Skip to comments.A New Era in Treating Imaginary Ills
Posted on 03/30/2004 12:17:42 AM PST by neverdem
March 30, 2004 A New Era in Treating Imaginary Ills By MARY DUENWALD
very doctor recognizes them.
The man who discovers a bruise on his thigh and becomes convinced that it is leukemia. The woman who examines her breasts so frequently that she makes them tender, then decides that the soreness means she has cancer. The man who has suffered from heartburn all his life but after reading about esophageal cancer has no question that he has it.
They make frequent doctors' appointments, demand unnecessary tests and can drive their friends and relatives not to mention their physicians to distraction with a seemingly endless search for reassurance. By some estimates, they may be responsible for 10 to 20 percent of the nation's staggering annual health care costs.
Yet how to deal with hypochondria, a disorder that afflicts one of every 20 Americans who visit doctors, has been one of the most stubborn puzzles in medicine. Where the patient sees physical illness, the doctor sees a psychological problem, and frustration rules on both sides of the examining room.
Recently, however, there has been a break in the impasse. New treatment strategies are offering the first hope since the ancient Greeks recognized hypochondria 24 centuries ago. Cognitive therapy, researchers reported last week, helps hypochondriacal patients evaluate and change their distorted thoughts about illness. After six 90-minute therapy sessions, the study found, 55 percent of the 102 participants were better able to do errands, drive and engage in social activities. Antidepressant medications, other studies indicate, are also proving effective.
"The hope is that with effective treatments, a diagnosis of hypochondriasis will become a more acceptable diagnosis and less a laughing matter or a cause for embarrassment," said Dr. Arthur J. Barsky, director of psychiatric research at Brigham and Women's Hospital in Boston and the lead author of the study on cognitive therapy, which appeared in the March 24 issue of The Journal of the American Medical Association.
Almost everyone has inexplicable physical symptoms from time to time, and many people experience a moment of worry that their odd rashes, bumps or pains are signs of real trouble. But an official diagnosis of hypochondria, according to the American Psychiatric Association, is reserved for patients whose fears that they have a serious disease persist for at least six months and continue even after doctors have reassured them that they are healthy.
In patients with hypochondria, experts say, ordinary discomforts appear to register more intensely than they do for other people.
"The person's nervous system is like a radio whose volume has been turned up so high, the background static becomes intolerable," Dr. Barsky said.
Researchers have found that hypochondria, which affects men and women equally, seems more likely to develop in people who have certain personality traits. The neurotic, the self-critical, the introverted and the narcissistic appear particularly prone to hypochondriacal fears, said Dr. Michael Hollifield, an associate professor of psychiatry at the University of New Mexico. As many as two-thirds of hypochondriacs also have other psychiatric disorders. Studies suggest that 40 percent suffer from major depression, 10 to 20 percent have panic disorder, 5 to 10 percent have obsessive-compulsive disorder, and some have generalized anxiety disorder.
The fear of illness comes in varying degrees of intensity. Hypochondria may be mild, a faint background noise, or so intense it drowns out all other thoughts.
"It can be hard to sleep or think of anything else other than your hypochondriacal fears," said Dr. Brian Fallon, an associate professor of clinical psychiatry at Columbia.
In some cases, patients become so fearful about their imagined illness that they make the symptoms worse.
"A headache that you believe is due to a brain tumor is a lot worse than a headache you believe is due to eyestrain," Dr. Barsky said.
For the hypochondriac, a nagging worry often becomes panic, which then leads to further symptoms.
"Because patients are anxious, their heart starts to race and they become dizzy," said Dr. Jonathan S. Abramowitz, a clinical psychologist at the Mayo Clinic in Rochester, Minn., who treats patients with hypochondria.
The new symptoms cause further anxiety, and the cycle continues.
In the most extreme cases, patients can worry to the point that they develop delusions or become almost entirely disabled by fear.
"They become so afraid of what is going on with their body, they become shut-ins," said Dr. Hollifield of the University of New Mexico. "They think that anything they do is going to rile their body."
Yet hypochondria does not typically lead to suicidal thoughts, said Dr. Don R. Lipsitt, a professor of psychiatry at Harvard, if only because people who fear illness also fear death. "These people have a tendency to live out a pretty healthy life," he said. "They nurse themselves. They mother themselves in a sense."
Hypochondria has a long and colorful history. In the 18th century, Boswell wrote a weekly magazine column, "The Hypochondriack," describing his obsession with personal health. In the 19th century, Darwin worried over unexplained palpitations, fatigue and trembling in his fingers, which flared up when he had to discuss his new theory of evolution. Proust was so protective of his health that he kept himself wrapped in layers of overcoats and mufflers.
The ancient Greeks used the word hypochondria to describe symptoms of digestive discomfort, combined with melancholy, that they thought arose from the spleen and other organs in the hypochondrium, the region under the rib cage. The disorder was thought to occur only in men. In women, unexplained symptoms were attributed to hysteria, a dislocation of the uterus.
This view prevailed for 2,000 years, until physicians in the 17th century realized that hypochondriacal fears probably originated in the brain, not the body.
Yet doctors could offer little in the way of treatment beyond the traditional strategies of bleeding, sweating and inducing vomiting.
In the 20th century, Freud recognized that hypochondria had both psychological and physical properties. But because the disorder was not relevant to his theories, he had little interest in it. Other doctors held that the suffering of hypochondriacs must be "all in their heads."
But many experts now say that discounting patients' symptoms only makes matters worse.
"When you think about it, it's the ultimate hubris for a physician to proclaim that a patient's symptoms are not real," Dr. Fallon of Columbia said. "If a person is experiencing something, it is real, whether or not you can explain it physiologically."
Still, it is psychiatry that offers patients the best hope of getting control of their anxiety. That often leads general practice doctors into a delicate dance, as they try to find ways to refer patients to psychiatrists without offending them.
Just mentioning the word hypochondria to a patient, Dr. Barsky said, can cause trouble.
"That comes across as, you're telling me I'm a faker, the malingerer, that it's all in my head," he said. "It's tremendously pejorative."
As a result, some experts have suggested that doctors drop the word altogether, substituting the term health anxiety, which has fewer negative connotations.
If a name change can allow more patients to accept their problem, the logic goes, perhaps more patients will seek treatment. Cognitive therapy, as demonstrated by Dr. Barsky's study, has proved surprisingly effective in helping patients who read into every ache and pain a portent of disaster.
In the study, the patients, whose fixation on illness had greatly interfered with their daily lives, did not see their symptoms disappear. But they did learn to pay much less attention to them.
The therapy taught the patients to re-examine their assumptions about the symptoms.
"We talk with patients about other possible explanations for their headaches, their tension or their lack of sleep," Dr. Barsky said.
The therapists, who included psychologists, social workers and nurses, also coaxed patients to temporarily suspend some of the usual ways they reassured themselves, like checking the Internet for health information, taking their pulse or blood pressure and scheduling appointments with doctors.
The researchers also sent letters to the patients' primary doctors, advising them about ways to help. The doctors were told to see the patients for regularly scheduled appointments only, not for emergency visits when their symptoms flared up; to be conservative about providing treatment or ordering tests; and to aim to help patients cope with symptoms rather than eliminate them.
"You have to work with the primary care doctors," Dr. Barsky said, "because hypochondria affects the doctor, too."
The patients who received cognitive therapy continued to improve for as long as 12 months after treatment, the study showed. Of the 80 patients in the control group who saw their regular doctors as usual, 29 percent also improved during the year, Dr. Barsky said. He added that because the subjects were screened over a short period, some in both groups might have had only temporary hypochondria.
Other experts said the study's findings were an encouraging sign that hypochondria was not as intractable as people had thought.
"The study highlights the cognitive distortions that the patients engage in," Dr. Fallon said. "And it gives them a practical tool with which to confront their fears and their physical sensations."
Early research into medication as a form of treatment is also promising. Dr. Fallon, for example, has found that two antidepressants, Prozac and Luvox, can ease hypochondriacal fears and fixations in as many as 70 to 80 percent of patients.
The drugs appear to be most effective in patients who believe they are afflicted with a specific illness, Dr. Fallon said, and less effective in those troubled by symptoms like headaches, joint pain or vision problems but do not know what may be causing them.
Dr. Russell Noyes, an emeritus professor of psychiatry at the University of Iowa, is exploring whether interpersonal therapy, which encourages patients to examine their social and family relationships for clues to their problems, is effective.
Inevitably, some patients will stand by their hypochondriacal convictions in the face of any effort to dislodge them.
"There will always be someone who says, `What I really need is for somebody to biopsy my liver,' " Dr. Barsky said.
Besides, from all the disclaimers, it would seem that most of the drugs they try to market are better suited for testing one's liver and immune system than at actually curing anything...
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