“Am I a hypochondriac?”
It’s a question I hear with quite some regularity, almost never from people who suffer from bona fide anxiety disorders related to their health.
No, the fact that all you have is a simple upper respiratory infection — the common cold — instead of a potentially lethal strain of H1N1 avian flu does not qualify. Not when your response to my reassurance is relief. That’s completely appropriate, and I have no problem providing all the reassurance you need. Whether it’s explaining why your headache that goes down the back of your neck that worsens when you fight with your spouse is definitely not a brain tumor, or that the itchy rash on both arms and one leg can’t possibly be shingles, I’m good. Confirming that what you have isn’t serious is right in my wheelhouse.
I never actually use the term “hypochondriasis,” mainly because it’s not particularly useful. These individuals have a real disorder: It’s just not physical. It’s also known as “health anxiety”, a term I swear I came up with on my own, completely independently from Wikipedia. Because that’s what it is: an anxiety disorder.
Have you ever been worried about something? Really worried about something potentially serious? My working assumption is that everyone has. If you think about it, you’ll realize these patients are miserable. Their hearts race, they can’t stop their mind from working overtime — forget about sleep. Whether it’s cancer or AIDS or Ebola or Lyme — whatever happens to have been making the media rounds most recently, these people can’t get their minds off their bodies.
Ordinary sensations become magnified and over-interpreted until they are convinced there’s something dreadfully wrong with them. Sometimes these symptoms cross over into delusions — fixed false beliefs — at which point nothing, by definition, can convince them otherwise.
So what do we do with these patients?
Two answers: First, there’s what we ought to do; second, there’s what’s usually done.
In the usual course of events in a busy medical office, patients presenting with statements of physical symptoms are generally taken at face value. Those symptoms are worked up, usually with testing and imaging. (“But how can you know for sure if you don’t do any tests, doctor?”) Everything comes back negative. The feared diagnosis is ruled out. The patient is told nothing is wrong, but they don’t really believe it. So they come back again the next week or the next month or the next year, and the whole thing starts anew, wasting untold amounts of time and money, not to mention exhausting resources that could be put to better use for other patients; the ones with actual physical conditions.
What ought to be done is to address the anxiety part of the condition. Yes, it’s a mental illness. And however great the stigma, however reluctant the patient may be to bear the label of mentally, as opposed to physically ill, we do them a great disservice by repeating workup after workup after workup, inadvertently validating their perception of a physical condition.
It’s tough, I know. It’s time-consuming; boy, do I know! But how many CT scans, how many MRIs, how many scopes and specialist will it take to say enough.
We need to do a thoughtful, thorough history and a careful focused physical exam, followed by specific testing and imaging indicated by our findings. Then we need to help the patient deal with the real problem: anxiety. Believe it or not, they’ll be glad we did.
Note: Please don’t flood the comments with stories of missed conditions by patients waving their incorrect anxiety diagnosis at me in anger. I’m not talking about difficult-to-diagnose conditions. I’m talking about people who over the course of many years present repeatedly with non-physiologic or changing complaints with repeatedly negative workups. For every patient whose symptoms were dismissed causing prolonged suffering with genuine disease, there are at least ten others (or more) whose accurate diagnosis really is anxiety-based.
Lucy Hornstein is a family physician who blogs at Musings of a Dinosaur, and is the author of Declarations of a Dinosaur: 10 Laws I’ve Learned as a Family Doctor.