Patients Refusing to Be Well: A Disease of Many Symptoms
By DANIEL GOLEMAN
Published: August 21, 1991
THE young man said his head felt as if it were filled with cotton, his heart felt "weak," his arm was numb and tingled, his veins ached.
By the time he was referred to Dr. Arthur Barsky, a psychiatrist at Massachusetts General Hospital in Boston, he had been examined by specialists in infectious disease, endocrinology, allergy, kidney disease and neurology and was scheduled for tests at three different Boston hospitals.
But none of the tests showed any medical problems. "He just had the conviction he was sick, and so interpreted all his vague aches and pains as proof," Dr. Barsky said. Many Unexplained Symptoms
The young man is not alone. "Up to 50 percent of patients in physicians' offices are there for at least one symptom with no medical explanation," said Dr. Charles Ford, a psychiatrist at the University of Alabama who is a leading expert on hypochondria. "And 10 percent of patients have no evidence of any medical disease whatever."
Doctors, out of frustration, often dismiss such patients as hypochondriacs or "crocks." Sometimes the problems are with the doctors: the patients have real problems but the doctors cannot identify them. But often the patients are "somatizing," expressing emotional conflicts or the need for attention as physical maladies.
While in the past such patients shuttled from emergency rooms to specialists to medical labs, doctors are finding new methods to identify these patients and help them.
One motive for the recent interest in treating somatizers is economic. "Somatizers have medical costs 10 to 14 times higher than the national average," said Dr. Michael Kashner, a medical economist at the University of Arkansas medical school in Little Rock. Dr. Ford, who earlier this year prepared advice for the American Academy of Family Physicians on how to treat somatizers, said somewhere between $20 and $30 billionwas spent each year on unneeded health care for such patients. The cost is borne, not only by the individual, but by all those people whose insurance premiums rise because of these bills.
Of course, it is prudent to consult a doctor when there is a symptom of illness. And the symptoms that most commonly bring people to a doctor's office usually have no medical cause.
A 1989 study of 1,000 patients seeking help from internists found that the most common symptom, chest pain, signified a medical problem in just 11 percent of cases. For fatigue, the next most common, there was a medical cause in only 13 percent of cases. For dizziness, the figure was 18 percent. A Step Further
"Hypochondriacs carry it a step further," Dr. Barsky said. "Unlike most of us, they don't feel better when a doctor reassures them that there's nothing wrong."
He added, "Somatizers have the firm belief that they are sick and so reinterpret ambiguous sensations like dizziness or being out of breath as proof." The more symptoms they notice, the more anxious they get and this, in turn, makes them physically upset, thus providing them with still more symptoms.
One man Dr. Barsky treated feared he had tuberculosis and had a skin test for it. "For the test, they prick your arm," Dr. Barsky said. "Everyone gets a red flare for a while, but all that matters is what's there after 48 hours. His test was normal, but he remained convinced his initial skin flare meant he had TB."
Dr. Barsky's research suggests that hypochondriacs are prone to complaining about their symptoms in part because they are more sensitive than others to physical sensations in general.
In an article published this year in the Journal of Psychiatric Research, Dr. Barsky said a study of 41 hypochondriacs showed that compared with other people, the hypochondriacs tended to feel bodily sensations of all sorts more intensely and tended to interpret them as disturbing. While other people would see sensations, like cold hands or a twitching eyelid, as perfectly normal, the hypochondriacs seized on them as a sign of disease.
"If most people start to pay close attention to their throat, they'll begin to notice it's dry, scratchy and itchy, and try to clear it or start coughing," Dr. Barsky said. "That's a normal response, which comes from paying close attention to a bodily sensation. It's the hyponchondriacs who will then interpret that as a medical symptom of some sort rather than normal discomfort." Counseling Distraction
Because part of the problem for hypochondriacs is that they focus so intently on scanning their bodies for signs of disease, Dr. Barsky's treatment includes teaching them to distract themselves when they find they are worrying about some sensation.
Another facet of his suggested therapy for hypochondriacs is teaching them to relax. "When they're anxious, they get hypervigilant and start scanning their body for something worrisome," Dr. Barsky said. "If they calm down, they won't do that so much."
A third approach is to explain to those prone to hypochondria "what are normal aches and pains," Dr. Barsky said. "They have completely unrealistic views of good health, so they see any bodily discomfort, from a bloody nose or cramp to feeling dizzy, as a symptom" he said.
For many somatizers, the real problem is depression or anxiety. A study published in the Archives of General Psychiatry last March found that in 68 women who were somatizers, two-thirds suffered from depression and three-quarters had an anxiety disorder, like panic attacks. The study was published by Jacqueline Golding, a psychologist at the Institute for Health and Aging at the University of California at San Francsisco, and colleagues.
Psychiatrists say that when the underlying depression and anxiety are treated, the hypochondria often disappears. But because hypochondriacs are convinced that they have medical problems, it can be hard to get them to consider psychotherapy.
"Psychotherapy often is just not appropriate," said Dr. Ford said. "Somatizers get angry if you refer them to a psychiatrist, since they don't believe there could be a psychological cause."