Brian Fallon is associate professor of clinical psychiatry at Columbia University in New York. He became interested in hypochondria in the late 1980s after meeting a patient whose fixation on health seemed like a form of obsessive compulsive disorder. Fallon tried the patient on Prozac, which proved a success, and then he carried out a small trial (Journal of Clinical Psychiatry, vol 52, p 457). Fallon is now a leading proponent of treating hypochondria with selective serotonin re-uptake inhibitors, the Prozac class of drugs.
Have you ever been a hypochondriac?
No, but I know what it’s like to worry about an inexplicable symptom. One morning I noticed my arm was swollen and I was quite concerned. I thought I might have a blockage of my lymphatic system, perhaps caused by cancer. My supervisor pointed out it was probably just a result of spending the previous day using a chainsaw. It was a good demonstration of how, when anxiety takes over, you start to lose some of your more rational powers of observation.
Advertisement
How common is it?
Hypochondria is extremely common, especially when you have things like anthrax around – people suddenly become hyper-vigilant about symptoms. Somewhere between 4 and 6 per cent of patients who visit their doctor are afflicted with full-blown hypochondria, and a much larger percentage have transient hypochondria.
So what is true hypochondria?
Everybody gets worried if they have a new medical symptom – that is what brings you to the doctor, so that’s healthy. But hypochondria is the fear of disease that persists even after a doctor’s examination and reassurance. A person with hypochondria might be reassured initially, but later in the day a nagging uncertainty re-emerges and leads the patient to wonder, “Did I really explain my symptoms adequately?” or “Wasn’t the doctor distracted by that phone call?”. Hypochondriacs can spend large parts of the day thinking about their symptoms and discussing them. They will track down numerous experts and will find the loopholes in every medical test, and seek more sensitive ones to make sure that the last doctor hasn’t missed something.
What is the most extreme behaviour you’ve seen?
I had one patient who was being considered for a study and we conducted an initial blood test. I didn’t realise how anxious she was about the results until, about four days later on a Sunday, she called me at home to ask me what the results were. I have no clue how she tracked me down – I live about 50 miles away from the research clinic in another state. She said that she had called about 20 people to find my home phone number. I was astounded by how persistent she had been.
What causes hypochondria?
People come to it from a variety of different directions. The traumatic loss of a loved one can result in repressed anxiety and the emergence of physical symptoms six months or a year later. It may also stem from your childhood – if you had an overprotective mother who jumped any time you had a physical symptom, that naturally would lead a child to conclude that a good way to get attention and love is to develop physical symptoms. That can become a totally unconscious thing. And I am firmly convinced that hypochondria can happen biologically, from the link that’s been observed with obsessive compulsive disorder (OCD).
How are they linked?
They are separate illnesses, but about a third of hypochondriacs have a form that has striking similarities to OCD. I made the link about 15 years ago when I was working as a psychiatrist. I was assigned a patient who was complaining of headache and thought it was a brain tumour. It struck me that the symptoms this guy was manifesting were so similar to OCD – the repetitive intrusive thoughts, and the compulsion to check over and over again with a medical professional. There were research studies going on in our department indicating that Prozac was a very effective treatment for OCD. I suggested giving him a trial of Prozac and recommended the high dose that you use in OCD. About three months later I ran into this patient in the hallway and he was markedly improved. It was such a stunning example to me.
So we started treating other hypochondriacs with selective serotonin reuptake inhibitors, the Prozac class of drugs. The two main types of treatments that have emerged over the past 15 years are SSRIs and cognitive behavioural therapy. Our experience is that SSRIs result in significant improvement in 70 to 75 per cent of patients.
What about the two-thirds of hypochondria patients who do not have OCD?
There’s another third who have more prominent depressive features with their hypochondria. They come in tearful and barely able to tell you that they fear they are dying of cancer and they feel guilty because they are not going to be there to feed their family. Or maybe they have engaged in an extramarital affair and now they believe they have become infected with HIV, and they think they may have transmitted it to their spouse. It’s generally assumed that hypochondriacs torture doctors with repeated visits, but this depressive group might even avoid going to their doctor because they are so despairing that there is any hope for them. This depressive group also does extremely well with drug treatments.
The last third are a group of patients who I feel are harder to treat. They feel they have a multitude of symptoms, and they worry that they have a serious disease. Those patients in my experience have done less well with drugs.
Are there any biological differences between hypochondriacs and other people?
The studies are not conclusive. One study got people to put their hands in a very cold vat of water. The hypochondriacs had a greater drop in body temperature and a greater increase in heart rate. You could explain that physiologically, but you could also say it’s psychological – they got more stressed, which caused a change in physiological activity. Some hypochondriacs seem to be enormously suggestible.
How?
They seem to be extremely responsive to the placebo effect. I treated one woman who was a severe hypochondriac, always thinking she had one disease or another. Eventually she entered our placebo-controlled study of Prozac. She had some initial physiological symptoms that suggested to me that she might be on the drug. And she got tremendously better, and started to dress well and look extremely happy. Then one session she came in extremely upset. It turned out someone was trying to blackmail her about an affair she was having. Then in a subsequent session she told me she was going to buy a gun and take care of this person.
At the time, Prozac had been in the media a lot because of claims it could cause people to have murderous intentions. I advised her to give me back the medicine, but she refused because she was so happy that it was helping her.
Eventually the crisis calmed down and she said she wasn’t going to get the gun. But she never gave me back the medicine. I was all ready to write my letter to the editor of The New England Journal of Medicine about my suspicions when the trial’s blinding was broken and I learned that the patient had been on a placebo the whole time.
Hypochondriacs are also susceptible to the “nocebo” effect, when they suffer noxious side effects from placebo medication. For example, the patient comes in and tells me they have various adverse effects, so I’m convinced they’re on the medicine, as is the patient, and then I find out at the end they were really on a placebo the whole time. I have been fooled too many times.
How do other doctors react to hypochondriacs?
They are human beings – some are bound to get very frustrated by a hypochondriac’s complaints. Some may erroneously draw the conclusion that any symptom that the person comes in with is a symptom of hypochondria. Most doctors and even psychologists used to take a very dismissive and derogatory approach to hypochondriacs. More recently, hypochondria has been taken more seriously because it’s been recognised that it is an illness that is fairly prevalent, and is associated with significant disability and distress. And it also fits a profile that is characteristic of patients who have obsessional problems.
Is there a danger that when hypochondriacs get a real illness it could be missed?
Yes. I nearly missed one myself. This was a man who six years earlier had had a severe bout of depressive hypochondria, which had only been cured with a course of electroconvulsive therapy. At the time of his retirement, his anxiety started to re-emerge. He began to feel that his body was throbbing and he had these pins and needles and felt extremely fatigued, and he started to worry that he had some terrible illness like cancer. He was evaluated and everything was negative from a medical point of view. So the logical assumption was that this was hypochondria again. But this time nothing worked, not even electroconvulsive therapy. At which point they referred him to me.
He was one of the most severe cases I had ever met – it was extraordinarily difficult to sit in the room with him, because he asked the same questions over and over again. I wondered how anybody could live with him. I entered him in the SSRI study, but he wasn’t getting better at all. Then he came in with this big rash, which looked exactly like the bull’s eye rash of Lyme disease, which can also cause psychiatric symptoms. In Lyme disease people can get what are called late-appearing rashes, so he might have contracted this disease six months before. I called this gentleman’s doctor to inform him, and there was a long silence at the other end of the telephone. We treated the patient with antibiotics and within two or three months all his symptoms were gone.
Does the opposite ever occur, when doctors believe hypochondriacs too much and make things worse?
That certainly happens as well. If a patient goes to the doctor with a set of vague and non-specific complaints, the doctor might say, “Well this could be a number of diseases – it could be lupus, it could be other connective tissue diseases.” As you can imagine, going through a list of very serious diseases creates enormous anxiety.
Has the internet made things worse?
The internet is an absolute nightmare. They type in their symptoms and come up with a vast number of diseases that they might have, all of which are serious. Then they find the chat rooms for that disease, and they receive a tremendous amount of rapid diagnoses and misinformation. There are a lot of people in chat rooms who are just enraged at the medical profession.
Do you ever get impatient with your patients?
They try your patience for sure, because they ask the same question over and over again. But I am less impatient these days because I have a lot of confidence that I am able to help most people.