hypochondria

Interview with MD Aleksandra Bubera, psychiatrist and psychotherapist, with journalist Branislava Laćarak, published in Večernje novosti daily papers 29.03.2014.

Hypochondria is often thought of as a condition of enormous fear of an illness, which is not important enough to be dealt with more seriously. To what extent is hypochondria a really serious condition and how much can it affect one’s life? Is this condition only “in one’s head” or can it cause some specific problems to a person?

Hypochondria implies excessive preoccupation with physical symptoms, health and illness due to pathological fear that a person suffers from a serious illness. Hypochondria was known even in ancient Greece, while the term has been used in medical practice since 16^th or 17^th century.

It belongs to fear-related disorders and belongs to the class of neuroses, i.e., light mental disorders. When I say light, I do not mean the suffering that a patient experiences because of the disorder, but I mean the cause, course and the prognosis of the disorder that are easier to approach to and treat, often by psychotherapeutic methods in contrast to severe mental disorders. And because of this hypochondria should be distinguished from delusional hypochondriac ideas that occur in severe, psychotic disorders – delusional ideas are unrealistic and sometimes very bizarre such as, for example, when a patient is fully convinced that he[1] has stomach-ache because he has frogs in his stomach, or that he has cancer because of the influence of evil forces from an unknown planet. In such cases the patient usually suffers from a very serious disorder that requires long-term and inevitable medical treatment, while psychotherapy can sometimes be applied.

Like all other disorders associated with fear, hypochondria is a disorder that greatly affects the quality of life, and/or a person is in constant fear, preoccupied, convinced that he is very ill, which affects his daily routines and enjoyment. When diagnosed with hypochondria, this means that a patient has been fully examined and found to be free from any physical illness. However, although someone does not have a bodily illness, this does not mean that he cannot have sensory experiences. Every emotion, pleasant and unpleasant, due to a physiological body reaction to emotion, which actually prepares the body for action, is felt in the body as a set of sensations and can be misunderstood as a symptom of an illness.

What is it caused by, how does it occur and what can affect its development in a favourable manner?

The so-called “emotional illiteracy” (alexitimia), which implies that a person does not recognize emotions, that he does not know what they serve for and thus he does not relate (normal) body reactions to (most often unpleasant) emotions, is the primary cause of the development of disorders. A person feels an emotion that he does not recognize (it is usually a very intense and unpleasant emotion), the body physiologically reacts with the preparation for action, which is reflected literally on the whole body – heart, breathing, blood pressure, sugar level, oxygen and carbon dioxide, muscle tone, functioning of internal organs, glands with external and internal secretion, brain, etc., and then a person, being not aware of the emotions he has felt, does not recognize the emotion, but only recognises the body reaction. Since the body reaction to intense emotions is also intense and the person is only aware of that emotion, other than of the psychological mechanism that resulted in the body reaction – he concludes that something unusual is happening in the body, something that is a sign of an illness. For example, heart palpitation, tightness and abdominal pain, headache, sweating, numbing of arms and legs, heavy breathing, etc. This condition includes the development of the so-called “hypochondriac mentalisation” in a person, and/or a system of beliefs that the body, organ or organ system will surely “let” him down.

The development of hypochondria is favourably influenced by the environment and education that do not deal with emotions, which is often for many reasons: generations deal with survival rather than with quality of life, while dealing with emotional life belongs to the domain of a comfortable life zone, not survival, which of course also entails not paying attention to emotions, either to all of them or just to some of them, and if we are not emotionally literate ourselves, we can hardly teach our children, pupils, students to be emotionally literate.

To what extent does the environment contribute to a person becoming preoccupied overnight with illnesses (media, newspapers, TV, movies, series…)?

These disorders rarely develop “overnight”, although there are cases when we can precisely identify the situation when it all started.

For example, the case of a patient whose hypochondria has been treated for several years and he has been examined almost every week for a body illness in a precisely defined, always identical part of the body, while psychotherapy identified the event when he had an intense unpleasant feeling for the first time and related his intense body reaction with this feeling, other than with an illness.

After this, when he thought back, he realized that the pains in that particular part of the body appeared ALWAYS when he felt the same emotion, which had been completely suppressed due to a certain context and circumstances. More repetitions of the model “emotion – not recognizing – a body reaction – interpretation as a symptom” is usually needed so that a person could conclude that he is certainly ill.

It often happens that when someone around the person gets sick or dies of some severe illness, and especially if the deceased person was close and dear to him, the person begins to have certain symptoms that may point to the same or similar severe illness. Especially if the deceased person was a cousin, the person is afraid of the “genetic resemblance” and of becoming ill.

Due to the overflow of unpleasant emotions (sorrow, fear, anger), which a person does not recognize as such and feels them in his body, which leads to the conclusion that something with the body is wrong, the person concludes that something terrible happens with him and that and he got sick.

Various traumatic events, such as the survival of one’s own severe illness or accident and various other traumatic events may also trigger this pathological cycle of the development of hypochondria.

The phenomenon of medical students who, while learning about a certain disease during their studies, start to “recognize” symptoms of the disease one by one, until finally they realize that they are not ill, but that they were only “immersed” in their studies about the disease, is also known.

Certain influence can be made by media effects to young people who do not yet have enough life experience, especially if they deal with a disease with sensationalism and in a very scary way.

What are the most frequent illnesses that persons suffering from hypochondria are afraid of?

Nowadays people are most often afraid of cancer, although they are also afraid of some other usually severe and hard-to-cure or incurable illnesses. Today they are often afraid of AIDS, which is most often associated with the feeling of guilt due to some sexual behaviour that a person considers inadequate.

People are also afraid of “bird” and “swine flu”, SARS, Ebola and similar severe infectious diseases.

Fears of diseases that were incurable at the time, such as tuberculosis, plague, cholera, etc., were more often present in the past.

Are the symptoms they feel and describe invented or realistic (heart pounding, dizziness, hand tremor…)?

Patients feel very realistic symptoms in the form of pains in various parts of the body – stomach ache, headache, chest pain, heavy breathing, heart palpitations, dizziness, sweating, trembling, they have an impression that they have temperature, weakness, fatigue, they have an impression that they have felt some lumps on various parts of the body, etc.

Therefore, they often undergo various laboratory tests, X-ray examinations, ultrasound examinations, CT scanning, magnetic resonance imaging, ergometry, spirometry, various “scopies” (bronchoscopy, colonoscopy, etc.) …

If doctors do not want to see and examine them, convincing them that a week ago they underwent an examination and that everything was fine and that they should not repeat it, they often get angry with doctors, because they feel doctors have no understanding and that they really feel physical symptoms and it must be a sign of a disease.

And, if they financially can afford it, they will change a doctor and the medical facility and undergo examinations from the beginning – and so on indefinitely.

At what age does hypochondria usually occur?

Most commonly it occurs during the period from late twenties to the fifties, although there are cases when it occurs in teens, as well as in mature age and in the old age.

What kind of people does it usually occur in (education, interests, physical and mental condition…)?

Hypochondria “does not choose” its victims. This means that persons susceptible to the development of this disorder cannot be profiled by education, interests and physical condition.

Generally speaking, persons who are emotionally illiterate or insufficiently literate are susceptible to hypochondria, and they interpret the emotional body reaction as a symptom of an illness, rather than as a normal physiological reaction of the body to emotion.

Therefore, the more we are in touch with our emotions and the more we know why we feel the way we feel, and which thoughts, situations or interpretation of the situations this emotion is connected with, the more we know what emotion we exactly feel, what it serves for, how to adequately demonstrate it and use it for such an action that will best contribute to adapting to the current life conditions, the less we will be susceptible to this and all other disorders related to somatization.

Somatization is a tendency not to recognize mental conflicts as such, but to manifest them in the form of physical disorders.

What are the signs indicating hypochondria and what should be done when it is recognized in someone? (Should an expert be consulted to obtain advice what to do next, where to go, who should a person talk to and what is your advice in this regard)?

When there is a persistent belief that a person suffers from a physical illness, regardless of having undergone numerous examinations that have not confirmed the existence of such illness, and of course, when a person does not believe physicians who claim non-existence of the illness, the person suffers from being preoccupied with the illness to the extent that various aspects of his daily routines are affected.

If these symptoms last six months or longer, a person can be diagnosed with hypochondria.

In this case, it is best to talk to a person and point out to him that all those difficulties may not come from a physical illness, but that there is a psychological conflict that he does not recognize and that it would be good to consult a psychotherapist, psychologist or psychiatrist.

In most cases, a person, if not sufficiently informed, will experience this as “calling out” that he is “psychotic” and resist such an approach.

But you may help him by informing him that there is a mechanism for emotion suppressing and somatization, that alexitimia exists and that as part of the treatment most of the psychotherapeutic schools work on correcting distorted beliefs and on developing emotional literacy at the same time, and in this way symptoms control, i.e. body reaction to emotions is achieved. During such treatments, triggers may often be identified, i.e., why the disorder occurred and what mental conflict is in the background.

Once this is clarified, a person can approach conflict resolution and learn how to resolve conflicts in the future rather than somatise it, after which the person has been cured.

How is hypochondria treated, how long does the treatment last, and can it be successfully or only partially cured?

There is no “spontaneous” healing – and/or, it is possible that a person himself stops to have fears, if he is aware of his distorted beliefs, the psychological conflict and the circumstances under which the disorder has occurred.

But in quite a number of cases, psychotherapy is needed, which will help the person to clarify this problem faster.

Sometimes medication is required – anxiolytics (benzodiazepines) and drugs that act in an anxiolytic manner and which are better in the long run – antidepressants, which have a good anxiolytic effect almost without exception.

What happens when hypochondria is not treated and what further problems can it result in?

If a person does not get into the nature of his or her own problems, it can greatly damage the quality of life, and in some cases, the person blames himself for, which can result in the secondary depression.

Are there persons who pretend to be hypochondriac, who are hiding behind this diagnosis and how should they be distinguished from those truly affected by hypochondria?

Persons who pretend to be hypochondriac are rare as hypochondria is not such a disorder that can be used to get a specific benefit out of it – as for example, if you successfully act out some serious disorders to get some material gain.

Someone would hardly accept to undergo all examinations that hypochondriacs undergo and who will repeatedly undergo unpleasant and unnecessary examinations week in, week out, to be calm for a certain period of time.

Can hypochondria be acted and why would someone do it?

Any disorder can be acted, but there is a clinical experience, as well as tests that can distinguish between true and “acted” disorders in most cases.

A person who acts the role of a hypochondriac would soon realize that the benefit is very short-lived – i.e. the concern of the persons he is close to will soon turn into preaching and/or ignoring, as this unfortunately also happens to people who really suffer from hypochondria because they are not only a burden for themselves but also for their environment, and people close to them often find it very difficult as they do not know how to behave with the patient – they have usually tried with having care, understanding, preaching, anger, ignoring, pleading, threatening etc., and the patient still has the same problems he has had before.

Do real hypochondriacs constantly visit doctors and seek help or not, and what does it depend on?

Real hypochondriacs constantly seek the help of a doctor, they constantly ask for referrals for new examinations, they are afraid that doctors have missed something, that they have not paid enough attention to some symptom or finding, they ask doctors to calm them down, but they also do not believe them.

They usually respond to a warm approach and understanding, but empathy is not enough to solve the problem.

Systematic problem solving is required, starting with work with symptoms, relating them with the body, emotions, thoughts and conflicts or trauma to solve the problem.

What percentage of the population can be classified as hypochondriacs and are there some subcategories of this condition, and how many of such people are there in our country (if any such information is available)?

There is no accurate data on how much this disorder is common in our country, it is estimated that this disorder is present in 1% to as much as 7% of the population. These higher percentages refer to the number of patients who seek advice in primary healthcare facilities, i.e., from general practitioners.

Less than half of these people gets to a psychiatrist, psychologist and psychotherapist, as some cases are treated in general practice, which is good if such treatment is successful.

The interview is available at the website of Večernje novosti.

[1] He/she may be used alternatively

Fears

Interview of MD Aleksandra Bubera, psychiatrist and psychotherapist, with journalist Ranko Pivljanin, in Blic Magazine weekly journal, issue 04.08.2013.

What fears are citizens of Serbia faced with?

Citizens of Serbia do not differ in what they fear from people living in similar conditions and similar societies. All the feelings, even fears, depend on what the person finds important. And most of us find the existence, health, family, relationships with other people important. Naturally, every person has some additional, specific things that he finds very important. When we estimate that one of these values is endangered, we will have an unpleasant feeling.

Whether we feel fear, anger or sadness will depend on our estimation whether we feel “stronger” than the situation (anger) or weaker than it, whether we can escape (fear) or whether we feel that the situation cannot be changed and we cannot escape it (passivity, sadness).

Therefore, when we estimate that we are “weaker” than the situation, but that we can escape, we feel fear. The only problem is that when we are afraid of the things we are only thinking about, but they do not happen in reality and we are not even aware of them, it’s like fighting an “invisible” enemy and we cannot even escape them. That’s why it’s very embarrassing and people feel to be at an impasse.

What are the examples from your practice? What do people say, what kind of problems do they have when it comes to fears?

People who have panic attacks most often ask for help, and these attacks are often accompanied by agoraphobia.

Panic is a fear that we will die very soon, often in a few seconds or minutes, because we are directly endangered by something and we try to find salvation and help as quickly as possible. Most often people believe they will get a heart attack or a stroke or that they will go mad. That’s why they contact emergency medical services most often because they believe they will die if they do not get help on time.

After several attacks and usually after a thorough examination by a cardiologist and a neurologist, numerous reassurances that the person is physically all right and recommendations to visit a psychiatrist, psychologist or psychotherapist, he[1] realizes that he is physically healthy, but since the symptoms continue and are very unpleasant, the person then believes that he has started to lose common sense.

The symptoms include heart palpitations, occasional arrhythmia, feeling that he cannot breathe and that he will suffocate, paleness or reddening, sweating, tingling, trembling and feeling of weakness in his hands and feet, feeling that he will fall and lose consciousness, sometimes that he will urinate or need to defecate, lose control and do something strange…

Agoraphobia is a fear of open space, but also of a place crowded with people or of a place which a person estimates that he cannot quickly and easily exit from. This happens because a person associates panic attacks with the places where they occur and these places are often the above mentioned places. A person then begins to avoid them, believing that these places and situations are the cause of panic attacks, not knowing that the cause is something completely different.

In fact, a person is anxious because of a situation, a problem, etc., which he does not recognize. Any feeling, whether pleasant or unpleasant is accompanied by a physical reaction that prepares us to better adapt ourselves to the situation. However, since we are usually anxious and worried about things that do not happen now and in front of us, but because of some things we think about or remember or we think that they might happen, we are often unaware of this process and therefore we do not know why our body reacts violently.

For example, if you feel heart palpitations or that you cannot breathe and that your legs are trembling because you just avoided being hit by a car at a zebra crossing, your body reaction would not be surprising, because it’s clear that it is normal in the given situation. However, if you are on vacation and sitting on your balcony drinking a morning coffee completely relaxed and your heart “suddenly” starts to pound, you cannot breathe and you feel dizzy – you will think that something’s wrong with you physically. In fact, you are not aware that while you were drinking your coffee, you were thinking about how you must return to work and that was not certain that you would keep your job because your employer had announced the layoff for the purpose of rationalization and cost reduction. It is logical that you are frightened and worried when you think about it and our body reacts in the same way when we are thinking about the circumstances we are afraid of, like when such circumstances actually happen and in that moment.

A comparatively large number of people are not sufficiently “emotionally literate”, i.e., they do not recognize well enough their feelings that are connected with reality, with what we are thinking about, and thus also they do not relate physical reactions to their feelings. Therefore in fact, they only register the reaction of the body other than the process of thinking and feeling that preceded it, which happens very quickly, often in milliseconds. And then they interpret this body reaction as a sign of disorder or illness – because of which they are even more scared, which further enhances the body reaction and creates a “vicious circle” or “spiral of fear”, when a person is more and more afraid, until it finally results in a panic attack, which is one of the most unpleasant conditions that we can experience.

Fortunately, although it is very unpleasant, the panic attack is completely harmless.

The problems that they actually start with can be very different, but it is always related to whether a person will be able to deal with them, whether he will be able to put up with them, and/or control them.

The most common problems are related to a bad image of oneself, relationships with other persons or failure to establish them – regardless of whether these persons are parents, children, partners, friends; the problems related to important life events – schools, studies, marriage, pregnancy, divorce, relocation, etc.; the problems related to work – whether it’s unemployment or fear that a person will not have satisfactory performance at his work, occasional fear of illness, etc.

There is a saying – “so many people, so many fears”. After learning how to control panic attacks, it is important that a person should find out exactly why he has certain fear at that particular moment of his life and when it is identified, then we should work with the person on the very cause of fear, other than on the symptoms that cause physical reaction to fear. Then it is causal rather than symptomatic therapy.

Which fear is bigger – fear of illness or fear of losing a job?

It would be logical to have a bigger fear of illness, especially of those that are life threatening, because the more important the value is threatened, the fear is more intense, but not for all people.

Unfortunately, there are people whose job is more important than health, because they feel that they are only worth if their performance is good. But also because the business is related to survival – i.e., “if I lose my job, I will not be able to support myself and my family” – this fear is usually quite strong, especially in a situation when jobs are few and hard to find, as in the situation of the “double crisis” in Serbia – chronic lack of money, unemployment, insecurity, collapsing and fast changes in the value system during the last few decades, plus the global economic crisis.

Do we have irrational fears and what are they?

Yes, we have. Irrational is any fear that is not based in reality and therefore is not adequate, which means that we are more or less afraid than we should be when it comes to the given situation.

Fear is reasonable when there is really something that threatens us and when our reaction is to escape to save our life or health.

There are several types of rational fears:

When we say fear, we mean the fear of something concrete in the outside world that threatens us – for example, the fear of a big aggressive dog running towards us and barking at us.
Apprehension or worry, and/or fear of something threatening that could really happen in the near or distant future.
Anxiety, which I will explain below, because it is most common.
Panic, when a person estimates that the situation is life-threatening, that he does not have enough time and tries to find a quick solution by applying the method “trial-error-trial”, which often seems completely disorganized and that is why a person is said “to have panicked” and moving “like a headless chicken”.
Stage-fright, fear of whether we will be seen by others as we would like to be seen, and/or whether our performance will meet the criteria of the one who evaluates it (for example, at auditions, exams, etc.). Stage-fright can be motivating, when it helps people to do their best and blocking, when a person actually blocks and fails to accomplish what is needed at that point, and such stage-fright is inadequate.

All the fears listed so far are the so-called “sympathetic fears”. The term “sympathetic” refers to the regulation by the so-called sympathetic autonomous nervous system in the body and practically means that adrenaline participates in all these fears, which brings a person’s body to a higher level of functioning and prepares it for active defense and protection. The autonomous nervous system is called “autonomous” because it is not actually under the control of our consciousness, but it autonomously regulates body functions that are important for maintaining life, such as breathing and cardiac action, for example. However, with conscious actions we can influence autonomous regulation to a certain extent – for example, breathing techniques, progressive relaxation, etc., which in turn create the conditions for the regulation systems in our body to obtain information that nothing threatening happens and that they can resume the ordinary regulation system, which is in effect when everything is all right.

There is another type of fear, called “horror”, when a person estimates that his end has come, that he is dying and that there is no salvation – this is a parasympathetic fear when the body applies protective mechanisms like “freezing”, such as when a person urinates, defecates or faints – which is the inherited defense mechanism.

For example, when a predator animal reaches an animal that is its prey, the animal prey can sometimes avoid death by stiffening and dropping like being dead, as some predators do not notice animals that do not move, while some predators do not eat dead, but only hunted animals. Similarly, people sometimes think that their end has come, they react in a similar manner, and/or lose consciousness, because it is an old inherited response (and in some situations such reaction can save one’s life, of which there are records of survivors from shooting, for example – a person fainted although he was not shot and came to consciousness after everybody moved away and he survived).

In clinical practice, anxiety is the most common type of fear. Anxiety is a fear that we will not be able or that we will not be capable enough of dealing with a certain situation or more such situations.

If in reality a person is not capable enough of dealing with a situation or problem and this is required from him or for some reason he must (and the word “must” is used only when something is really compulsory, and/or when it refers to basic living needs related to survival), then the person will be reasonably anxious. In most cases, however, a person either underestimates his ability, or overestimates the weight and importance of the situation and then he is unreasonably anxious.

Unreasonable/irrational fears are the ones that people most often ask help for.

There are several most common groups of irrational fears, and they are classified based on a person’s (irrational) estimate of what threatens him:

their own incapacity or a situation for which they estimate that it exceeds their capability (anxiety);
fear that they will be threatened by something external, by some object, animal etc. (phobias);
the fear that their own body will “betray” them and the belief that they are suffering from some usually severe and non-curable illness (hypochondria);
fear that they are “attacked” by some impulses and thoughts of being urged to do something rude or aggressive and that they will lose control over them and do it (obsessive fears);
Fear that they will be endangered or that they are endangered by other people (paranoia and paranoid fears).

Agoraphobia, anxiety, phobias, hypochondria, irrational fears, obsessive fears, panic attack, panic, paranoia and paranoid fears, fears, stage-fright, horror, apprehension, worry

[1] He/she may be used alternatively