Worried Sick : Doctors Can’t Ease Pain Hypochondriacs Feel

BALTIMORE — When Dr. Rudolph Hoehn-Saric was in medical school, he had a professor who was a certifiable hypochondriac.

“He was constantly going for test after test, complaining about his health problems,” recalls Hoehn-Saric, director of John Hopkins Hospital’s anxiety disorder clinic here. “But then, he developed phlebitis in the leg and was too frightened to get anything done about it, got an embolism and died.

“The funny thing is, some hypochondriacs will worry about their health, go through all these tests, but underneath it all maybe they really know there’s nothing wrong,” he adds. “But if they’re really sick, then they’re too scared about it to go to the doctor.”

Such is the nature of hypochondria, or outsized fears about one’s health that can’t be eased for all the medical tests and doctor’s visits in the world.

It is a disorder that can seem almost laughable--think of Felix, the neat, neurotic one in “The Odd Couple”--or annoying or ridiculous.

Unless you have it.

“They do have definite pain,” says Dr. Mark Ehrenreich, a psychiatrist at the University of Maryland Hospital here, “no matter where it comes from.”

Even though most people know someone they would tag as a hypochondriac, not much is known about this psychological disorder--what causes it, how many people suffer from it, how best to treat it, whether it even can be treated effectively.

Hypochondria, known as hypochondriasis in medical terminology, is generally defined as abnormal preoccupation with one’s health and a fear of having or getting a disease despite physical evidence to the contrary.

“As with a lot of psychiatric illnesses, there’s a continuum of what’s normal and what’s abnormal,” says Ehrenreich, assistant director of the hospital’s psychiatric consulting liaison service. “Some hypochondriasis is normal. Someone just might have had a heart attack and will be worried about his condition. But when it interferes with your functioning, when despite receiving all the tests that are negative, they persist in thinking something is wrong with them, and an inordinate amount of time spent on medical care, then it becomes more severe.”

Hypochondria can be more than the bothersome, but essentially harmless, way that your old Uncle Joe goes on and on about his ailments, real or imagined. Often, hypochondria masks a more serious problem, doctors say.

“These patients lack the language to describe other feelings or psychological problems, so they make physical complaints instead,” Ehrenreich says.

There are people who appear to be afflicted with hypochondriasis, but have something else, like depression, that they can only express in somatic signs, he adds. They may not be willing to accept depression as the problem.

“That’s something you see particularly in elderly patients,” agrees Dr. Mark Teitelbaum, who heads the psychiatric consultation liaison service at Johns Hopkins Hospital. “And sometimes it may be part of an anxiety disorder. They’ll have an anxiety attack, their hearts will race and they’ll go to cardiologists thinking they’re having a heart attack. It’s a symptom of another psychiatric disorder that needs to be diagnosed.”

The problem, however, is that hypochondriacs want to believe their ailment is physical rather than emotional. That is the nature of the disorder.

“Many of the hypochondriasis patients resist psychological care,” says Dr. Teitelbaum. “Instead, they will ‘doctor shop,’ and have multiple medical workups.”

And, ironically, that is perhaps the worst thing a hypochondriac can do.

“What they should do is establish a relationship with one doctor, and schedule regular visits,” Ehrenreich says. “Then you get to know the patient, and know when a new complaint arises. You talk about what’s going on in a patient’s life, for example, if there’s a problem with his marriage, maybe that’s why he’s complaining about stomach problems. With regularly scheduled visits, you’re providing for his dependency needs and recognizing the stresses in his life.”

That, Ehrenreich admits, is an ideal solution that often doesn’t happen in real life. Hypochondriacs turn up frequently in emergency rooms, and the doctor on duty often won’t know the patients’ backgrounds, spending time examining them and ordering tests for what ultimately turns out to be a baseless complaint.

“Probably daily we see this, in one form or the other,” says Dr. Brian Browne, clinical director of emergency medicine at University of Maryland Hospital. “Worst of all, particularly in emergency rooms, you see so many peculiar people, it’s hard to tell, is this patient peculiar or does he really have a problem?”

Indeed, just because you’re a hypochondriac doesn’t mean there’s nothing physically wrong with you sometimes.

“Even hypochondriacs actually get sick,” Browne says. “It’s like someone who predicts every day it’s going to rain. Eventually, it does rain.

“No matter how many times they’ve been in and out, you have to deal with this particular episode,” he added. “It takes time. Even if he has a well-documented medical record of hypochondriasis, what about today?”

No one is sure just how many hypochondriacs there are out there. Researchers believe that hypochondria is equally common among men and women, and studies show from 3% to 14% of patients seen in a medical practice might be hypochondriacs. It is not clear, however, if that is the same percentage found in the general population.

Today’s heightened interest in health and fitness may be a modern-day twist of this age-old disorder, some believe.

People read about chronic fatigue syndrome or Lyme disease or whatever the current malady of the week is, and think, “Hmmm, maybe that is what’s wrong with me.”

Some believe the proliferation of health information through television and magazines has extended what is known as “medical school syndrome”--in which students become convinced, usually temporarily, that they have whatever ailment they are reading about--to the rest of us.

“There are some hypochondriacs who will get particularly concerned about certain diseases--in the past, it was tuberculosis or syphilis,” Hoehn-Saric says. “Today, it’s AIDS.”

While infectious diseases indeed are something everyone should worry about, hypochondriacs will take that natural concern to an extreme, he says.

“It becomes hypochondria when the concern is out of proportion, when you can’t correct it with information,” he says. “People who are hypochondriacs, you can’t reassure them with information. Or if you can, it’s only for a short time.”

Treating hypochondria can be difficult. There is no “cure.” If the disorder is related to another one, treating that may cause the hypochondria to ease up.

“If there is something else present, like depression or anxiety, you would treat that,” Hoehn-Saric says. “You could use psychotherapy, explore some of the thinking patterns, find out whether their family was extremely health-conscious and they remember being taken to the doctor a lot as a child.”

There is some evidence that people who grew up in households in which a family member suffered from a major disease or in which health was a preoccupation may be predisposed to becoming hypochondriacs.

And one researcher, Dr. Arthur Barsky, a Harvard Medical School psychiatrist who wrote the book “Worried Sick,” has found that hypochondriacs may be more sensitive than others to sensations such as pain, temperature, noise and hunger. That may cause them to overreact to symptoms that other people would ignore.

Hypochondriacs are different from people who have Munchausen’s syndrome, in which patients actually make themselves sick or make themselves appear to be sick, and then try to get themselves admitted to hospitals.

“It’s related, in a sense, but the ordinary hypochondriac actually believes he’s sick. The Munchausen’s (patient) consciously feigns being sick,” Teitelbaum says. “He might put a tourniquet on his leg and then go to the doctor’s complaining of a swollen leg. Or he might ingest a lot of amphetamines to make his blood pressure go up.”

“There’s a difference between someone who’s a hypochondriac and someone who’s faking,” Browne says. “With real hypochondriacs, they’re not out to deliberately fake you out. They’re really suffering from these things--these headaches, these stomach problems.”