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Hypochondriasis
Hypochondriasis Medical Management and Psychiatric Treatment ARTHUR
J.
BARSKY,
M.D.
This study describes a 2-part approach to the hypochondriacal patient: 1) a strategy for medical management, and 2) a specific psychiatric therapy. Medical management rests on the physician's recognition that patients have psychological and interpersonal reasons for feeling symptomatic and seeking medical attention. After gaining this appreciation. the physician can stop trying to cure the patient's symptoms, and the goal of management then shifts to assisting the patient in coping with the symptoms. A specific psychotherapy is then presented. Group discussions and cognitive and behavioral exercises are used to teach patients to moderate four factors that amplify somatic distress and hypochondriacal health concerns: the attention they pay to their symptoms, their thoughts about them, the context in which they experience their symptoms, and their moods. (Psychosomatics 1996; 37:48-56)
H
ypochondriasis is an unusual disorder in that it affects both patients and physicians alike. Hypochondriacal patients feel chronically ill and endure significant role impairment. They seek medical care frequently and persistently, with high rates of physician visits, laboratory tests, diagnostic procedures, and "doctor shopping." But they find their care as ineffective and unsatisfactory as it is extensive. l -4 The physician is affected too; from hislher viewpoint, hypochondriacal patients are difficult to care for and tend to evoke strong antipathy.s Straightforward reassurance and symptomatic medical management seem ineffective. More aggressive medical interventions typically lead to complications, side effects, worsening symptoms, or new symptoms to replace the 0Id.2.6·7 In addition, the medical care process inadvertently reinforces the patient's somatization by ignoring his or her psychosocial distress and supplying a somatic lexicon for expressing it. But because hypochondriacs tenaciously resist psychiatric referral, their care ultimately rests with 48
their medical physicians. No specific, widely accepted psychiatric treatment of demonstrated efficacy now exists. Some promising new approaches are emerging, however. 8- '6 This study describes a 2-part approach to the hypochondriacal patient: I) a strategy for medical management, and 2) a specific psychiatric therapy. It is intended for patients whose hypochondriacal symptoms are chronic, severe, long-standing, and disabling. It is not intended for "worried well" patients with more reactive, transient, and circumscribed health concerns. The psychiatrist has an important consultative role to play in medical management. The psychiatrist can explain the condition to the Received December 30. 1993; accepted March 4, 1994. From the Division of Psychiatry, Brigham and Women's Hospital. Boston, MA. Address reprint requests to Dr. Barsky, Division of Psychiatry, Brigham and Women's Hospital, 75 Francis St., Boston, MA02115. Copyright @ 1996 The Academy of Psychosomatic Medicine.
PSYCHOSOMATICS
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medical physician as well as describe a management strategy based on the notion that the hypochondriacal patient has psychological, interpersonal, and situational reasons for feeling symptomatic and visiting the doctor. In seeking care, such patients are not seeking cure; rather they are signaling that they are in dire straits and need special attention. Once the patient's symptoms are viewed from this perspective, the physician can stop trying to remove them and can thereby avoid struggling with the patient and feeling thwarted. The goal of treatment then shifts to coping with residual discomfort and establishing a doctor-patient relationship, which is in itself palliative.
"nothing is wrong," or by expecting the patient to respond to symptomatic treatment. They fail to see that "no pill can cure, and no surgery can excise, the need to be sick." The physician must remember that the hypochondriacal patient has psychological, interpersonal, and psychiatric reasons for his or her symptoms; therefore, the patient cannot simply relinquish them. Allowing the patient to retain his or her symptoms and focusing instead on coping with them avoids the vicious circle into which care of the hypochondriacal patient often degenerates-namely that attempts at symptom relief lead only to intensified complaints and heightened demands.
MEDICAL MANAGEMENT
Underdiagnose and Undertreat
A Single Primary Care Physician
Significant medical disease must never be overlooked; therefore, the patient's symptoms must be completely evaluated. That having been said, however, hypochondriacal patients are more often harmed by overly aggressive diagnostic testing and overly aggressive treatment than by a more conservative approach. Diagnostic tests often lead to complications, side effects, and new symptoms. The physician should always question the patient carefully and check the old records before ordering a diagnostic study, since it is likely to have been obtained already. (Even after having decided to obtain a test, the physician would do well to count to 10 before ordering it.) Likewise, when it comes to treatment, avoid treating incidental and equivocal findings whenever possible; hypochondriacal patients tend to respond to even benign therapeutic interventions with intensified symptoms, new symptoms, or iatrogenic illness. The most powerful therapeutic tool is the physician himself, his or her attention, concern, interest, and careful listening. Hence the old maxim "don't just do something, stand there." Frequent physician visits, a laying on of hands, and careful physical examinations are most helpful. Simple and benign remedies such as ace bandages, lotions, vitamins, heating pads, massage, and slings are helpful. They offer vis-
Successful medical management of the hypochondriacal patient is founded on the bedrock of a longitudinal, trusting relationship with a single primary care physician who directs all of the patient's medical care. A key feature of their relationship is that this physician becomes the gatekeeper through which all medical consultation and care must flow. This role prevents redundant and excessive medical care, and provides the patient with a stable, long-term relationship that is dependable, consistent, and not manipulable. Care Rather Than Cure The objective of medical management is not to eliminate the patient's symptoms, but to optimize coping with them; in short, the goal is care rather than cure. The physician's role is akin to that in managing chronic medical illness, where the doctor neither seeks nor expects outright cure, but instead helps the patient to live successfully with, adapt to, and minimize chronic symptoms and residual disability. Medical physicians view somatic symptoms as guideposts to underlying structural disease, and when none is found, they dismiss the patient's symptoms, either by explicitly stating that VOLUME 37. NUMBER I • JANUARY - FEBRUARY 1996
49
Hypochondriasis: Management and Treatment
ible proof of the physician's interest and furnish tangible evidence of the patient's ongoing symptoms and suffering. Access to the Sick Role When hypochondriasis is conceptualized as an interpersonal process, the patient is understood as someone who needs to be viewed by others as sick and suffering, and who desperately seeks a relationship with a physician. 17 The need for a doctor must be recognized. and the patient must be assured of their relationship without having to be symptomatic. In short, contact with the physician should be divorced from the patient's clinical status, and access to the doctor is not made contingent on continued symptoms and suffering. This is done by accepting the patient as a person and expressing genuine interest in him or her as an individual. Over time. the physician evidences an increasing interest in the personal and social history. and on learning about the patient's background. family. job. and future plans. This demonstrates that their relationship encompasses more than the patient's physical health. In addition, visits should be scheduled on a regular basis. rather than as needed or pro re nata. They should agree on a satisfactory frequency of visits. and the physician then tries to maintain this schedule, neither increasing nor decreasing it with changes in the patient's symptoms. (This may not always be possible, of course, if the patient develops more emergent symptoms.) When practicable, the hypochondriacal patient can also be provided with a regular weekly call-in time. This too illustrates the legitimacy of contacting the doctor without the necessity of having an alanning change in clinical status. The net effect of uncoupling medical attention and somatic distress is to reduce the latter. Providing an Etiological Explanation Hypochondriacal patients need an etiological explanation for their distress. As one patient noted, "the doctor keeps telling me what I don't 50
have, but he never tells me what I do have." An explanation should attempt to move the patient from his structural model of a specific, discrete, occult lesion localized somewhere in the body, to a model of dysfunction. The physician can suggest that the source of the problem lies in the central nervous system's processing of bodily sensation, that the patient has an extraordinarily sensitive nervous system that amplifies bodily dysfunctions and discomforts that others experience as less intense. The physician may offer the analogy of a radio whose volume has been turned up so high that background static has become disturbing and noxious. This explanation must be coupled with the explicit assurance that this proves that the patient's symptoms are "real" and not "made up" or "only in [your] mind." It is also important to reassure the patient that this also means that he or she does not have a lethal or grave disease that might progress or worsen. 18-20 That is, while there is no definitive medical diagnosis, and while his or her symptoms may continue, the process is not fatal or progressive or crippling. PSYCHIATRIC TREATMENT In addition to serving as a consultant. the psychiatrist cares for some hypochondriacal patients directly. Although many patients are reluctant to see psychiatrists, some will. In these cases. the psychiatrist has three tasks: first, to search for psychiatric comorbidity behind the veil of somatic complaints and concerns; second, to consider the use of psychophannacological agents; and third, to treat the hypochondriasis itself. Psychiatric Comorbidity Hypochondriacal patients have high rates of Axis I comorbidity. In our study of 60 medical outpatients meeting DSM-III-R criteria for hypochondriasis, 43% were found to have lifetime major depression, 45% to have dysthymia, and 17% to have panic disorder. 21 Comorbid disorders are especially difficult to detect when PSYCHOSOMATICS
Barsky
hypochondriasis is present: we found that primary care physicians were significantly less accurate in their diagnosis of anxiety and depressive disorders in hypochondriacal than in nonhypochondriacal patients. s Depression may be suggested by the hypochondriacal patient's attitude. The depressed patient feels that he is not worth treating, that he will never get better, and that his suffering is deserved. Patients with primary hypochondriasis, in contrast, are adamant in demanding the care they feel they deserve and are entitled to. Major depression may also be indicated by its episodic time course, which is not as characteristic of hypochondriasis. In generalized anxiety disorde~ concern extends beyond the bounds of health to encompass at least one additional area; in panic disorder, the anxiety arises more suddenly and the diseases feared are acute rather than chronic (e.g., heart attack or stroke as opposed to cancer or inflammatory bowel disease). Psychotropic Medications The use of psychotropic medications in primary hypochondriasis poses a dilemma. 8 In general, these agents are not markedly beneficial, as the patients often react with bothersome side effects or with new symptoms. In addition, the hypochondriacal patient often views the prescription of medication as a paltry and unsatisfactory substitute for the personal interest and attention of the physician. However, psychoactive medications definitely have a place when a comorbid Axis I disorder is present. Major depressive disorder, panic disorder, or obsessive compulsive disorder all deserve treatment with the appropriate agents. Even when these conditions are present at a subthreshold or subdefinitional level, a therapeutic trial is often indicated. Psychotropics are best prescribed with a note of caution, even pessimism, thus avoiding the specter that the patient will be entirely cured of all symptoms. The patient may be told that it is uncertain whether the medication will help, and that while it is unlikely that it will be markVOLUME 37. NUMBER I • JANUARY - FEBRUARY 1996
edly beneficial, it may be worth a try. It is important to avoid a prolonged struggle with the patient over the potential benefits. If the patient is skeptical or pessimistic, little is gained in disputing this, and to do so will only confinn the patient's suspicion that the physician is trying to dismiss the patient and usher him or her out the door. Cognitive-Educational Therapy Hypochondriacal patients tend to resist psychiatric referral and refuse psychological interventions. Since they believe their problem is medical, psychological treatment seems irrelevant and fundamentally misguided. It may be acceptable, however, if an (apparently unrelated) area of emotional distress can be identified, or if the psychological treatment is explicitly aimed at their somatic symptoms and physical health status. Some hypochondriacal patients acknowledge emotional distress for which they will accept treatment, although they adamantly deny any causal relationship to their symptoms. For example, they may admit to marital discord, difficulties at work, or to feeling depressed or anxious. The patient need not acquire insight into a relationship between the hypochondriacal symptoms and the dysphoria; classical psychodynamic insight does not appear to be particularly helpful in treating hypochondriasis. Other patients will accept treatment if its purpose is to ameliorate physical symptoms and somatic distress. Many accept the premise that their health is adversely affected by "stress"; therefore, they are willing to undertake therapy if it is entitled "stress reduction" or "stress management." Recently, a number of authors have developed and described cognitive and behavioral treatments for hypochondriasis.IO·II.D.14.22-24 In the remainder of this article, a fonn of cognitive-educational treatment is presented that has been derived from our work on the cognitive and perceptual bases of hypochondriasis. 25 .26 J. Parameters of Treatment. The goal oftreatment is to learn about the nature, perception, 51
Hypochondriasis: Management and Treatment
and reporting of physical symptoms, and about the psychological factors that amplify somatic distress. (Paradoxically, when the charge to the group has been framed in this exclusively medical fashion, members often digress into discussing their life circumstances, their families, their jobs, and even their feelings.) Treatment is undertaken in groups and is limited to 10 sessions. Ideal group size is between six and eight members. The tenor, format, and conduct of the meetings (or "classes") is more educational than psychotherapeutic. There are a syllabus, background readings, homework assignments, and an agenda for each session. Meetings are held in the medical rather than psychiatric setting, a more familiar and acceptable location. Each session follows the same format. First, the group leader presents didactic material on the topic of the week. Next, patients participate in an exercise or behavioral experiment that demonstrates or illustrates the information presented earlier. Finally, the participants apply the material to their own unique situations through group discussion. The goal of treatment is improved coping and reduced disability, not the total elimination of symptoms. We stress that patients cannot eliminate their symptoms, but that they can learn to control and cope with them. Bodily perception is portrayed as an active process in which the perceiver creates the world he or she perceives. The experience of bodily symptoms is analogous to the experience of music or art: the conscious experience of a Beethoven symphony or a Rembrandt portrait is more than the passive registration of sound and light wavesit is a complex emotional experience created by the perceiver. Succeeding sessions are devoted to four influences on the perception of bodily sensation: attention, cognition, context, and mood. The final session is devoted to a review and wrap-up. 2. Amplifier #1: Attention. Attention influences the intensity and discomfort associated with a bodily symptom. Paying attention to a sensation amplifies it, whereas distraction attenuates or diminishes it. The therapist iIIus52
trates this phenomenon with examples drawn from daily experience and with research findings. Everyday instances abound: the pain of banging one's shin while skiing (when one's attention is diverted) is much less intense than that resulting from the identical injury sustained by tripping over the furniture at home. The amplifying effect of attention has been studied. Thus, the more often postoperative patients have their attention called to their pain, the more severe they rate it. 27 Joggers on an exercise treadmill feel more fatigued and more sweaty and report more palpitations when they are listening to the sound of their own labored breathing during the test rather than when they are listening to distracting bits of street conversation. 28 In the experiential portion of the session on attention, each participant is asked to concentrate on his or her throat and to notice how this amplifies sensations of itchiness, scratchiness, and dryness. This often leads to the need to clear one's throat, and eventually some members begin to cough spontaneously. We also ask patients to exacerbate their discomfort by concentrating on their presenting symptoms. We then point out that if they can amplify a symptom by attending to it, then they must also be able to attenuate it by ignoring or overlooking it. Relaxation techniques are introduced here because patients can use them to direct their attention away from their symptoms. The focus is on abdominal breathing techniques and skeletal muscle relaxation, because these use patients' highly developed skills of bodily vigilance. Videotapes of the analgesia attained by good hypnotic subjects can be shown to the group to illustrate the great power of attention and distraction under certain circumstances. In the final portion ofthis session, members discuss their own attentional patterns. When do they notice their symptoms and when do they overlook them? What techniques have they found to distract themselves? People often note, for example, that as their alarm about a bodily symptom grows, they focus more and more upon their bodies and begin making finer and finer sensory discriminations. To these patients, PSYCHOSOMATICS
Barsky
it seems that new symptoms are developing. In much the same way, a painter learns to distinguish through experience many different shades of what appeared before to be a single hue. 3. Amplifier #2: Cognition. The cognitive appraisal of bodily sensation powerfully influences its unpleasantness; what one thinks about a symptom affects how intense and noxious it is. We experience and describe our somatic sensations in terms of the information, opinions, assumptions, and ideas that we have about them. Etiological beliefs and are particularly important in this regard. Symptoms that are normalized by attributing them to benign causes, such as dietary indiscretion, lack of sleep or exercise, or overwork, are less intense than when a threatening disease is suspected as their cause. Thus, the nociceptive stimulus accompanying a tight shoe and an osteosarcoma of the foot may be identical, but the two conscious experiences are dramatically different. Here we describe medical student hypochondriasis, because it illustrates the amplifying role of beliefs. As students learn about diseases, they acquire new and more ominous pathological explanations for old discomforts (e.g., visible arterial pulsations in the neckHreadful diseases about which they were previously ignorant. 29 These new explanations for their symptoms amplify them and make them more alarming. In the experiential and experimental portion of this session, patients begin observing and recording their symptoms in substantial detail. Following the session, they may keep symptom diaries and healthy family members may be asked to do the same for later comparison. IO•13 Patients record their thoughts about the symptoms, and they note the steps they go through in concluding that they are pathological. They then observe how the suspicion of disease leads to a reattribution of other benign and unrelated symptoms to the suspected disease. For example, one patient noted that after being told by a co-worker that he looked pale, he decided that his long-standing fatigue, which he had previously dismissed as "plain old weariVOL.UME 37 • NUMBER I • JANUARY - FEBRUARY 1996
ness," must be due to anemia. Another patient reported that after becoming convinced he had asthma, he attributed normal dyspnea on climbing stairs to a worsening of the asthma. In recording bodily symptoms and comparing them with those of healthy family members and other group members, patients discover a vast range of common symptoms (e.g., orthostatic dizziness, tinnitis) that are normal and do not indicate serious disease. Patients thereby learn that the state of good health is accompanied by myriad nonpathological discomforts and ailments that occur every day. The group discussions of cognition emerge out of these behavioral exercises. Patients are asked to choose one of their most worrisome symptoms, temporarily adopt the viewpoint that it is completely normal, and attempt to convince others of that. For the sake of argument, the patients are also asked to explain how their disease convictions and disease fears could be mistaken. These techniques are used because hypochondriacal patients' disease beliefs often have the characteristics of a cognitive schema and cognitive research indicates that schemata cannot be altered simply by explaining why and how they are incorrect. Rather, the holder needs to actively convince him/herself that he/she is wrong by arguing the contrary viewpoint. Another cognitive issue that often emerges here is hypochondriacal patients' intolerance of very low-risk probabilities, the finite but unlikely threats to health that most nonhypochondriacal persons are able to accept and dismiss. The therapist may point out that they worry about sudden cardiac death 6 hours after a normal electrocardiogram (a very unlikely event), but they do not worry about being in an auto accident on the way home after the session (a much more likely event).30 In this way, patients are helped to see that they can indeed tolerate certain risks. 4. Amplifier #3: Circumstance. People infer what they are perceiving from their circumstances. Setting, situation, and context can amplify somatic discomfort by providing clues that we use to interpret the meaning of what we are 53
Hypochondriasis: Management and Treatment
feeling and to decide on its significance. Everyday examples of this abound, and research data also illustrate the point. A backache is much worse when you face a day of onerous household chores you've been dreading than when you spend the day golfing with friends. If someone in your family has just caught a cold, when you next sneeze, you immediately conclude that you've caught it and now have a cold too. The phenomenon of battlefield anesthesia dramatically illustrates the power of circumstances: soldiers wounded in the heat of battle may have no pain and not request analgesics. 31 Experimental subjects instructed to monitor the sensations of "obstructed breathing" report more difficulty than the subjects told to monitor the "free flow of air" through their noses. 28 Circumstances and situation also intimate what we can expect to perceive in the future, and expectations can be powerful amplifiers. Future health expectations influence the appraisal of current status. For example, expecting a symptom to vanish with treatment makes its persistence worse than if we had never expected relief in the first place; as Ivan Illich wrote, "curable pain is unbearable pain. "n In the experimental portion of this session, we illustrate the effect of context on perception with figure/ground drawings. These demonstrate that the same sensory stimuli can be organized into radically different perceptual experiences depending upon one's vantage point or perspective. Patients often respond to these with examples of their own, recounting instances of discomfort worsening when expected relief fails to materialize. One member, for instance, recalled how the pain of a scratched cornea intensified after he had taken an analgesic and was waiting for it to take effect. The group experiments lead to a discussion of the amplifying effects of context. Hypochondriacal patients often assume that all discomfort is remediable; therefore, they believe that the physician's failure to cure them simply indicates that the doctor doesn't care enough about them. Were he more concerned about the patient's plight, surely he would find a medical solution. The group explores this assumption 54
and discusses medicine's limitations in dealing with the ailments of daily life (e.g., dry skin, headaches, backaches) and with common benign afflictions (such as upper respiratory tract infections, and gastrointestinal symptoms). Group discussion is also devoted to the paradox that successful coping cannot begin until the hypochondriacal patient accepts the symptoms and decides that he or she will have to learn to minimize them, ignore them, and downplay them. Patients cannot begin to feel better until they accept that they will not gel better. This leads to the patient's acceptance of a limit on further diagnostic testing and ultimately of an end to the quest for a definitive medical diagnosis. What limits would each group member accept on the pursuit of medical care?24 At what point would each be willing to give up the quest for a definitive diagnosis and put energies into coping with the condition? Individuals can be asked what they think the likelihood is that others in the group will find a cure for their symptoms, given their histories and experiences thus far. We ask the group to consider how patients with serious disorders like cancer learn to accept that nothing more can be done medically for them. 5. Amplifier #4: Mood. Anxiety and depression amplify somatic discomfort and hypochondriacal concerns. 33 Anxiety amplifies physical symptoms in three ways. First, it heightens bodily vigilance, causing an enhanced awareness of, a selective attention to, bodily sensation. Second, there is a selective bias toward threatening and danger-related stimuli, since anxious people are alarmed and anticipate physical harm. Third, anxiety has a negative influence on the appraisal of health-related information. Anxious people tend to misinterpret benign sensations and dysfunctions as ominous and threatening. Depression also amplifies bodily discomfort. Depressed people feel damaged, impaired, defective, and dysfunctional. They believe that they deserve to be sick and to suffer. The depressed individual thinks about misfortune, selectively recalls illness-related memories, and generally imagines the worst. The PSYCHOSOMATICS
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result is an amplification of noxious bodily sensations and a misattribution of these symptoms to serious disease. Anxiety and depression also have a secondary effect. They have somatic and autonomic concomitants that are themselves mistaken as new symptoms of disease. This in tum results in greater alarm and further self-monitoring, thereby perpetuating a vicious circle of dysphoria, heightened hypochondriacal concerns, and intensified dysphoria. In the group discussions, patients are asked for instances in which a stressful experience left them with symptoms like headaches, dizziness, or diarrhea. Most patients prefer to talk in terms of external stressors and hassles that make them anxious and depressed, rather than in terms of the affects themselves. The therapist merely emphasizes that dysphoria, whatever its cause, exacerbates somatic symptoms. Group members do sometimes admit to anxiety or depression, but emphatically insist that it is the result of their medical condition rather than the cause of it. The therapist need not confront this, although other group members may. Often, a sense of powerlessness about health emerges from these discussions. Hypochondriacs feel that only physicians can save them from their illnesses and that nothing they themselves do is effective. Hypochondriacal anxiety often stems from these individuals' profound sense of impotence and lack of control over their bodies and their health. A common depressive theme often expressed by hypochondriacal patients is that their condition is particularly unfortunate because there is no medical explanation or diagnosis to legitimize or validate their suffering. TREATMENT OUTCOMES AND PROGNOSIS Data on the natural history and longitudinal course of untreated hypochondriasis are lacking, and a wide range of outcomes have been described anecdotally. The general impression is that it is a long-standing, chronic, and disabling condition. Favorable prognostic indicaVOLUME 37. NUMBER I • JANUARY - FEBRUARY 1996
tors are thought to include youth, acute onset, concurrent anxiety or depression, less serious personality disorder, medical comorbidity, less dysfunctional illness beliefs, and less secondary gain. 1.6.8.1 1.23 The literature on treatment effectiveness is very limited. However, there is a growing sense that treatment, particularly cognitive and behavioral treatment, can be helpful and that a significant proportion of hypochondriacal patients who undergo psychiatric treatment improve or recover. 10.24.30.34--37 The paucity of this literature and the absence of definitive studies suggest that intervention trials are now a high priority. Such studies should include adequate numbers of patients, appropriate control groups, specified diagnostic criteria, standardized and sensitive measures of change, and treatments that are time-limited and can be described precisely and scripted. The need for such treatments will only grow with the growing imperative to contain medical care costs and to curtail undue medical utilization. Because hypochondriacal patients consume large amounts of physician services, laboratory tests, and diagnostic procedures, it will be increasingly critical to study them in this light.
This work was supported by a grant from the National Institute of Mental Health (Grant No. MH-40487). The author thanks Carol A. Wool. M.D .. and Edith Geringer. M.D ..for their invaluable contributions to this work.
References I. Kellner R: Somatization and Hypochondriasis. New York. Praeger. 1986 2. Lipsitt DR: Medical and psychological characteristics of "crocks." Psychiatry in Medicine 1970; 1:15-25 3. Beaber RJ, Rodney WM: Underdiagnosis of hypochondriasis in family practice. Psychosomatics 1984; 24:3945 4. Barksy AJ. Wyshak G. Klennan GL: Medical and psychiatric detenninants of outpatient medical utilization. Med Care 1986; 24:548-560 5. Barsky AJ. Wyshak G. Klennan GL: Hypochondriacal patients. their physicians. and their medical care. J Gen Intern Med 1991; 6:413-419 6. Ford CV: The Somatizing Disorders. Illness as a Way of
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Life. New York. Elsevier Biomedical. 1983 7. Brown HN. Valliant GE: Hypochondriasis. Arch Intern Med 1981; 141:723-726 8. Kellner R: Diagnosis and treatments of hypochondriacal syndromes. Psychosomatics 1992; 33:278-289 9. Sharpe M. Peveler R. Mayou R: The psychological treatment of patients with functional somatic symptoms: a practical guide. J Psychosom Res 1992; 36:515-529 10. Warwick HMC. Marks 1M: Behavioural treatment of illness phobia and hypochondriasis Br J Psychiatry 1988; 152:239-241 II. Shoner E. Abbey SE. Gillies LA. et al: Inpatient treatment of persislenl somatization. Psychosomatics 1992; 33:295-301 12. Kellner R: Psychotherapeutic stralegies in hypochondriasis: a clinical study. AmJ Psychother 1982; 36: 146-157 13. Salkovskis PM: Somalic problems. in Congitive-Behavioral Approaches to Adult Psychiatric Disorders: A Practical Guide. edited by Hawton K. Salkovskis PM. Kirk JW. el al. Oxford. England. Oxford Universily Press. 1989. pp 235-276 14. Lipowski ZJ: An inpatient programme for persistent somatizers. Can J Psychiatry 1988; 33:275-278 15. Roskin G. Mehr A. Rabiner 0. et al: Psychiatric treatment of chronic somatizing patients: a pilot study. Int J Psychiatry Med 1980-1981; 10:181-188 16. Melson SJ. Rynearson EK. Donzbach J. et al: Shon-term intensive group psychotherapy for patients with "functional" complaints. Psychosomatics 1982; 23:689~95 17. Barsky AJ. Klerman GL: Overview: hypochondriasis. bodily complaints. and somalic styles. Am J Psychiatry 1983; 140:273-283 18. Warwick H: Provision of appropriate and effective reassurance. International Review of Psychiatry 1992; 4:7680 19. Starcevic V: Reassurance and treatment ofhypochondriasis. Gen Hosp Psychiatry 1991; 13: 122-127 20. Kellner R: The case for reassurance. 1nternalional Review of Psychialry 1992; 4:71-80 21. Barsky AJ. Wyshak G. Klerman GL: Psychiatric comorbidity in DSM-III-R hypochondriasis. Arch Gen Psychi-
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atry 1992; 49:101-108 22. Warwick HMC. Salkovskis PM: Hypochondriasis. Behav Res Ther 1990; 28:105-117 23. Bass C. Potts S: Somatofonn disorders. in Recent Advances in Clinical Psychiatry. No.8. edited by GranvilleGrossman K. London. England. Churchill-Livingstone. 1993 24. Bass C. Benjamin S: The management of chronic somatization. Br J Psychiatry 1993; 162:472-480 25. Barsky AJ. Wyshak G: Hypochondriasis and somatosensory amplification. Br J Psychiatry 1990; 157:404-409 26. Barsky AJ. Coeytaux RR. Samie MK: Hypochondriacal patients' beliefs about good health. Am J Psychiatry 1993; 150:484-488 27. Levine JD. Gordon NC. Smith R. et al: Postoperative pain: effect of injury and attention. Brain Res 1982; 234: 500-504 28. Pennebaker JW: The Psychology of Physical Symptoms. New York. Springer-Verlag. 1982 29. Mechanic 0: Social psychologic factors affecting the presentation of bodily complaints. N Engl J Med 1972; 286: 1132-1139 30. Stem R. Fernandez M: Group cognitive and behavioural treatment of hypochondriasis. BMJ 1991; 303:12291231 31. Beecher HK: Relationship of significance of wound to pain experienced. JAMA 1956; 161:1609-1613 32. IIlich I: Medical Nemesis. New York. Pantheon. 1976. pp 133-154 33. Salovey P. Birnbaum 0: Influence of mood on health-related cognitions. J Pers Soc Psychol1989; 57:539-551 34. Kellner R: The prognosis of treated hypochondriasis: a clinical study. Acta Psychiatr Scand 1983; 67:69-79 35. Pilowski I: The response to treatment in hypochondrica1 disorders. Aust NZ J Psychiatry 1968; 2:88-94 36. Visser S. Bouman TK: Cognitive-behavioral approaches in the treatment of hypochondriasis: six single case crossover studies. Behav Res Ther 1992; 30:301-306 37. Starcevic V: Reassurance and treatment ofhypochondriasis. Gen Hosp Psychiatry 1991; 13:122-127
PSYCHOSOMATICS
J.
BARSKY,
M.D.
This study describes a 2-part approach to the hypochondriacal patient: 1) a strategy for medical management, and 2) a specific psychiatric therapy. Medical management rests on the physician's recognition that patients have psychological and interpersonal reasons for feeling symptomatic and seeking medical attention. After gaining this appreciation. the physician can stop trying to cure the patient's symptoms, and the goal of management then shifts to assisting the patient in coping with the symptoms. A specific psychotherapy is then presented. Group discussions and cognitive and behavioral exercises are used to teach patients to moderate four factors that amplify somatic distress and hypochondriacal health concerns: the attention they pay to their symptoms, their thoughts about them, the context in which they experience their symptoms, and their moods. (Psychosomatics 1996; 37:48-56)
H
ypochondriasis is an unusual disorder in that it affects both patients and physicians alike. Hypochondriacal patients feel chronically ill and endure significant role impairment. They seek medical care frequently and persistently, with high rates of physician visits, laboratory tests, diagnostic procedures, and "doctor shopping." But they find their care as ineffective and unsatisfactory as it is extensive. l -4 The physician is affected too; from hislher viewpoint, hypochondriacal patients are difficult to care for and tend to evoke strong antipathy.s Straightforward reassurance and symptomatic medical management seem ineffective. More aggressive medical interventions typically lead to complications, side effects, worsening symptoms, or new symptoms to replace the 0Id.2.6·7 In addition, the medical care process inadvertently reinforces the patient's somatization by ignoring his or her psychosocial distress and supplying a somatic lexicon for expressing it. But because hypochondriacs tenaciously resist psychiatric referral, their care ultimately rests with 48
their medical physicians. No specific, widely accepted psychiatric treatment of demonstrated efficacy now exists. Some promising new approaches are emerging, however. 8- '6 This study describes a 2-part approach to the hypochondriacal patient: I) a strategy for medical management, and 2) a specific psychiatric therapy. It is intended for patients whose hypochondriacal symptoms are chronic, severe, long-standing, and disabling. It is not intended for "worried well" patients with more reactive, transient, and circumscribed health concerns. The psychiatrist has an important consultative role to play in medical management. The psychiatrist can explain the condition to the Received December 30. 1993; accepted March 4, 1994. From the Division of Psychiatry, Brigham and Women's Hospital. Boston, MA. Address reprint requests to Dr. Barsky, Division of Psychiatry, Brigham and Women's Hospital, 75 Francis St., Boston, MA02115. Copyright @ 1996 The Academy of Psychosomatic Medicine.
PSYCHOSOMATICS
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medical physician as well as describe a management strategy based on the notion that the hypochondriacal patient has psychological, interpersonal, and situational reasons for feeling symptomatic and visiting the doctor. In seeking care, such patients are not seeking cure; rather they are signaling that they are in dire straits and need special attention. Once the patient's symptoms are viewed from this perspective, the physician can stop trying to remove them and can thereby avoid struggling with the patient and feeling thwarted. The goal of treatment then shifts to coping with residual discomfort and establishing a doctor-patient relationship, which is in itself palliative.
"nothing is wrong," or by expecting the patient to respond to symptomatic treatment. They fail to see that "no pill can cure, and no surgery can excise, the need to be sick." The physician must remember that the hypochondriacal patient has psychological, interpersonal, and psychiatric reasons for his or her symptoms; therefore, the patient cannot simply relinquish them. Allowing the patient to retain his or her symptoms and focusing instead on coping with them avoids the vicious circle into which care of the hypochondriacal patient often degenerates-namely that attempts at symptom relief lead only to intensified complaints and heightened demands.
MEDICAL MANAGEMENT
Underdiagnose and Undertreat
A Single Primary Care Physician
Significant medical disease must never be overlooked; therefore, the patient's symptoms must be completely evaluated. That having been said, however, hypochondriacal patients are more often harmed by overly aggressive diagnostic testing and overly aggressive treatment than by a more conservative approach. Diagnostic tests often lead to complications, side effects, and new symptoms. The physician should always question the patient carefully and check the old records before ordering a diagnostic study, since it is likely to have been obtained already. (Even after having decided to obtain a test, the physician would do well to count to 10 before ordering it.) Likewise, when it comes to treatment, avoid treating incidental and equivocal findings whenever possible; hypochondriacal patients tend to respond to even benign therapeutic interventions with intensified symptoms, new symptoms, or iatrogenic illness. The most powerful therapeutic tool is the physician himself, his or her attention, concern, interest, and careful listening. Hence the old maxim "don't just do something, stand there." Frequent physician visits, a laying on of hands, and careful physical examinations are most helpful. Simple and benign remedies such as ace bandages, lotions, vitamins, heating pads, massage, and slings are helpful. They offer vis-
Successful medical management of the hypochondriacal patient is founded on the bedrock of a longitudinal, trusting relationship with a single primary care physician who directs all of the patient's medical care. A key feature of their relationship is that this physician becomes the gatekeeper through which all medical consultation and care must flow. This role prevents redundant and excessive medical care, and provides the patient with a stable, long-term relationship that is dependable, consistent, and not manipulable. Care Rather Than Cure The objective of medical management is not to eliminate the patient's symptoms, but to optimize coping with them; in short, the goal is care rather than cure. The physician's role is akin to that in managing chronic medical illness, where the doctor neither seeks nor expects outright cure, but instead helps the patient to live successfully with, adapt to, and minimize chronic symptoms and residual disability. Medical physicians view somatic symptoms as guideposts to underlying structural disease, and when none is found, they dismiss the patient's symptoms, either by explicitly stating that VOLUME 37. NUMBER I • JANUARY - FEBRUARY 1996
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Hypochondriasis: Management and Treatment
ible proof of the physician's interest and furnish tangible evidence of the patient's ongoing symptoms and suffering. Access to the Sick Role When hypochondriasis is conceptualized as an interpersonal process, the patient is understood as someone who needs to be viewed by others as sick and suffering, and who desperately seeks a relationship with a physician. 17 The need for a doctor must be recognized. and the patient must be assured of their relationship without having to be symptomatic. In short, contact with the physician should be divorced from the patient's clinical status, and access to the doctor is not made contingent on continued symptoms and suffering. This is done by accepting the patient as a person and expressing genuine interest in him or her as an individual. Over time. the physician evidences an increasing interest in the personal and social history. and on learning about the patient's background. family. job. and future plans. This demonstrates that their relationship encompasses more than the patient's physical health. In addition, visits should be scheduled on a regular basis. rather than as needed or pro re nata. They should agree on a satisfactory frequency of visits. and the physician then tries to maintain this schedule, neither increasing nor decreasing it with changes in the patient's symptoms. (This may not always be possible, of course, if the patient develops more emergent symptoms.) When practicable, the hypochondriacal patient can also be provided with a regular weekly call-in time. This too illustrates the legitimacy of contacting the doctor without the necessity of having an alanning change in clinical status. The net effect of uncoupling medical attention and somatic distress is to reduce the latter. Providing an Etiological Explanation Hypochondriacal patients need an etiological explanation for their distress. As one patient noted, "the doctor keeps telling me what I don't 50
have, but he never tells me what I do have." An explanation should attempt to move the patient from his structural model of a specific, discrete, occult lesion localized somewhere in the body, to a model of dysfunction. The physician can suggest that the source of the problem lies in the central nervous system's processing of bodily sensation, that the patient has an extraordinarily sensitive nervous system that amplifies bodily dysfunctions and discomforts that others experience as less intense. The physician may offer the analogy of a radio whose volume has been turned up so high that background static has become disturbing and noxious. This explanation must be coupled with the explicit assurance that this proves that the patient's symptoms are "real" and not "made up" or "only in [your] mind." It is also important to reassure the patient that this also means that he or she does not have a lethal or grave disease that might progress or worsen. 18-20 That is, while there is no definitive medical diagnosis, and while his or her symptoms may continue, the process is not fatal or progressive or crippling. PSYCHIATRIC TREATMENT In addition to serving as a consultant. the psychiatrist cares for some hypochondriacal patients directly. Although many patients are reluctant to see psychiatrists, some will. In these cases. the psychiatrist has three tasks: first, to search for psychiatric comorbidity behind the veil of somatic complaints and concerns; second, to consider the use of psychophannacological agents; and third, to treat the hypochondriasis itself. Psychiatric Comorbidity Hypochondriacal patients have high rates of Axis I comorbidity. In our study of 60 medical outpatients meeting DSM-III-R criteria for hypochondriasis, 43% were found to have lifetime major depression, 45% to have dysthymia, and 17% to have panic disorder. 21 Comorbid disorders are especially difficult to detect when PSYCHOSOMATICS
Barsky
hypochondriasis is present: we found that primary care physicians were significantly less accurate in their diagnosis of anxiety and depressive disorders in hypochondriacal than in nonhypochondriacal patients. s Depression may be suggested by the hypochondriacal patient's attitude. The depressed patient feels that he is not worth treating, that he will never get better, and that his suffering is deserved. Patients with primary hypochondriasis, in contrast, are adamant in demanding the care they feel they deserve and are entitled to. Major depression may also be indicated by its episodic time course, which is not as characteristic of hypochondriasis. In generalized anxiety disorde~ concern extends beyond the bounds of health to encompass at least one additional area; in panic disorder, the anxiety arises more suddenly and the diseases feared are acute rather than chronic (e.g., heart attack or stroke as opposed to cancer or inflammatory bowel disease). Psychotropic Medications The use of psychotropic medications in primary hypochondriasis poses a dilemma. 8 In general, these agents are not markedly beneficial, as the patients often react with bothersome side effects or with new symptoms. In addition, the hypochondriacal patient often views the prescription of medication as a paltry and unsatisfactory substitute for the personal interest and attention of the physician. However, psychoactive medications definitely have a place when a comorbid Axis I disorder is present. Major depressive disorder, panic disorder, or obsessive compulsive disorder all deserve treatment with the appropriate agents. Even when these conditions are present at a subthreshold or subdefinitional level, a therapeutic trial is often indicated. Psychotropics are best prescribed with a note of caution, even pessimism, thus avoiding the specter that the patient will be entirely cured of all symptoms. The patient may be told that it is uncertain whether the medication will help, and that while it is unlikely that it will be markVOLUME 37. NUMBER I • JANUARY - FEBRUARY 1996
edly beneficial, it may be worth a try. It is important to avoid a prolonged struggle with the patient over the potential benefits. If the patient is skeptical or pessimistic, little is gained in disputing this, and to do so will only confinn the patient's suspicion that the physician is trying to dismiss the patient and usher him or her out the door. Cognitive-Educational Therapy Hypochondriacal patients tend to resist psychiatric referral and refuse psychological interventions. Since they believe their problem is medical, psychological treatment seems irrelevant and fundamentally misguided. It may be acceptable, however, if an (apparently unrelated) area of emotional distress can be identified, or if the psychological treatment is explicitly aimed at their somatic symptoms and physical health status. Some hypochondriacal patients acknowledge emotional distress for which they will accept treatment, although they adamantly deny any causal relationship to their symptoms. For example, they may admit to marital discord, difficulties at work, or to feeling depressed or anxious. The patient need not acquire insight into a relationship between the hypochondriacal symptoms and the dysphoria; classical psychodynamic insight does not appear to be particularly helpful in treating hypochondriasis. Other patients will accept treatment if its purpose is to ameliorate physical symptoms and somatic distress. Many accept the premise that their health is adversely affected by "stress"; therefore, they are willing to undertake therapy if it is entitled "stress reduction" or "stress management." Recently, a number of authors have developed and described cognitive and behavioral treatments for hypochondriasis.IO·II.D.14.22-24 In the remainder of this article, a fonn of cognitive-educational treatment is presented that has been derived from our work on the cognitive and perceptual bases of hypochondriasis. 25 .26 J. Parameters of Treatment. The goal oftreatment is to learn about the nature, perception, 51
Hypochondriasis: Management and Treatment
and reporting of physical symptoms, and about the psychological factors that amplify somatic distress. (Paradoxically, when the charge to the group has been framed in this exclusively medical fashion, members often digress into discussing their life circumstances, their families, their jobs, and even their feelings.) Treatment is undertaken in groups and is limited to 10 sessions. Ideal group size is between six and eight members. The tenor, format, and conduct of the meetings (or "classes") is more educational than psychotherapeutic. There are a syllabus, background readings, homework assignments, and an agenda for each session. Meetings are held in the medical rather than psychiatric setting, a more familiar and acceptable location. Each session follows the same format. First, the group leader presents didactic material on the topic of the week. Next, patients participate in an exercise or behavioral experiment that demonstrates or illustrates the information presented earlier. Finally, the participants apply the material to their own unique situations through group discussion. The goal of treatment is improved coping and reduced disability, not the total elimination of symptoms. We stress that patients cannot eliminate their symptoms, but that they can learn to control and cope with them. Bodily perception is portrayed as an active process in which the perceiver creates the world he or she perceives. The experience of bodily symptoms is analogous to the experience of music or art: the conscious experience of a Beethoven symphony or a Rembrandt portrait is more than the passive registration of sound and light wavesit is a complex emotional experience created by the perceiver. Succeeding sessions are devoted to four influences on the perception of bodily sensation: attention, cognition, context, and mood. The final session is devoted to a review and wrap-up. 2. Amplifier #1: Attention. Attention influences the intensity and discomfort associated with a bodily symptom. Paying attention to a sensation amplifies it, whereas distraction attenuates or diminishes it. The therapist iIIus52
trates this phenomenon with examples drawn from daily experience and with research findings. Everyday instances abound: the pain of banging one's shin while skiing (when one's attention is diverted) is much less intense than that resulting from the identical injury sustained by tripping over the furniture at home. The amplifying effect of attention has been studied. Thus, the more often postoperative patients have their attention called to their pain, the more severe they rate it. 27 Joggers on an exercise treadmill feel more fatigued and more sweaty and report more palpitations when they are listening to the sound of their own labored breathing during the test rather than when they are listening to distracting bits of street conversation. 28 In the experiential portion of the session on attention, each participant is asked to concentrate on his or her throat and to notice how this amplifies sensations of itchiness, scratchiness, and dryness. This often leads to the need to clear one's throat, and eventually some members begin to cough spontaneously. We also ask patients to exacerbate their discomfort by concentrating on their presenting symptoms. We then point out that if they can amplify a symptom by attending to it, then they must also be able to attenuate it by ignoring or overlooking it. Relaxation techniques are introduced here because patients can use them to direct their attention away from their symptoms. The focus is on abdominal breathing techniques and skeletal muscle relaxation, because these use patients' highly developed skills of bodily vigilance. Videotapes of the analgesia attained by good hypnotic subjects can be shown to the group to illustrate the great power of attention and distraction under certain circumstances. In the final portion ofthis session, members discuss their own attentional patterns. When do they notice their symptoms and when do they overlook them? What techniques have they found to distract themselves? People often note, for example, that as their alarm about a bodily symptom grows, they focus more and more upon their bodies and begin making finer and finer sensory discriminations. To these patients, PSYCHOSOMATICS
Barsky
it seems that new symptoms are developing. In much the same way, a painter learns to distinguish through experience many different shades of what appeared before to be a single hue. 3. Amplifier #2: Cognition. The cognitive appraisal of bodily sensation powerfully influences its unpleasantness; what one thinks about a symptom affects how intense and noxious it is. We experience and describe our somatic sensations in terms of the information, opinions, assumptions, and ideas that we have about them. Etiological beliefs and are particularly important in this regard. Symptoms that are normalized by attributing them to benign causes, such as dietary indiscretion, lack of sleep or exercise, or overwork, are less intense than when a threatening disease is suspected as their cause. Thus, the nociceptive stimulus accompanying a tight shoe and an osteosarcoma of the foot may be identical, but the two conscious experiences are dramatically different. Here we describe medical student hypochondriasis, because it illustrates the amplifying role of beliefs. As students learn about diseases, they acquire new and more ominous pathological explanations for old discomforts (e.g., visible arterial pulsations in the neckHreadful diseases about which they were previously ignorant. 29 These new explanations for their symptoms amplify them and make them more alarming. In the experiential and experimental portion of this session, patients begin observing and recording their symptoms in substantial detail. Following the session, they may keep symptom diaries and healthy family members may be asked to do the same for later comparison. IO•13 Patients record their thoughts about the symptoms, and they note the steps they go through in concluding that they are pathological. They then observe how the suspicion of disease leads to a reattribution of other benign and unrelated symptoms to the suspected disease. For example, one patient noted that after being told by a co-worker that he looked pale, he decided that his long-standing fatigue, which he had previously dismissed as "plain old weariVOL.UME 37 • NUMBER I • JANUARY - FEBRUARY 1996
ness," must be due to anemia. Another patient reported that after becoming convinced he had asthma, he attributed normal dyspnea on climbing stairs to a worsening of the asthma. In recording bodily symptoms and comparing them with those of healthy family members and other group members, patients discover a vast range of common symptoms (e.g., orthostatic dizziness, tinnitis) that are normal and do not indicate serious disease. Patients thereby learn that the state of good health is accompanied by myriad nonpathological discomforts and ailments that occur every day. The group discussions of cognition emerge out of these behavioral exercises. Patients are asked to choose one of their most worrisome symptoms, temporarily adopt the viewpoint that it is completely normal, and attempt to convince others of that. For the sake of argument, the patients are also asked to explain how their disease convictions and disease fears could be mistaken. These techniques are used because hypochondriacal patients' disease beliefs often have the characteristics of a cognitive schema and cognitive research indicates that schemata cannot be altered simply by explaining why and how they are incorrect. Rather, the holder needs to actively convince him/herself that he/she is wrong by arguing the contrary viewpoint. Another cognitive issue that often emerges here is hypochondriacal patients' intolerance of very low-risk probabilities, the finite but unlikely threats to health that most nonhypochondriacal persons are able to accept and dismiss. The therapist may point out that they worry about sudden cardiac death 6 hours after a normal electrocardiogram (a very unlikely event), but they do not worry about being in an auto accident on the way home after the session (a much more likely event).30 In this way, patients are helped to see that they can indeed tolerate certain risks. 4. Amplifier #3: Circumstance. People infer what they are perceiving from their circumstances. Setting, situation, and context can amplify somatic discomfort by providing clues that we use to interpret the meaning of what we are 53
Hypochondriasis: Management and Treatment
feeling and to decide on its significance. Everyday examples of this abound, and research data also illustrate the point. A backache is much worse when you face a day of onerous household chores you've been dreading than when you spend the day golfing with friends. If someone in your family has just caught a cold, when you next sneeze, you immediately conclude that you've caught it and now have a cold too. The phenomenon of battlefield anesthesia dramatically illustrates the power of circumstances: soldiers wounded in the heat of battle may have no pain and not request analgesics. 31 Experimental subjects instructed to monitor the sensations of "obstructed breathing" report more difficulty than the subjects told to monitor the "free flow of air" through their noses. 28 Circumstances and situation also intimate what we can expect to perceive in the future, and expectations can be powerful amplifiers. Future health expectations influence the appraisal of current status. For example, expecting a symptom to vanish with treatment makes its persistence worse than if we had never expected relief in the first place; as Ivan Illich wrote, "curable pain is unbearable pain. "n In the experimental portion of this session, we illustrate the effect of context on perception with figure/ground drawings. These demonstrate that the same sensory stimuli can be organized into radically different perceptual experiences depending upon one's vantage point or perspective. Patients often respond to these with examples of their own, recounting instances of discomfort worsening when expected relief fails to materialize. One member, for instance, recalled how the pain of a scratched cornea intensified after he had taken an analgesic and was waiting for it to take effect. The group experiments lead to a discussion of the amplifying effects of context. Hypochondriacal patients often assume that all discomfort is remediable; therefore, they believe that the physician's failure to cure them simply indicates that the doctor doesn't care enough about them. Were he more concerned about the patient's plight, surely he would find a medical solution. The group explores this assumption 54
and discusses medicine's limitations in dealing with the ailments of daily life (e.g., dry skin, headaches, backaches) and with common benign afflictions (such as upper respiratory tract infections, and gastrointestinal symptoms). Group discussion is also devoted to the paradox that successful coping cannot begin until the hypochondriacal patient accepts the symptoms and decides that he or she will have to learn to minimize them, ignore them, and downplay them. Patients cannot begin to feel better until they accept that they will not gel better. This leads to the patient's acceptance of a limit on further diagnostic testing and ultimately of an end to the quest for a definitive medical diagnosis. What limits would each group member accept on the pursuit of medical care?24 At what point would each be willing to give up the quest for a definitive diagnosis and put energies into coping with the condition? Individuals can be asked what they think the likelihood is that others in the group will find a cure for their symptoms, given their histories and experiences thus far. We ask the group to consider how patients with serious disorders like cancer learn to accept that nothing more can be done medically for them. 5. Amplifier #4: Mood. Anxiety and depression amplify somatic discomfort and hypochondriacal concerns. 33 Anxiety amplifies physical symptoms in three ways. First, it heightens bodily vigilance, causing an enhanced awareness of, a selective attention to, bodily sensation. Second, there is a selective bias toward threatening and danger-related stimuli, since anxious people are alarmed and anticipate physical harm. Third, anxiety has a negative influence on the appraisal of health-related information. Anxious people tend to misinterpret benign sensations and dysfunctions as ominous and threatening. Depression also amplifies bodily discomfort. Depressed people feel damaged, impaired, defective, and dysfunctional. They believe that they deserve to be sick and to suffer. The depressed individual thinks about misfortune, selectively recalls illness-related memories, and generally imagines the worst. The PSYCHOSOMATICS
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result is an amplification of noxious bodily sensations and a misattribution of these symptoms to serious disease. Anxiety and depression also have a secondary effect. They have somatic and autonomic concomitants that are themselves mistaken as new symptoms of disease. This in tum results in greater alarm and further self-monitoring, thereby perpetuating a vicious circle of dysphoria, heightened hypochondriacal concerns, and intensified dysphoria. In the group discussions, patients are asked for instances in which a stressful experience left them with symptoms like headaches, dizziness, or diarrhea. Most patients prefer to talk in terms of external stressors and hassles that make them anxious and depressed, rather than in terms of the affects themselves. The therapist merely emphasizes that dysphoria, whatever its cause, exacerbates somatic symptoms. Group members do sometimes admit to anxiety or depression, but emphatically insist that it is the result of their medical condition rather than the cause of it. The therapist need not confront this, although other group members may. Often, a sense of powerlessness about health emerges from these discussions. Hypochondriacs feel that only physicians can save them from their illnesses and that nothing they themselves do is effective. Hypochondriacal anxiety often stems from these individuals' profound sense of impotence and lack of control over their bodies and their health. A common depressive theme often expressed by hypochondriacal patients is that their condition is particularly unfortunate because there is no medical explanation or diagnosis to legitimize or validate their suffering. TREATMENT OUTCOMES AND PROGNOSIS Data on the natural history and longitudinal course of untreated hypochondriasis are lacking, and a wide range of outcomes have been described anecdotally. The general impression is that it is a long-standing, chronic, and disabling condition. Favorable prognostic indicaVOLUME 37. NUMBER I • JANUARY - FEBRUARY 1996
tors are thought to include youth, acute onset, concurrent anxiety or depression, less serious personality disorder, medical comorbidity, less dysfunctional illness beliefs, and less secondary gain. 1.6.8.1 1.23 The literature on treatment effectiveness is very limited. However, there is a growing sense that treatment, particularly cognitive and behavioral treatment, can be helpful and that a significant proportion of hypochondriacal patients who undergo psychiatric treatment improve or recover. 10.24.30.34--37 The paucity of this literature and the absence of definitive studies suggest that intervention trials are now a high priority. Such studies should include adequate numbers of patients, appropriate control groups, specified diagnostic criteria, standardized and sensitive measures of change, and treatments that are time-limited and can be described precisely and scripted. The need for such treatments will only grow with the growing imperative to contain medical care costs and to curtail undue medical utilization. Because hypochondriacal patients consume large amounts of physician services, laboratory tests, and diagnostic procedures, it will be increasingly critical to study them in this light.
This work was supported by a grant from the National Institute of Mental Health (Grant No. MH-40487). The author thanks Carol A. Wool. M.D .. and Edith Geringer. M.D ..for their invaluable contributions to this work.
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