioners are not equipped to do this and hypochondriacs are not willing to sit still long enough.”
Aamdal, for his part, swears that if Wilhelmsen’s clinic had been around 15 years ago, he would be a productive member of the work force today.
After he collapsed at work back in 1981, he went on sick leave--and ended up spending most of his newfound free time thinking obsessively about his collapse. What had caused it? Would it happen again?
He tried going back to work part time but had become so preoccupied with his health that he couldn’t concentrate in meetings. Finally, at 51, he consigned himself to early retirement.
Norway, an oil-rich Scandinavian welfare state, can afford to indulge people with such troubles; Aamdal received full pay while he was on sick leave, and has received two-thirds of his old salary throughout his long retirement.
“Economically, I got a really good deal,” he says. “But I must say, if I had received this treatment 10 years ago, I think I’d still be in a good job today.”
