Biology 103
2003 Third Paper
On Serendip

Right now, my shoulder really, really aches. It's a dull, uncentralized sort of pain, and over the past few days, it has spread to my neck and upper arms. My wrists hurt too, especially when I twist them a certain way. I'm tired all of the time, and thirsty.

I'm not worried about these symptoms. Their cause is obvious. I've spent the last four days hunched over my computer until early morning, furiously typing reports for finals week (this one included). I get an average of four to five hours of sleep a night, and the rest of the time, only a constant stream of caffeinated beverages can keep me awake. My back/shoulder/neck pain is caused by my stance at the computer; my tiredness is a result of---what else?---lack of sleep; I'm thirsty because all I'm drinking is soda.

If I were a hypochondriac, though, I'd probably think I had cancer.

Don't laugh. Hypochondria, or the attributing of benign symptoms such as backache and fatigue to serious illnesses, occurs in 1% of the population and 5% of America's medical outpatients ((7)). These people, while usually genuinely healthy, interpret every minor pain as indicative of something serious. They travel from doctor to doctor seeking treatment; if one doctor refuses to acknowledge their illness, or gives them a clean bill of health, they simply move on ((7)). This process can go on for anywhere from six months to years ((6)). The symptoms they feel are not delusions, nor are they purposefully-created fakes. Pretending to experience nonexistant symptoms is a behavior associated with a different disorder, Muchausen syndrome. Hypochondriacs' pain is very real. It's just not, as its sufferers assume, a sign of some fatal illness ((7)).

Actually, the story isn't even that simple. There are several different levels of hypochondria. For one, there are people who take normal aches and pains and self-diagnose themselves with something serious. For another, there are those who obsess unduly over an illness they already have ((6)). Then there are people who suspect they are riddled with several different ailments ((1)). All of these conditions have been lumped---correctly?---under the blanket term hypochondria.

This in itself is a problem. What *is* hypochondria, exactly? Rather, why does it occur? No one seems exactly sure. 20th century doctors dubbed it a purely psychological illness. Freud, typically, considered it a sublimation of the libido that manifested itself as pain below the ribcage ((6)). Other psychologists assert that traumatic experiences can trigger the disorder: the death of a loved one, for example, might heighten a person's sensitivity to disease ((1)). Childhood behavior patterns might also play a role. If a parent rushed his child to the doctor every time the child felt ill, that child might grow into an oversuspicious adult ((1)). Lifestyle, too, may influence the disease. One Norwegian doctor attributes the growth of the disease to an increase in affluence. Vikings, he says, didn't have time to worry about a headache. Likewise, one of his patients links hypochondria with seasonal-depressive disorder. Norway, dark for much of the year, is apparently a depressing place to live ((2)). And the list goes on. Because the symptoms associated with hypochondria aren't really "symptoms" at all---rather, they are benign pains with no connection to any disease---doctors have, for a long time, dismissed hypochondria as "all in the head."

Because of the disease's supposedly "psychological basis," treatment has, for years, been consigned to non-drug-based methods. These methods, popularly referred to as "therapy," have a high success rate. Psychiatrist Steven Locke studied a group of 114 hypochondriacs on their quest to heal themselves through group therapy. ((5)) A year after the sessions concluded, they had cut their doctor-visits in half (saving a whopping $1,008 in bills). Dr. Ingvard Wilhelmsen, of Norway, runs a special clinic for hypochondriacs from his home hospital in Bergen that is so popular it has its own waiting list ((2)).

Now, however, ideas are beginning to change. Psychiatrist Brian Fallon, an expert on the disorder, recently concluded a long experiment on the causes, effects, and possible treatments of hypochondria. His findings radically contradict all previous data on hypochondria. "I am firmly convinced that hypochondria can happen biologically, from the link that's been observed with obsessive compulsive disorder (OCD)," he says ((1)). He describes this link as a pattern of similar behavior. Hypochondriacs, for example, obsessively, repetitively check their condition with different doctors; they cannot stop "obsessing" over their symptoms; they cannot be convinced that the problem is in their minds. On a hunch, Fallon treated one of his hypochondriac patients with Prozac, a known prescription for sufferers of OCD. The man improved dramatically, and Fallon expanded the treatment to the other hypochondriacs under his care. It seemed to work, so in 1993, he conducted a full-blown study of 25 patients over 12 weeks of treatment. 70% of them did extremely well, Fallon notes ((6)). He suspects that Prozac's effectiveness is due to its ability to boost the amounts of brain-borne serotonin, a type of neurotransmitter whose deficit has been linked to many psychological disorders, including OCD. ((6)) He is enthusiastic about extending the treatment further.

It is here that my problems begin. I dislike Fallon's race to employ drugs in treating hypochondriacs for three main reasons. One is medical, one is practical, and one is moral.

I'll deal with the medical first, because the problem is one Fallon fully acknowledges---and yet seems to ignore. This is, simply put, that Prozac is nowhere near as effective as his statistics claim. Several of his "cured" cases were actually patients on placebo. Fallon himself gives a detailed example of a woman whose recovery was so complete he was sure---until the test results came in---that Prozac had worked for her ((1)). "She got tremendously better, and started to dress well and look extremely happy," ((1)) he notes satisfactorily. The story gets darker, however. The woman also experienced psychological "nocebo" effects: in other words, adverse symptoms to the sugar pill. These included a vow to murder someone who was blackmailing her about the affair she was having ((1)). Other patients have done just as well with the placebo as they have with the real thing, suggesting that hypochondria is better treated through psychological therapy than pill-popping.

On the other hand, is this type of experiment (ie, one that includes placebos) even a good idea? Fallon admits that "Some hypochondriacs seem to be enormously suggestible" ((1)). By the nature of their illness, hypochondriacs feel pain that has no real cause. When they are placed on placebos and subsequently develop "nocebos" (painful side effects), they are simply repeating the pattern they followed before treatment: attributing discomfort to a condition that doesn't really exist. Therefore, the "nocebo" effect would actually serve to worsen their condition.

Another medical problem stems from the elusiveness of the disorder. Fallon himself points out that there are several different types of hypochondria, which are grouped together more by symptom than by cause. However, he attempts to blanket-diagnose all of these differing conditions with a single pill. About a third of his patients are barely affected by the drugs. Worrisomely, this group is, as Fallon puts it, "harder to treat. They feel they have a multitude of symptoms, and they worry that they have a serious disease" ((1)). Excuse my pickiness, but isn't "worrying that you have a serious disease" the basic definition of hypochondria? Are his other patients doing something different? Fallon says Prozac works, but even he is not quite sure how. Could only one type of hypochondria, in fact, be related to OCD and ergo treatable through medicine? If so, what about the other types---are they related physiological disorders, purely mental conditions, or something else altogether? If they're not specifically linked to OCD, is attempting to treat them with Prozac a good idea?

My second beef with Fallon's methods is a practical one. While Prozac may serve to dull anxiety and depression related to hypochondria in 70% of cases ((1)), I want to argue that it's not an effective long-term treatment. It's not going to cure hypochondriacs, because it actually makes their illness worse. Think about it logically. Hypochondriacs, when they jump from doctor to doctor, are seeking confirmation that they actually *do* have a serious physiological illness, one that can be treated through medicine ((3)). When they reach Fallon's office, they're told that they *are* sick, it *is* physiological, and it *can* be treated through medicine. Basically, it's giving them exactly what they want. It lets them quote, smugly, the proverbial epitaph on the proverbial gravestone: "I *told* you I was sick." Fallon's blackmailed patient's reaction was similar to this. So overjoyed to be diagnosed, she vehemently refused to relinquish her pills when Fallon requested ((1)). It wasn't medical withdrawal she was feeling---she was actually on a placebo. Rather, she was so desperate to hang onto the one real diagnosis she had received (and which she made herself believe was working), that she hoarded her sugar-pills like a lion.

More importantly, pills aren't an effective long-term solution because they don't deal with the problem that's at the heart of the disease: recognition of their condition. Dr. Wilhelmsen explains the importance of this recognition. "The patient with hypochondria can realize that he has anxiety, and not a serious physical disease, and gradually reduce his anxiety. The patient is not healed when he realizes that he has health anxiety (just as a person can still be afraid of flying even though he knows it), but it is an important first step," ((2)) he writes. While therapy helps patients take these steps, slowly allowing them to realize their hyper-anxiety and reduce it, Prozac removes the patient's responsibility. He doesn't have to worry about actively fighting his condition; he can simply pop a pill and wait for recovery to kick in. Therapy, on the other hand, allows the patient to seize control over the disorder. Wilhelmsen explains his hospital's therapy program: "The program includes home work assignments which might be behavioral (less checking of the body, activation etc.) or cognitive work (registration of situations, thoughts, feelings and behavior)" ((2)). If medication is ever used (rarely), it is always in conjunction with therapy.

Hypochondria, despite Fallon's claims of OCD connection, remains an essentially psychological disorder. It's only appropriate, then, that it's dealt with in the manner of other psychological disorders: through therapy. This not only allows patients to take an active role in their recovery, it's an extreme countermeasure to the associated depression/anxiety of their condition. Dr. Locke's experimental therapy sessions utilized this technique to astonishing success:

"The two-hour structured groups taught participants how to see a link between their experiences and their physical sensations. They also got training in meditation and how to break self-defeating behavior. In the year after the six-week group, each participant's medical costs were $1,008 less than patients who hadn't been in the groups, even after deducting the expense of the therapy, Locke says. Group participants made roughly half as many doctor visits as they'd had in the year before their treatment" ((5))

Results like these strongly suggest that if patients feel they are working for a goal, they'll feel better about themselves. They'll feel better able to handle their own condition. In short, they'll just feel *better.*

My final, and biggest problem with Fallon's treatment is a purely moral argument. I think it's a legitimate one, as it has been brought up in connection with other psychological conditions, most notably, ADD (Attention Deficit Disorder). It's the issue of over-prescription, of readily distributing pills as a cure-all. Remember the Ritalin controversy a few years back? Proponents of the drug argued that it cut down ADD in school-age children; detractors countered that ADD was being overdiagnosed and Ritalin given to every child who couldn't sit still in class. Although some of these kids had a legitimate disorder, for many of them their behavior was psychological. It was, detractors argued, a consequence of lax parenting and inept teaching. The same might be said for hypochondria. As has been mentioned before, the disorder comes in many forms, but only a few seem biologically occurring. Others are simply social conditions. Dr. Richard Friedman gives the example of hypochondria originating in a single, isolated incident: "for example, the common experience many have after a minor accident. Suddenly, the person becomes aware of ''new'' physical symptoms that are assumed to be a result of the mishap when they may have been lurking in the background all along" ((7)). This type of hypochondria is the consequence of a single experience, not a genuine physiological disorder. It's not biological. Can it really be treated with a tube of pills?

Wait. That's not even the issue. Even if it could be fixed via Prozac, *should* it be? If Wilhelmsen is right and hypochondria is a consequence of affluence---if the Vikings did *not* have hypochondriacs---is it fair to try and treat the condition medically? The same goes for similar disorders, such as ADD. Of course there will be those who truly suffer a "physiological" version of these illnesses, but for the majority of sufferers, problems can be overcome through dedication and the right type of therapy. Why, then, is there such emphasis on finding a medical "solution" to the problem? This may sound harsh, but isn't this just irresponsible self-indulgence? The doctors who search for these miracle cures, and the patients who rely on them, simply come off as too lazy to commit themselves to a tougher (if more effective) treatment. Pills are great tools, but they should not be applied to every situation. They're just an easy, temporary fix for a longterm psychological problem. Therapy works. It may take longer, and require greater effort on the part of both physician and patient, but it works. Furthermore, it instills a useful self-confidence in patients who was, before, riddled with anxiety over their physical soundness. It teaches them one of the most important lessons recovering hypochondriacs can learn: you do *not* have to live your life in fear of any disorder. Including hypochondria.

In conclusion, right now, my neck back, and shoulders hurt like hell. However, I'm not worried. That's what you get for staying up until 4 a.m. to finish biology essays.

But even if I was worried that it was something serious---in other words, if I *was* a hypochondriac---I would know that I wasn't at the mercy of my own phantom symptoms. I would know that, with some work and a lot of good therapy, I could overcome my condition. I would recognize my anxiety for what it was, and know that it was a mental rather than a physical problem, and therefore fixable.

Most importantly, I would know that I wouldn't have to rely on pills for my recovery.

That being said, I'm going to go pop a few aspirins.

***

References

Works Cited

1)Prozac works?, ... Dr. Fallon and prozac

2)The Norwegian Doctor, ... Dr. Wilhelmsen's idea about treatment

3)Some basics on hypochondria , ... more basics on hypochondria. Due to the updating of Columbia's records, this page may no longer exist. Sorry!

4)Hypochondria and the internet, ... can the internet actually make hypochondriacs worse?

5) The USA Today on hypochondriacs, ... basic information on hypochondria

6) Columbia University's health journal, ...due to updating of Columbia's records, this page no longer exists! I'm sorry!

7) The difficulty with treating hypochondriacs , one doctor's perspective...

8) Dr. Wilhelmsen, Part 2 , ... why treatment works.


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