Reasonable doubt: the special threat of health anxiety (hypochondria)

When you’re irrationally or excessively worried about your health, that’s “hypochondria.”1 It should not be diagnosed lightly (or even thought of lightly). One of the worst problems in medicine is how often people who have real medical problems are not believed, assuming instead that they are just being like a Victorian lady with a case of the vapours.

Not that modern women fare much better in the medical system. Systemic prejudices in healthcare have always been a huge problem.

But hypochondria is surely real and common, even if it’s not nearly as common as the clinical suspicion.2 Fear of health problems makes a lot more sense than many phobias, many of which are obviously irrational. “Fear itself” is obviously more of a problem than a lot of the things we’re afraid of. Health anxiety works differently because the threats are more real, more serious, and harder to disprove. Speculation can run amok, and run amok it does!

One of the all-time great epitaphs. 🪦 It’s true that hypochondriacs are often “dramatic” and colourful people — but remember that drama queens can also actually get sick.

“It’s a trap!” Health anxiety is a particularly nasty trap for the fallible human mind in three ways:

1. Hypochondria causes itself. Symptoms drive more health anxiety which drive more symptoms … a vicious cycle.
2. Hypochondria thrives on “seeds of truth.” Many psychosomatic symptoms are not generated out of thin air, but exaggerations and complications of actual problems, which immensely complicates diagnosis.
3. Hypochondria deftly shifts the blame for the symptoms it causes onto the body itself, removing suspicion from itself. Sneaky.

If you’re nauseous as you prepare for a speech, there is little room for doubt or debate about the roots of your flip-flopping stomach. It’s obviously not a pathology! Nausea from stage fright is one of the greatest hits of all psychosomatic symptoms. But if you have a symptom because you’re scared of sickness itself, instead of a clear non-medical threat, then all suspicion can fall on health threats instead of your own mind … and those fears are based on mostly plausible and unfalsifiable hypotheses about your internal state. You have worried ideas, and they cannot easily be put to rest. Devious! No matter how many explanations you dismiss as unlikely or even absurd, there’s always another to take its place. Any symptom could have a surprising medical cause, right? Literally any symptom!

Indeed, anxiety-powered symptoms can be worse and weirder than the pathology-powered ones. “The colours of the chameleon are not more numerous and inconstant than the varieties of the hypochondriac and hysteric disease.”3

That fearful speculation is also hard to stop for another reason: there are so many credible “seeds of truth” that are terrific scapegoats. Our lives are peppered with genuine medical threats, misfortunes, and discomforts. Nothing boosts hypochondria like an actual illness! And so many people effectively have two problems: a health problem and excessive anxiety about it. Who’s to even say whether it’s “excessive,” if the problem is scary enough? Or scary to you? There are many kinds of common health phobias, of course.

Even for the open-minded patient — someone willing to brave the stigma of hypochondria, someone who embraces the diagnosis — it’s hard to make progress because what we fear is so easily blamed on something else rather than “fear itself.” When we try to honestly ask ourselves if worry is our real problem, worry can (and usually does) always responds the same way: “Okay, maybe. But what if it’s not?” And it can never be satisfied.

Like a good defense lawyer, healthy anxiety can always stir up some reasonable doubt.

“A Hypochondriac’s Nightmare,” by Randall Munroe, xkcd #1097

This post is an excerpt from my guide to anxiety for chronic pain patients — and a gift for my free newsletter subscribers, because it’s part of a members-only section of that guide. Other paywalled topics in that guide include:

• Can a psychologist help you think your way out of anxiety? The state of the evidence about cognitive behavioural therapy for anxiety
• Theory vs practice: you’re not always going to get ideal CBT
• Fighting, flighting, tending, and befriending
• Does stress wreck us?
• Stress and injury risk and poor injury recovery
• If anxiety causes pain, does that mean the pain is “all in your head”?
• Anxiety and thinking
• The biological signature of anxiety
• The behavioural signature of anxiety (stiff upper lip syndrome)

Notes

1. Why hyp-o? It seems like excessive worry should be named hyp-er something? And isn’t “chondria” from the Greek (khondros) for the ribs? Right you are, gold star! What a confusing word. It’s weird because it comes from one of those hopelessly confused archaic medical notions, namely that “melancholy” came from liver and spleen … which are “under the ribs.” So hypochondria was originally the word for “that problem that comes from under the ribs.” Before we knew about anything else that could possibly go wrong with those organs.
2. I tried to find some data on the actual prevalence of hypochondria, or some evidence-based hint about how overdiagnosed it might be. I failed, which probably isn’t surprising, because there’s no objective test for it — just as there is no objective test for pain. The nearly insurmountable problem is that we have no way of knowing who actually has hypochondria instead of diseases and injuries. It’s kind of like trying to figure out how many innocent people are convicted of serious crimes.
3. Whytt, Robert. On Nervous, Hypochondriac, or Hysteric Diseases. 1764.

   Yes, 1764! Anxiety is not a new problem.