Jerome Groopman: Can Hypochondria Be Cured?:

“Studies show that at least a quarter of all patients report symptoms that appear to have no physical basis, and that one in ten continues to believe that he has a terminal disease even after the doctor has found him to be healthy. Experts say that between three and six per cent of patients seen by primary-care physicians suffer from hypochondria, the irrational fear of illness. The number is likely growing, thanks to increased medical reporting in the media, which devotes particular attention to scary new diseases like sars, and to the Internet, which provides a wealth of clinical information (and misinformation) that can help turn a concerned patient into a neurotic one. Nevertheless, hypochondria is rarely discussed in the doctor’s office. The ‘‘worried well,’’ as sufferers are sometimes called, typically feel insulted by any suggestion that their symptoms have a psychological basis. Most patients are given a formal diagnosis of hypochondria only after ten or so years of seeing physicians, if they get such a diagnosis at all.” The New Yorker

Groopman writes this wonderful series for the magazine in which he considers area of medical controversy with compassion and insight. I was particularly interested in his take on this topic on the border of psychiatry and ‘real’ medicine. In hypochondriasis, patients are essentially exploiting the phsician’s fallibility and wish to be reassuring for unconscious reasons; a non-psychiatrist grappling comfortably with the problem would have to be penetrating about the limitations of the doctor’s art as well as intuitive about unconscious process — no mean feat. Groopman profiles a primary care physician who is, and then turns to a depiction of the work of neuropsychiatrist Brian Fallon (whom I knew way back when before either of us went to medical school). Because it is anathema to suggest to a hypochondriacal patient that it is psychological at root, this quintessentially psychiatric problem is rarely treated by psychiatrists. Fallon has an interesting take on it, having struggled to get referrals of patients considered hypochondriacal by his non-psychiatric colleagues to study.

Fallon has reconceived hypochondria as a heterogeneous disorder: some sufferers are indeed obsessive-compulsives, whereas others are experiencing a prolonged reaction to a traumatic event, like the death of a loved one. He also believes that people who are labelled hypochondriacs can behave in diametrically opposite ways in terms of seeking medical care. For some, the fear of illness is so great that they avoid all doctors. These patients indulge in the fantasy that if a doctor doesn’t examine them, then the illness won’t appear. Another group needs to see doctors constantly, even when these visits cause more anxiety or humiliation.

What this heterogeneity hints at is that the hypochondriacal ‘label’ may have something, or as much, or more, to do with the distasteful reaction her physicians have to such a patient as it does to the underlying process in the patient herself. (This is a familiar problem in psychiatry as well, which I refer to as ‘diagnosis by countertransference’, usuallly seen when a disagreeable or difficult patient is labelled with borderline personality disorder. In my teaching and supervision with regard to both hypochondriasis/somatization and borderline personality dynamics, it is one of the most difficult issues for trainees to dea with.) Groopman’s article ends with a patient’s summation of perhaps the best approach to treating such difficult cases:

‘‘Hypochondria is not at all funny, like people think,’’ she said. ‘‘It’s not a ‘Seinfeld’ episode. It’s a horrible, horrible way to live.”