Not just in the mind

Jane E. Brody talks about a new approach to treating hypochondria as an illness anxiety disorder

By ?NYTNS
  • Published 27.06.18
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This spring, when every tree in Brooklyn seemed to be shedding pollen all at once, I developed a nagging itchy throat with frequent spasms of coughing that made it difficult to talk or walk. I attributed the problem to allergies even though I'd never had such a reaction before.

But when I got worse instead of better after taking antihistamines, I began to wonder if I had something more serious - maybe walking pneumonia or possibly even throat cancer.

Though I tried to dismiss such sleep-disrupting thoughts, anxiety about my health loomed until the cough finally abated, then disappeared. But the incident hinted at what it must be like to have chronic health anxiety - a problem long called hypochondriasis, in which people are convinced they have a serious undiagnosed illness despite repeated medical reassurances that they do not.

The current psychiatric diagnostic manual has abandoned hypochondria as a disorder, replacing it in 2013 with two new concepts: somatic symptom disorder and illness anxiety disorder.

Dr Jeffrey P. Staab, a specialist in psychosomatic and behavioural medicine at the Mayo Clinic in Rochester, Minnesota, US, said it took two decades of research to come up with the new concepts, which eliminate the focus on medically unexplained symptoms. Instead, they focus on undue attention to bodily symptoms and excessive health concerns, which, when properly explained, can be very reassuring to patients.

"Health anxiety and body vigilance are much more understandable to patients when they realise they can have these things despite what their doctor finds," he said in an online report to health professionals. "We found it much easier to engage patients if we identified what the problem was instead of what it was not."

In patients with somatic symptom disorder, chronic symptoms result in excessive concern, fear and distress that something is seriously wrong, prompting them to seek repeated exams that rarely relieve their fears despite negative findings. In fact, negative results can increase patients' fears that their problems will never be correctly identified and treated.

As many as 5 per cent of patients visiting doctors' offices believe they have a serious, undiagnosed illness when none can be found. The persistent anxiety itself becomes a debilitating illness. Such patients are likely to insist that the medical care they received was inadequate. Even their doctors may wonder if they might have overlooked something.

Patients with illness anxiety disorder may, or may not, have a real medical condition, but they experience exaggerated bodily sensations, like sweating or a rapid heart beat, that can result in extreme anxiety about the possibility they have a serious underlying illness. They constantly check their bodies for signs of illness and devote undue time and energy obsessively seeking an explanation for what might be wrong. Every cough is pneumonia, every chest pain a heart attack, every headache a possible brain cancer or incipient stroke.

In fact, health anxiety can start a vicious cycle; health-related fears can be exaggerated by physical symptoms that develop as a result of anxiety about being sick or getting sick. Anxiety itself can cause a rapid heart rate, chest pain, nausea and sweating that patients then misinterpret as a sign of physical illness. Although there is no one cause of undue health anxiety, experts say it can run in families.

Psychiatrists have long thought some sort of trauma years earlier was the driver of health-anxious behaviours, Staab said, "and if we can't find it, it can become a speculative wild goose chase for trauma. Now we can identify these symptoms in a positive way and help patients modify them."

As with other anxiety disorders, cognitive behavioural therapy (CBT) is now the most recommended treatment method. Often used by psychologists as well as psychiatrists, CBT helps patients recognise the beliefs and feelings that feed the problem and then adopt more wholesome thought patterns and behaviours. They can then learn to cope more realistically with anxiety-provoking situations. The therapy has been shown to remain effective in reducing symptoms of health anxiety for at least a year.

Doctors, too, can benefit from the new approach to diagnosing health anxiety, Staab believes. "Now we can acknowledge that a patient's preoccupation with physical symptoms is higher than normal whether there is a diagnosis or not."

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