Health Anxiety

How a hypochondriac reads a minor cough

Hypochondriacs become unduly alarmed by any physical or psychological symptom they notice, however minor, and are convinced they have or are about to be diagnosed with something serious. A minor cough becomes tuberculosis. The ordinary noises an intestine makes become evidence. The worry commonly fixes on one symptom as its catalyst, gastro-intestinal trouble, palpitations or muscle fatigue among the usual candidates, and to qualify for the diagnosis the symptoms must have run for at least six months.

Why reassurance does not settle health anxiety

Reassurance does not settle it. The condition frequently persists after a physician has examined the person and explained that the concern has no medical basis, or that a real illness exists but the worry attached to it far exceeds the level of disease. Many express doubt about the diagnosis outright and report that reassurance is unconvincing or wears off fast, and many need reassurance constantly, from doctors, from family, from friends. Blood pressure, stress and anxiety rise in the presence of doctors or inside a medical facility, which is White Coat Syndrome.

The behaviour then splits in opposite directions. Some visit medical facilities frequently and sometimes obsessively. Others avoid every reminder of illness so thoroughly that they neglect their health and let a serious condition go undiagnosed. Some live in despair, certain of a fatal disease no physician can help with. Some treat the disease as punishment for past misdeeds. Some never speak about it at all.

How hypochondriasis is diagnosed and reclassified

The ICD-10 classifies it as a mental and behavioural disorder and sets three conditions:

1. a persistent belief of at least six months in at least two serious physical diseases with one named specifically, or a persistent preoccupation with a presumed deformity
2. distress or interference with daily functioning that drives the person to seek medical treatment or investigations, or equivalent help from local healers
3. a persistent refusal to accept advice that no adequate physical cause exists, allowing only for short periods of acceptance after an investigation

The same manual files nosophobia, the fear of contracting one specific named disease, under the hypochondriacal disorders as well, which leaves the boundary between the two an argument rather than a line.

The DSM-IV called it a somatoform disorder and one study found it in about 3 per cent of visitors to primary care settings. Then the 2013 DSM-5 abolished the diagnosis, redistributing it: roughly 75 per cent of people who met the old criteria now meet those for somatic symptom disorder, and 25 per cent those for illness anxiety disorder. The classification argument is old. The first two editions of the DSM called it a neurosis, the third and fourth a somatoform disorder, and the fifth stopped listing it.

Which conditions accompany hypochondriasis

The commonest accompanying conditions are:

• bipolar disorder
• clinical depression
• obsessive-compulsive disorder
• phobias
• somatisation disorder
• panic disorder

A generalised anxiety diagnosis at some point in life travels with them.

The cycle of intrusive thought followed by compulsive checking looks like obsessive-compulsive disorder and is not the same thing. Someone with hypochondriasis is afraid of having an illness. Someone with OCD worries about getting one, or about passing one to somebody else, which is the ground germ fear occupies. A person may have both, and they remain distinct conditions.

There is also a trap in the physiology. Depression produces appetite change, weight fluctuation, fatigue and loss of interest. Intense anxiety produces a fast heart, palpitations, sweating, muscle tension, stomach discomfort, dizziness, breathlessness and tingling in the hands or forehead. Patients frequently do not know that their own depression and anxiety are generating those sensations, and read them instead as evidence of the disease they fear.

What twin studies rule out about hypochondriasis

The genetic contribution is probably moderate, with heritability estimated between 10 and 37 per cent. Most of the variance in the key components, fear of illness and disease conviction, is explained by non-shared environmental factors, meaning experiences that differ between twins in the same family. The contribution of shared environment is approximately zero, which rules out a great deal of what people assume about how it is transmitted.

Which particular non-shared factors matter is largely unknown. Exposure to illness-related information is widely believed to raise health anxiety in the short term and to have contributed in individual cases. Excessive focus in childhood on minor health concerns, or on the serious illness of the person or a family member, has been implicated. An underlying anxiety disorder raises the risk.

Media supplies a specific mechanism. Articles, television and advertising about cancer and multiple sclerosis often present those diseases as random, obscure and somewhat inevitable, and inaccurate portrayals of risk together with the identification of non-specific symptoms as signs of serious illness can sharpen the fear. Major outbreaks and predicted pandemics do the same.

Why hypochondriasis often starts after a death

The anecdotal route is the most human of them. Some people become hypochondriac after a major diagnosis or the death of a family member or friend. Others, healthy and content until then, fall into it on approaching the age at which a parent died prematurely of disease, convinced they have the same illness, sometimes with panic attacks and the matching symptoms.