From the office: hypochondriacs and their ilk

I see a lot of folks who are anxious about their health; most have actual health issues. What if my IBS flares up while away from home? What if the ‘abnormal’ PSA or mammogram reveals I have cancer? Medicine often takes the ‘wait and watch’ approach for nonspecific matters, which puts the patient on vigil for any sensation of problems. ‘Watch for chest tightness or pains’ and if there is anything of the sort anxiety surges ‘this could be it’.

Then there are patients anxious about a symptom or set of symptoms for which there is no medical explanation – at least so far. They are worked up and down for something to explain and there isn’t anything to explain it. This is seldom assuring. Patient and doctor both get frustrated and more tests are done. Specialists are consulted often to no avail. It’s about then they are referred to Urs Truly for the possibility of anxiety or depression. This proposal generally goes over like a lead balloon. Patient heart this as ‘it’s all in your head” and not real. I do a lot of education and assurance what they are experiencing is quite real. The physical symptoms are often physical manifestations of stress or anxiety. Sometimes this is assuring but not usually. Patients still hope their symptoms will have a concrete physical explanation; it just hasn’t been found yet. Most folks know of someone who had their symptoms poo-pooed or downplayed by doctors only to find the patient had an actual ‘real’ problem after all. My patients hope they too ‘just haven’t gotten the right cause yet”.

These are tough cases.

The term ‘hypochondriac’ is no longer used in psychiatry; it’s a dated and negatively-charged word. We use the diagnosis ‘illness anxiety’ when there isn’t anything specific and ‘somatic disorder’ to report a specific condition arising from a mental disorder.

An important point of treating these types of cases is never dismiss their worries. I point out 50% of folks with any chronic disease have co-morbid depression/anxiety – if they address the mental aspects their physical symptoms will improve. Most of the time depression and anxiety don’t manifest as mental anguish but as dyspnea, tightness, muscle aches, tremors, and GI upset. This is more so as we age.

A common fear of patients receiving such diagnosis is their other doctors will henceforth attribute all physical complaints as ‘just anxiety and go see your psychiatrist’. I remember a case of a woman who regularly went to the ER for fears of having a heart attack only to be told again and again she had no cardiovascular disease; she was having panic attacks. This was treated although she went back to the ER where she was almost immediately turned away until someone there actually listened to her ‘this one feels different’ and lo! she had a pulmonary embolism.

Sorting it all and figuring out what to do is a complicated endeavor. I hope in time people are less prone to the ‘either a physical or a mental problem approach’ to physical symptoms.