Normal worry, or hypochondria?

Dan Page for the Boston Globe/Dan Page

A woman I see rarely other than for her annual physical came in with a scratchy throat, concerned she may have caught strep from her daughter. When an exam and a throat culture excluded that diagnosis, the woman came up with a different one: “I’m such a hypochondriac!” she said.

Many patients tell me, apologetically and with some embarrassment, that they’re hypochondriacs. Usually what they mean is that, like the woman with the sore throat, they’re worried they have a condition more serious than what they actually have. But I don’t call that hypochondria. I call that getting good news from your doctor.

True hypochondria involves anxiety about illness so severe or persistent that it becomes an illness itself. The New England Journal of Medicine reported the case of a hypochondriac obsessed with the idea that her abdominal discomfort indicated pancreatic cancer. She spent so many hours on the Internet researching the condition and logging her symptoms that she neglected her children. Finally, she threatened to commit suicide if she really did have pancreatic cancer — which a CAT scan had already ruled out — and she required psychiatric hospitalization.

Recently, the American Psychiatric Association retired the term “hypochondria.” The latest edition of the APA’s diagnostic manual, DSM-5, combines hypochondria, somatization disorder, conversion disorder, and other diagnoses into a new category: somatic symptom disorders. People with these disorders experience intrusive or even disabling thoughts, feelings, or behaviors related to physical symptoms.

Somatic symptom disorders can be quite painful and even life-threatening. Patients who go from doctor to doctor seeking tests, medications, and surgery for imaginary diseases frequently end up with physical complications of their psychiatric conditions. Conversely, a patient terrified that his or her symptoms signal a lethal disease may avoid doctors altogether and suffer from insufficient medical care.

By definition, many patients with somatic symptom disorders lack insight into the nature of their problem — someone who is sure she has pancreatic cancer may not be eager to see a psychiatrist — which makes treatment challenging. Still, psychotherapy, cognitive behavioral therapy, anti-anxiety and anti-depressant medications, exercise, and relaxation techniques can all help.

Most helpful to someone with a somatic symptom disorder is having a good relationship with a primary care practitioner. If I know a patient really well, I’m better able to resist ordering an MRI for every minor bruise or headache “just in case,” and also better able to stay alert to the fact that occasionally a patient with a somatic symptom disorder really does have the disease they most fear. One new patient who did have insight into his health anxiety told me he needed to trust me to tell him when it was reasonable to worry.

I understand the APA’s rationale for creating a more streamlined diagnostic system, but I hate to see “hypochondria” go the way of “dropsy,” “lumbago” and other colorful, now-obsolete entries in the medical lexicon. In Greek, “hypochondria,” means “under the ribs.” Centuries ago, physicians considered internal organs the source of emotional distress. While I don’t think this is literally true, I do believe there’s more overlap between mental and physical illness — and even between imaginary and real illnesses — than we acknowledge.

A few years ago my patient, Barbara, developed a series of symptoms so disabling she was forced to leave her job: chest pains, fatigue, tingling of her arm and facial twitching. Almost daily, she experienced episodes in which her whole body shook violently, sometimes for over an hour. Her husband captured one these spells on his smartphone and during one visit, just as he was showing me the video, Barbara began to shake on the exam table. For 35 minutes she flailed her arms, clenched her jaw, and blinked her eyes rapidly. All the while, she spoke to us, clearly and calmly.

Though the episode resembled a grand mal seizure, several features were atypical, including the pattern of Barbara’s arm movements and the fact that she remained fully awake. Plus, her EEG, a test of brain wave activity, was normal, which would be unusual in someone having daily seizures.

A neurologist concluded that Barbara’s symptoms were “functional,” meaning that they could not be explained by any physical abnormality and likely were manifestations of psychological distress. A psychiatrist agreed and prescribed medication and therapy for depression and anxiety. The episodes became less frequent and severe. Surprisingly, though, meditation and deep breathing, which the psychiatrist also recommended, actually worsened Barbara’s symptoms. When she tried to sit still, she shook and twitched.

About two years after her symptoms started, the neurologist who continued to follow Barbara along with the psychiatrist diagnosed mild Parkinson’s disease. Barbara responded well to medication for Parkinson’s, and still receives treatment for her psychological issues too.

I asked Barbara recently whether, in retrospect, her specialists feel the dramatic shaking episodes were an early manifestation of Parkinson’s disease. She told me that nobody knows. They could have been, or perhaps they were related in some as yet unidentified way. Or maybe the two were related only by coincidence. She seems to accept this uncertainty with equanimity.

Seeing Barbara triggered a memory. One fall, when I was 14, I semi-consciously faked a cough. After a couple of days at home, my pediatrician ordered a chest X-ray which showed pneumonia. Had the pneumonia been brewing, independent of my fakery? Or had all that theatrical hacking caused me to aspirate?

Only decades later did I realize that the timing of this incident was significant. My mother, who had always been a stay-at-home mom, had gone back to school just a few weeks earlier. My illness drew my mother’s attention away from her books and back to me, which was no doubt what I desired. But could that desire really have caused a lung infection?

Like Barbara, I am unsure. I only know that we all have both minds and bodies and that they sometimes interact in mysterious ways.