Hypochondria

Every doctor recognises them—the man who discovers a bruise on his thigh and becomes convinced that it is leukaemia. The woman who has suffered from heartburn all her life but after reading about oesophageal cancer has no question that she has it. They make frequent doctor's 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 per cent of the United States' staggering annual health care costs.

Yet how we deal with hypochondria, a disorder that afflicts one of every twenty 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.

Recently, however, there has been a break in the impasse. New treatment strategies are offering the first hope since the ancient Greeks recognised hypochondria 24 centuries ago. Cognitive therapy, researchers report, helps hypochondriacal patients evaluate and change their distorted thoughts about illness. After six 90-minute therapy sessions, one study found, 55 per cent of the 102 participants were better able to do errands, drive and engage in social activities. In the study, the patients, whose fixation on illness had greatly interfered with their lives, did not see their symptoms disappear, but they did team to pay less attention to them.

'The hope is that with effective treatment, a diagnosis of hypochondria 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. He is the lead author of the study on cognitive therapy, which appeared in the Journal of the American Medical Association.

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. 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.

Sometimes patients become so fearful about their imagined illness that they exacerbate the symptoms, 'A headache that you believe is due to a brain tumour is a lot worse than a headache you believe is due to eyestrain,' Dr Barsky said. In the most extreme cases, patients can worry to the point where they develop delusions or become almost entirely disabled by fear.

The ancient Greeks used the word 'hypochondria' to describe symptoms of digestive discomfort, combined with melancholy that they thought originated in the organs of the hypochondrium, the region under the rib cage. The term applied only to men. In women, unexplained symptoms were attributed to hysteria, resulting from a misalignment of the uterus.

This view prevailed for 2,000 years, until the 17th century when symptoms of hypochondria - digestive trouble, pain, convulsions, shortness of breath and heart palpitations - were seen as arising from the brain, set off by fear, grief and other feelings. Thomas Sydenham, an English physician, said that hypochondria in men and women should be considered the same affliction. Yet doctors could offer little in the way of treatment beyond the traditional strategies of bloodletting, sweating and inducing vomiting.

In the 18th century, George Cheyne, a Scottish physician, described hypochondria as 'the English malady', noting that it occurred mainly in people of high intelligence and members of the upper class, and was caused by moist air, variable weather, heavy food and sedentary living. But traditional treatments still prevailed. In the 19th century, hypochondria was viewed as melancholia, a term that covered everything from slight hypersensitivity to physical symptoms, delusions and suicidal tendencies. Treatment became more humane: spa visits for exercise, fresh air, nutritious food and relaxation. But some physicians still relied on old methods, including potions and elixirs.

In the 20th century, Freud recognised that hypochondria had both psychological and physical properties. Some doctors tried hypnosis and later psychoanalysis to help patients uncover the psychological roots of their problem. But other doctors held that the suffering of hypochondriacs must be 'all in their heads'.

Today, 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, a malingerer, that it's all in my head",' he said. 'It's tremendously pejorative.' Some experts have suggested that doctors drop the word altogether, substituting the term 'health anxiety, which has fewer negative connotations.