Worried sick: What can doctors do about hypochondria?
■ Although the cause of hypochondriacal patients' pain is inexplicable, it presents a real challenge to primary care physicians.
They can try the patience of even the most calm, cool and collected physician with ongoing complaints of a headache that is certainly a brain tumor or an aching arm that signifies bone cancer. No degree of assurances to the contrary can diminish their fears. Ultimately, addressing their needs poses a considerable and time-consuming clinical challenge.
Mastering the care of them, however, is also a priority for primary care physicians, because the number of these patients is great -- on average, as many as one out of 20 sitting in waiting rooms across the country at any given moment is a hypochondriac.
"Every physician has a thousand examples," said Robert D. Gillette, MD, a family physician, now semiretired, who works outside of Youngstown, Ohio. "The only question is whether you recognize it and know what to do about it or do you just kind of blow it off."
Ignoring such patients is a technique that has been employed by many. But Dr. Gillette and others have come to understand that dismissing such patients can lead to more trouble down the road for themselves, their patients and the other physicians to whom the patients will inevitably turn. In fact, he decided years ago that a sign he saw on a plumbing shop wall applied to their care: If you can't find the time to do it right, how will you find time to do it over?
"If you have a patient like this and you don't deal with it adequately, you are going to keep seeing the patient over and over again until they go somewhere else. Whereas if you can deal with it effectively, it takes a little longer up front, but it saves time in the long run," he said.
But hypochondriasis is difficult to diagnose, and once diagnosed, it is difficult for physicians to treat. Although it is described in the fourth edition of the American Psychiatric Assn.'s Diagnostic and Statistic Manual among the somatoform disorders, care is rarely delivered in psychiatrists' offices, because hypochondriacs are generally loathe to believe that their ailments could have a psychological basis.
Instead, they are seen in the offices of primary care physicians, where they can use up a lot of the doctors' goodwill.
Hypochondriacs can seem like a distraction from a physician's fundamental task, which is to detect and cure serious disease, said Arthur Barsky, MD, director of psychiatric research at Brigham and Women's Hospital in Boston and professor of psychiatry at Harvard Medical School. Physicians might think these issues are beside the point, the chaff that should be weeded out of medical practice, he added.
In addition, doctors often don't think they are very helpful to the patient. "The patient's symptoms don't seem to get better, and so physicians find themselves frustrated with their inability to help," said Dr. Barsky, who is one of the few physicians to have researched hypochondria.
A distinct group
Hypochondriacs diverge sharply from another group of frequent physician visitors -- the worried well. The later respond to health reassurances by saying, "I'm delighted to hear that it is nothing serious. That's just what I wanted to hear. I'm out of here. See you in a year for my regularly scheduled appointment," Dr. Barsky explained.
The hypochondriacal patient responds to reassurance with anger. They develop new symptoms to replace the old ones, and they intensify their complaints. Their reaction: " 'You wouldn't dismiss my symptoms if you knew how severe they were,' " he added.
And if the treatment issues aren't already difficult enough, physicians must add the possibility that a hypochondriacal patient could have a real ailment. It is the responsibility of physicians to do everything that is medically appropriate to make sure they aren't missing something important, Dr. Barsky said. "It happens. People are dismissed, and then it turns out they've got some awful illness," he added.
This is a nightmare scenario for physicians.
But on the flip side, more hypochondriacal patients are harmed by overly aggressive and invasive tests than they are by under-aggressive management of symptoms, Dr. Barsky said.
Knowing when to draw the line on ordering additional tests is an individual physician's decision, said J. Michael Pontious, MD, a family physician who teaches in a rural residency program at the University of Oklahoma College of Medicine. "Many of us are comfortable in what we know and what we've been taught and what we see," Dr. Pontious said. "But that doesn't mean we aren't surprised sometimes, and something slips through the cracks."
Some physicians can rely too heavily on available technology to shape their diagnoses, he added.
"And there is always one more test to order. In some ways, I think that's pathological as well, and you don't help the patient deal with their condition."
Dr. Pontious urges the residents and medical students he teaches to think broadly about a patient's symptoms.
What to do?
After appropriate tests are completed and nothing turns up, Dr. Pontious will say to his patient, "I've done the workup that is appropriate for this, and we have not found anything that helps us discern exactly what is going on. I believe that you are uncomfortable, but now my job is to try to help you deal with that."
How many tests to order is a problem for many physicians in these litigious times. Some might find test after test easier than it is to "sit down and have that eyeball-to-eyeball talk," Dr. Pontious said.
Dr. Barsky suggests one way to think it through. "Pretend your patient has an identical twin who has exactly the same medical history but is not hypochondriacal, and then do whatever you would do for that patient. Essentially, you try as best you can to ignore the hypochondriacal overlay and treat the patient," he said.
Michelle Riba, MD, president of the American Psychiatric Assn. and a clinical professor of psychiatry at the University of Michigan Medical School, suggests seeing such patients on a regular basis, so the appointment does not need to be driven by a host of new symptoms. During such visits, physicians should treat what they can one symptom at a time.
Also, as physicians get to know their frequent visitors, they might be more readily able to determine which symptoms are new and worth testing.
Physicians also must strive not to make their patients feel ridiculous or silly, or to question the veracity of what they are saying, she said.
In addition, doctors should be aware of disruptions that are probably occurring in patients' lives. Family problems and marital discord are likely because of their self-absorbed struggle to resolve health problems, and employers sometimes look askance at their high absentee rates because of numerous physician appointments. "One really needs to attend to these side issues, which can become very important," Dr. Riba said.
But steering a patient toward mental health care is an uphill climb. "The idea of any kind of psychological intervention makes no sense to them at all," Dr. Barsky said.
"Most patients have not even considered the possibility that their problem might be imagined," said Dr. Ingvard Wilhelmsen, who runs a clinic in Bergen, Norway, treating hypochondriacal patients. He often will refer to "excessive health anxiety" when he talks to patients as a term to which they can more easily relate.
Whether primary care doctors can get their hypochondriacal patients to consider such help depends on whether these patients can be persuaded to shift their concept of what's going on in their bodies, Dr. Barsky said.
Hypochondriacal patients have a pretty clear idea that there is something broken. "There's a lesion, a structural lesion someplace that just has to be diagnosed," he said.
But if the physician can refocus the patient's thinking away from the idea of a structural breakdown and toward dysfunction, the patient might be more amenable to psychological help. "Their GI tract isn't working right, or their sensory nervous system is not working right, and they are amplifying all kinds of sensations that most other people wouldn't notice or wouldn't be bothered by," he said.
Once patients acknowledge that something might not be functioning correctly, physicians are better able to turn their attention to therapeutic techniques that could help with the patient's perception of a symptom.
Dr. Barsky particularly likes the way an internist he knows handles the situation.
The internist tells patients that their central nervous systems are exquisitely sensitive to what's going on inside their bodies. He equates their nervous systems to radios in which the volume has been turned up so high that the background static has become really unpleasant and uncomfortable.
The explanation could begin to get across the idea that the patient's perception of a symptom will need to be corrected via therapy and that this is a more hopeful strategy than is excising a lesion that the physician can't find.
Despite his work toward understanding hypochondriasis, which includes studies showing that cognitive behavioral therapy can be helpful, it remains is an enormous problem, Dr. Barsky said. There is a belief that pain that doesn't have a medical basis is somehow less distressing, less disturbing than pain that does, he said. "But we know these people are not faking; they are not making it up."
These patients need a lot of help, Dr. Riba said. Not only does hypochondriasis turn an individual's life upside-down, but it costs society a lot of money, not only in the needless expense of tests, but in time lost from work.
And the problem is far from going away. Ready access to the Internet and its vast supply of good and bad medical information has provided additional fuel. Hypochondriacal patients often surf the Web with the hope they are going to find something reassuring, Dr. Barsky said.
"But almost all of them will tell you that by the time they finally get off the computer, they are more frightened than they were initially. They learn about all kinds of other diseases they never even knew about and now they can worry about them. I think it's not very helpful for these people at all."