The hypochondriac is a virtuoso of interpretive flourishes, one whose impulse to assign dark meaning to the flotsam and jetsam of bodily sensation is unstoppable. No back pain, stomach discomfort, or patch of dry skin is beneath suspicion, which always inclines toward extravagant causes. Among the most characteristic, and noxious, features of hypochondriacal thinking is its catastrophism. “Hypochondriacs go for diseases that are most dramatic and acute,” notes Brian Fallon, associate professor of clinical psychiatry at Columbia University Medical Center. “They’re drawn to insidious diseases—cancer, MS, heart disease, lupus—that can’t necessarily be identified with 100 percent accuracy by the medical profession, and that affect multiple systems, and have a large variety of symptoms that come and go. In that way, hypochondriacs can always find something to support their fears.” Theirs is a kind of perverse grandiosity, preying on the impossibility of proving a negative. Who can say for sure that one’s body is not being infiltrated by disease? The hypochondriac wades into a spiral of dread, as Barsky says, “because the headache that you think is due to a brain tumor feels a lot worse than the one you think is due to eye strain.” Predictably, hypochondriacs are remarkably vulnerable to bleak suggestion. Hearing about a new threat—SARS, bird flu—can induce panic; glancing at a medical show on television can lead to disease fixation; learning of the illness of a friend or acquaintance can generate a debilitating empathy. (Hypochondriacs often practice elaborate rituals of avoidance—refusing, for instance, to visit sick family members—in an effort to control their fears.) Michael McKee, a Columbia University Medical Center psychologist who has specialized in the treatment of anxiety disorders, points out that there is no safe middle ground for hypochondriacs between perfect health and deadly disease. “The hypochondriac has a thought, and it bursts into flame,” he says.
Just as some people have sharper vision than others, researchers have found that hypochondriacs may be prodigiously attuned to their bodies.
Unwilling to surrender themselves to fate, unable to accept the imperfect authority of medicine, hypochondriacs, Fallon remarks, “suffer from the pathology of doubt and are plagued with uncertainty.” Most can bear their physical symptoms; what they find intolerable is being denied an explanation for what they are feeling. They latch onto a theory about what, for instance, is causing their chest pain—heart failure, anyone?—and then they scan themselves for further signs of the disease. “It’s a disorder of extreme internal vigilance,” says Fallon. “They think they’re facing something that will kill them.” When friends and physicians fail to support their fears, hypochondriacs turn away, feeling resentful and abandoned. They seek comfort, instead, in amateur medical sleuthing. Not long ago, they could be found primarily in the health sections of bookstores and public libraries, furtively poring through reference books. More recently they have taken to wandering the infinitudes of the Internet. “Going online can be a nightmare for the hypochondriac,” Fallon says. “They can spend hours and hours going from site to site. It doesn’t help them feel any better, it often makes them feel worse, and it can totally wreck their home and work life.” Fallon and others call the behavior “cyberchondria.”
Although its features had long been known, it wasn’t until 1980 that the American Psychiatric Association took the first steps to recognizing “hypochondriasis” as a distinct disorder, including it in that year’s edition of the canonical Diagnostic and Statistical Manual of Mental Disorders (DSM) and being careful to distinguish the transient hypochondria that most people experience from time to time—at least 30 percent of patients’ visits to doctors are believed to have no identifiable medical cause—from the hard-core version of the malady. The threshold is high. Not only must the clinical hypochondriac be in the throes of life-altering distress and impairment as a result of an unsupported preoccupation with disease, but the preoccupation has to last at least six months. It takes a lot of stamina to sustain the lonely belief that one is dying for that long. According to Barsky, though, the crucial difference between a casual worrier and a hypochondriac is that the hypochondriac’s imagination of disaster is impervious to rebuttal. “These people are not reassurable,” Barsky says. “For instance: If you notice a mole on your hand, and it seems to have changed, maybe you’ll worry that you have a melanoma. That’s normal. But when you go to get it checked, and your physician tells you it’s not serious, you say, ‘Thank God, that’s what I wanted to hear.’ The hypochondriac responds in the opposite way. Their symptom gets worse.” Indeed, many of the most incorrigible hypochondriacs don’t bother visiting physicians at all. Inconsolable, they keep to themselves, paralyzed by fear that a doctor can do nothing for them but confirm their nightmare.
As the workings of hypochondriacal thought have begun, in recent years, to receive serious attention, much of the research that has emerged takes the form of intriguing hints—suggestions that the brain of the hypochondriac, like that of the person with obsessive-compulsive disorder, becomes an enemy of the restful mind. Barsky and colleagues found that hypochondriacs report higher than average sensitivity to bodily sensations—heat, cold, hunger, noise—and admit to finding minor irritants like insect bites and splinters unusually upsetting. Just as some people have sharper vision than others, Barsky proposes, hypochondriacs may be prodigiously attuned to their bodies. Their problem is that they don’t know how to tune out the bodily “background noise” of daily aches and pains that others barely notice. For the hypochondriac, according to Barsky, “the background static becomes intolerable.” Naturally, what you notice has everything to do with how you feel. James Pennebaker, a psychologist at the University of Virginia, tested two groups of college students on treadmills. One group of the subjects listened to music and street sounds over headphones; another was made to listen to the sounds of their own breathing. There was no difference between the two groups on physiological measures of performance, but those who focused on the sounds of their own bodies reported headaches, racing heart beats, and higher levels of discomfort. The implication, then, is that hypochondria is the product of distorted processes of attention and understanding.