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The special threat of health anxiety (hypochondria)

 •  • by Paul Ingraham
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Weekly nuggets of pain science news and insight, usually 100-300 words, with the occasional longer post. The blog is the “director’s commentary” on the core content of a library of major articles and books about common painful problems and popular treatments. See the blog archives or updates for the whole site.

One of the worst problems in the world is not believing people who have real medical problems. That said, unfortunately hypochondria is undoubtedly actually a real thing and probably common. And really quite pernicious.

Health anxiety is particularly nasty in three ways:

  1. It causes itself. Symptoms drive more anxiety which drive more symptoms… a vicious cycle.
  2. It 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. It deftly shifts the blame for the symptoms it causes onto the body itself, removing suspicion from itself. A tidy trap.

If you’re nauseous as you’re preparing for public speaking, then there is little room for debate about the cause of your flip-flopping stomach; it’s clearly not a pathology. But if you have a symptom because you’re scared of sickness itself, instead of some obvious external threat, then all suspicion can fall on unfalsifiable hypotheses about your internal state. 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.

This can go on for ages, especially because there are so many credible “seeds of truth” that are terrific scapegoats: the genuine medical threats, misfortunes, and discomforts that pepper our lives. Nothing gives hypochondria a boost like an actual illness! Many people effectively have two problems: a health problem and excessive anxiety about it. And the anxiety can be worse, and seriously weird. “The colours of the chameleon are not more numerous and inconstant than the varieties of the hypochondriac and hysteric disease.” (Whytt, On Nervous, Hypochondriac, or Hysteric Diseases, 1764 — yeah, anxiety is an old problem.)

Even for the open-minded patient who is willing to brave the stigma of hypochondria, it’s hard to make progress. When we try to honestly ask ourselves if worry is the real problem, worry always responds the same way: “Okay, maybe. But what if it’s not?” And it can never be satisfied. It is like a canny defense lawyer who can always stir up some reasonable doubt.

This post is an excerpt from my guide to anxiety for chronic pain patients.