To describe the destructive effects of intense health anxiety to his young doctors in training at Columbia University Irving Medical Center in New York City, psychiatrist Brian Fallon likes to quote 19th-century English psychiatrist Henry Maudsley: “The sorrow which has no vent in tears may make other organs weep.”
That weeping from other parts of the body may come in the form of a headache that, in the mind of its sufferer, is flagging a brain tumor. It may be a rapid heartbeat a person wrongly interprets as a brewing heart attack. The fast beats may be driven by overwhelming, incapacitating anxiety.
Hal Rosenbluth, a businessman in the Philadelphia area, says he used to seek medical care for the slightest symptom. In his recent book Hypochondria, he describes chest pains, breathing difficulties and vertigo that came on after he switched from a daily diabetes drug to a weekly one. He ended up going to the hospital by ambulance for blood tests, multiple electrocardiograms, a chest x-ray, a cardiac catheterization and an endoscopy, all of which were normal. Rosenbluth’s worries about glucose levels had led him to push for the new diabetes drug, and its side effects were responsible for many of his cardiac symptoms. His own extreme anxiety had induced doctors to order the extra care.
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Recent medical research has shown that hypochondria is as much a real illness as depression and post-traumatic stress disorder.
Hypochondria can, in extreme cases, leave people unable to hold down a job or make it impossible for them to leave the house, cook meals, or care for themselves and their families. Recent medical research has shown that hypochondria is as much a real illness as depression and post-traumatic stress disorder.
This work, scientists hope, will convince doctors who believed the disorder was some kind of character flaw that their patients are truly ill—and in danger. A study published just last year showed that people with hypochondria have higher death rates than similar but nonafflicted people, and the leading nonnatural cause of death was suicide. It was relatively rare, but the heightened risk was clear.
The research has also shown that the condition is actually two syndromes. One is illness anxiety disorder, Fallon says, in which the general idea of a sickness prompts excessive fear and preoccupation. The second syndrome is somatic symptom disorder, in which people worry about actual symptoms—a rapid heartbeat, say, or high blood pressure. The leading psychiatry handbook, the Diagnostic and Statistical Manual of Mental Disorders, now uses these two more specific diagnoses. (When referring to aspects that both conditions have in common, I use the word “hypochondria,” which is widely used by doctors and many patients, or the phrase “intense health anxiety.”) In addition, a new feature of hypochondria has garnered attention: cyberchondria, in which people spend an inordinate amount of time on the web researching medical conditions they think they might be suffering from.
Studies have also pointed to more effective treatments. Short-term cognitive-behavioral therapy (CBT) provides people with techniques to more rigorously evaluate the causes of their concerns—particular physical responses, in the case of somatic symptom disorder, or general fears about contracting a disease, for illness anxiety—and quell their spiraling sense of terror. Antidepressant drugs also help. Dismissing a patient with comments such as “it’s all in your head,” however, only makes things worse.
Estimates of hypochondria’s frequency range from as high as 8.5 percent to as low as 0.03 percent in medical settings. The COVID pandemic, which combined a real health scare with isolation and more time to ruminate, may have pushed the incidence up. In Australia, it jumped from 3.4 percent before the emergency to 21.1 percent during it.
The ancient Greeks thought hypochondria originated in a region of the body just under the rib cage that produced “black bile,” an ill-defined substance that caused a variety of physical ailments. Eventually hypochondria came to be associated with the nervous system, and in the early 20th century Sigmund Freud termed it an “actual” neurosis. He tied it, as he did many things, to feelings of guilt and sexual repression. It wasn’t until the 1990s, after clinical treatment studies with talk therapy and drugs, that psychiatrists stopped linking hypochondria to guilt about sexual and aggressive feelings.
Despite the pain and anguish it causes, “for centuries, hypochondria was deemed a fashionable, even a desirable disorder,” perhaps as a sign of an intellectual, thoughtful disposition, according to hypochondria reference material from the Wellcome Collection.
Some of the most revered minds have claimed to have the disorder, complete with mournful descriptions. There’s this from James Boswell, 18th-century biographer of English writer Samuel Johnson: “A Hypochondriack (sic) fancies himself at different times suffering death in all the various ways in which it has been observed and thus he dies many times before his death.” Avowed hypochondriac and 18th-century German philosopher Immanuel Kant noted that hypochondria was not a “really existing disease” but an apprehension. Twentieth-century French philosopher Jacques Derrida, convinced throughout his life that his death was imminent, used to say, “Life will have been so short.” He died of pancreatic cancer at 74.
Much of the more modern research was done by Arthur Barsky, now a professor of psychiatry at Brigham and Women’s Hospital in Boston. In the 1970s he was doing his psychiatry training at Massachusetts General Hospital. Primary care doctors would stop him in the hallway or at lunch to ask him about patients with headaches, dizziness, fatigue, palpitations or shortness of breath. “They keep coming back,” Barsky remembers the doctors complaining, “but I’ve done everything I can.”
“It’s not so much death that’s often feared,” says patient Annalisa Barbieri, “but being ill, being dependent, the loss of control.”
Barsky searched the medical literature and couldn’t find much to guide clinicians. He decided to dig in, and eventually he published a series of defining papers on the nature and epidemiology of hypochondriasis and treatments for the illness that, along with work by Peter Tyrer of Imperial College London, provided a more accurate scientific basis for treating the disease. The American Psychiatric Association eventually decided to divide the condition into illness anxiety disorder and somatic symptom disorder. Fallon, who was a consultant to the committee of psychiatrists behind the renaming, says a major reason for jettisoning the old category was that it focused on the absence of medical explanations for symptoms, and that enhanced the stigma when such a label was attached to a patient’s chart. The two new descriptions are about actual symptoms, such as unusual thoughts and behaviors related to a person’s medical concerns. Fallon estimates that about 20 to 25 percent of hypochondria cases are illness anxiety disorder, and the rest are somatic symptom disorder.
Hypochondria may, at first glance, seem to be a version of a related problem: obsessive compulsive disorder, or OCD. Both are marked by intrusive thoughts and distressing fears. There are differences, however. Some people with OCD may have intrusive thoughts about getting an illness, but these individuals usually also have other manifestations of OCD, such as an extreme need for order or symmetry. Among people with hypochondria, their fear is primarily of having an illness.
Cyberchondria, the latest manifestation of the disorder, has been the topic of more than 100 medical publications. (The Diagnostic and Statistical Manual hasn’t officially recognized it yet.) This version involves more than opening a laptop and checking Dr. Google—it interrupts people’s lives, taking away from time with their families or work and increasing their anxiety. In 2016 Fallon and his colleagues asked 731 volunteers about “online symptom searching” and about their level of health anxiety. Those at the lower end of the illness anxiety scale tended to feel better after checking their symptoms online, but not so for those with higher anxiety. “Contrary to their belief,” Fallon says, “checking the Internet for answers only makes them feel worse.”
In one study of cyberchondria in Germany, half the people who used symptom-checker apps qualified as having hypochondria. Frequent users of such apps, if they had the disorder, were likely to be unsettled by what the apps told them. A study of nurses in Turkey showed that cyberchondria coincides with an obsession with healthy eating, and a study of medical students in Egypt revealed an association with smartphone addiction.
Treating any kind of hypochondria is a challenge for doctors. They’ve got to rule out organic disease, and if they do but the patient keeps coming back, it can be frustrating. Back in 1991 Barsky and several of his colleagues asked patients in a large medical clinic what they thought of their physicians, and they also asked those physicians what they thought of their patients. The patients with hypochondria were less satisfied with their physicians than were other patients in the clinic. And perhaps not surprisingly, their physicians reported that those patients were more frustrating to care for and less likely to listen to them.
Clinical trials have shown that hypochondria as a whole, and somatic symptom disorder in particular, can be successfully treated with CBT or with antidepressants that improve the availability of the neurotransmitter serotonin (known as SSRIs). A combination of the two also works. More than 30 years ago, soon after the first SSRI, Prozac, went on the market, Fallon tried it on a patient who was very unhappy about being sent to a psychiatrist. “He had a dramatic improvement,” Fallon says, which inspired the psychiatrist to test it in a small trial. Just over 60 percent of the patients improved. Subsequent larger, double-blind studies by Fallon and others showed Prozac’s benefits, though at somewhat lower rates.
CBT for hypochondria can take different forms, all of which rely on identifying ways that health anxiety limits a patient’s ability to function and developing a plan the person can put into action when the disabling thoughts hit. A therapist might get a patient ready with stress-reducing breathing techniques to apply when needed. Another option is being prepared to recognize bad thoughts and practicing good replacement thoughts. If a woman is convinced the pain in her leg is cancer, for example, she can restructure the worry into a plan that includes contacting her doctor if pain continues. A therapist may also suggest she stop asking other people to share their symptoms with her.
Barsky and Fallon teamed up to compare Prozac alone, CBT alone, the two together and a placebo medication. They were aiming for an improvement of 25 percent or more on two scales that measure the disorder. After about six months the combination of Prozac and CBT came out on top with 47 percent improvement. Results for the groups that received a single treatment type were about equal, averaging a 42 percent improvement—12 percentage points better than the placebo group.
When someone with hypochondria hears they have a one-in-100 or even a one-in-1,000 chance, they may end up convinced that they are that one unlucky person.
After hypochondria was divided into two diagnoses, Fallon went back to this study. He found that patients he could classify as having somatic symptom disorder appeared to do noticeably better with Prozac than with CBT. For those with illness anxiety disorder, results tentatively suggested that CBT worked better than Prozac. That may be, Fallon says, because people in the group with somatic symptom disorder had substantially more depression and anxiety than those in the group with illness anxiety disorder.
The cause (or causes) of either condition remains a mystery. A slew of genes have been associated with depression, but this discovery hasn’t happened for hypochondria. If there is a genetic cause, it isn’t likely to be a simple one. When a trait appears more often in identical twins (who share a genetic profile) than in fraternal twins, it’s reasonable to think genes rather than environment are to blame. A Canadian study published nearly 20 years ago compared rates of health anxiety in fraternal and identical twins. Earlier studies had suggested that genes can explain about a third of the burden of health anxiety, but these researchers found that some of the hallmarks of health anxiety (treatment seeking and fear of illness, pain and death) were at most “modestly heritable.”
Experts in the field suggest that vulnerable people may be lured into full-bore illness by commercialism in our medical system. “Every symptom is significant if you listen to television,” Barsky says. “Pharmaceutical companies are telling us every day when we turn on the television that we should go to our doctors
and check things out.” Rosenbluth blames his switch to a heavily advertised drug and his subsequent hyperanxiety on having repeatedly watched a promising advertisement.
Whatever the cause, hypochondria is associated with a certain level of innumeracy, or trouble grasping risk levels—difficulty perhaps compounded by anxieties about those risks. Tobias Kube, a psychologist currently at the University of Kaiserslautern-Landau in Germany, found this out when he was working with Barsky at Harvard Medical School. In a study, they compared 60 people with hypochondria and related disorders to 37 volunteers without the conditions. The researchers asked the participants how worried they’d be if they were told they had a certain chance of having or not having a particular medical condition. If told to consider a one-in-10 or a one-in-100 or a one-in-100,000 chance of having something, people with intense health anxiety disorders reported greater concern than did volunteers without the conditions. “Patients still think, okay, it may be unlikely, but it’s still possible,” Kube says.
People with intense health anxiety also were more worried than the other group if they were told they had a 90 percent chance of not having a disease, although this more positive framing of risk prompted less concern. And people with hypochondria-related disorders were also more concerned by frequency numbers—say, one in 100—than by the same value presented as a percentage, such as 1 percent.
So does innumeracy cause hypochondria, or do the fears and anxieties associated with hypochondria make understanding odds difficult? “I suppose that both directions are possible,” Kube says. “But I consider it more likely that hypochondria causes the difficulties with interpreting likelihoods of medical diagnoses.” He reasons that finding out there is a low likelihood of having a disease diverges so much from the patient’s fears that the person hears only that a chance does exist. Instead of being relieved, they figure something must be wrong.
“Expressing empathy first and then offering to help the person connect with resources can be a good approach.” —Jessica Borelli, clinical psychologist
This inability to take comfort was supported by a second study. The same team asked 129 people—some with hypochondria and related issues, some with depression and some without either condition—to watch a videotape of a doctor being reassuring about gastroenterological complaints. After watching the talk, people with hypochondria still reported more concern than those in the other groups.
These challenges in evaluating information have implications for doctor-patient discussions. “Doctors can’t rely on simply explaining that it’s unlikely and then expecting patients to be fine,” Kube says. When someone with hypochondria hears they have a one-in-100 or even a one-in-1,000 chance, they may end up convinced that they are that one unlucky person. Kube and his co-authors suggest that doctors emphasize to their worried patients their high chances of not having a particular disease rather than their low chances of having it.
Effective treatments could be lifesaving, as indicated by a study in Sweden. The research started when, several years ago, psychologist David Mataix-Cols of the Karolinska Institute wondered just how far the consequences of hypochondria could go. “These people suffer enormously over many, many years,” he says. “And yet no one had actually looked—do they die?” He realized he had a powerful database to help him answer the question.
Sweden has detailed health and demographic records that include whether a patient has ever been diagnosed with hypochondria by a specialist. Mataix-Cols and his colleagues checked the death rate among all 4,129 people with a diagnosis of hypochondria between 1997 and 2020 (an undercount, he says; he suspects doctors in Sweden are reluctant to label their patients with a stigmatized condition). They compared that number with the rate among 41,290 demographically matched control subjects and reported their results last December in JAMA Psychiatry.
They found a hazard ratio for death of 1.69, meaning a nearly 70 percent increase in the probability of death in the hypochondria group from both natural and unnatural causes over the course of the study. Suicide was the primary cause of unnatural death. Mataix-Cols emphasizes that although the fourfold increased suicide risk they found is alarmingly high, the absolute risk in the population with hypochondria was still quite low. Suicide occurred, in fact, in fewer than 1 percent of people with the condition. “People should not be panicking like, ‘Oh, my God, I’m going to die because of my hypochondria’—this is not the message they should get,” he says. Rather the message he would like repeated is that hypochondria is a serious condition that should be treated.
The results of Mataix-Cols’s study startled Fallon and Barsky—neither has lost a patient with hypochondria to suicide. Barsky notes that people with hypochondria are hunting for a disease to match their symptoms so the disease can be treated; they’re not looking to die.
Annalisa Barbieri, a 58-year-old woman in England with hypochondria, has feared she had Parkinson’s disease, liver cancer, and other illnesses. “It’s not so much death that’s often feared but the dying, the being ill, the being dependent, the unknown, the loss of control,” she says. After CBT, Barbieri learned to reframe and replace these terrifying thoughts with more realistic assessments of her body. Today, she says, the monstrous anxiety inside her mostly sleeps. It does reawaken during times of stress, such as the kind she felt recently after her mother and several other people died in a short period. She rolls out what she learned during her CBT: to separate out assumptions from facts and to make a plan. It takes work, she says, and it does work.
Rosenbluth found writing his book about his condition cathartic, and the antianxiety medication he reluctantly takes has helped. He says he’s able to think things through with the help of a new doctor, who often spends 45 minutes per visit hearing out Rosenbluth’s concerns. Finding the best way for doctors to talk with patients who have hypochondria will improve their lives, according to experts in the field. Kube, in Germany, is exploring optimal approaches to these conversations. He plans to study in more detail how doctors can best frame “likelihood” statistics and how they can better communicate probabilities. He also wants to test the effect of a physician’s demeanor by asking volunteers to watch videotapes of doctors demonstrating varying levels of warmth and competence.
Some of the researchers in the Swedish early-death study plan to train medical personnel on how to recognize cases of hypochondria earlier and how to get those patients into treatment. Other scientists in Sweden have already shown that computer-based information on health anxiety combined with telehealth sessions with therapists can help as much as face-to-face therapy encounters. They looked at how 200 patients did with either face-to-face sessions or online self-help modules and occasional e-mail check-ins. In both groups, hypochondria dropped about 13 points on a 0- to 54-point scale after 12 weeks of treatment.
Family members and friends can also help someone they know and love who is overcome by obsession and fear about health. “Expressing empathy first and then offering to help the person connect with resources can be a good approach,” says clinical psychologist Jessica Borelli of the University of California, Irvine. “That might look like, ‘I’ve noticed that you have a lot of worries about your health, and that sounds really hard. I’d like to help you find some support. Is that something you are open to?’”
Borelli saw her first patient with hypochondria about 20 years ago and has seen many since. If you know someone who has hypochondria, she says, it might be helpful to offer them a suite of options—perhaps assistance in scheduling an appointment with a therapist or medical doctor or help organizing errands or cooking if an illness obsession has driven them to let things slide. Sometimes making life seem more manageable can help people begin to function in a healthier way.
When a person has been doctor hopping for years, looking in vain for a medical diagnosis, a therapist might be where to start. There also may be real but unexamined medical issues at the root of a patient’s anxiety, Borelli notes. If a person has not seen a primary care doctor—some people’s fear of hearing bad news keeps them away, for instance—helping them to find a physician, schedule a visit, and even offering to go with them would be a good first step away from unreasonable fear.
IF YOU NEED HELP
If you or someone you know is struggling or having thoughts of suicide, help is available.
Call the 988 Suicide & Crisis Lifeline at 988 use the online Lifeline Chat at 988lifeline.org/chat or contact the Crisis Text Line by texting TALK to 741741.
