‘This should not be ridiculed’: the link between hypochondria and early death
In an English cemetery, the gravestone of Irish comedian Spike Milligan has a chastening message for those who knew him: “I told you I was sick.”
We can all identify with Milligan’s concerns. Who hasn’t explored supposed symptoms in panic, fearing the worst? His joke speaks to our fear that legitimate health issues will be dismissed as nothing to worry about – “Oh, it’s just hypochondria.”
But there’s a difference between a single appointment with Dr. Google and long-term, serious health concerns. This persistent fear of an undiagnosed illness can lead to endless doctor visits, or the opposite: avoiding medical care altogether. What if we don’t take hypochondria itself seriously enough?
That is the conclusion of a recent Swedish study which showed that people with what is now called illness anxiety disorder can die earlier than others. It’s a disturbing finding that makes the disorder sound like a self-fulfilling prophecy. As one concerned observer put it, “It’s not enough to just worry – now you have to worry about your worries.”
But that doesn’t mean people with the disorder should despair. The research has an important and ultimately hopeful message. “This is a serious mental disorder. This is not unusual or something that should be ridiculed,” says the lead author, David Mataix-Cols of Sweden’s Karolinska Institute. The deaths recorded in the study were largely preventable, the researchers noted. Their findings underscore the need for diagnosis and treatment – and the good news is that the treatment is very effective.
The study, which appeared in JAMA Psychiatry, examined data from approximately 45,000 people, comparing mortality rates among those with diagnosed hypochondria (approximately 4,000 people) with those without hypochondria (approximately 41,000 demographically similar individuals). They found that people with the disorder were 84% more likely to die during the study period, and they died an average of five years younger than those without the diagnosis, at 70 versus 75 years old.
It may all sound counter-intuitive: the people most concerned about their health would take good care of it, right? But “as with all anxiety disorders and chronic stress over many years, decades, we know that this is not good for your health,” says Mataix-Cols, although he emphasizes that the study does not examine the reasons behind the disparity.
Subjects with the disorder were more likely to die from both natural and unnatural causes, with most unnatural deaths resulting from suicide. This may seem especially surprising in people who are seen as having a great fear of death. But people with illness anxiety disorder can experience “a lot of suffering and hopelessness,” Mataix-Cols says, and feel like others don’t understand them. As for natural causes, the researchers noted that anxiety is associated with cardiovascular disease, and Mataix-Cols says some subjects with the condition also struggled with chronic stress, as well as drugs and alcohol. (He also points out that while the inequality seems stark, the absolute risk of death among people with health anxiety remained low.)
And then there’s the lack of access to treatment. The “biggest surprise” for Mataix-Cols was how few people had actually been diagnosed with the disorder, compared to the number known to be living with it. Research has shown that about 3-5% of people suffer from “what we call pathological health anxiety,” says Mataix-Cols. “According to these figures, we should have found 100,000 to 200,000 people (in Sweden) with this diagnosis over a period of twenty years. And we only found 4,000,” meaning the condition is “severely underdiagnosed” and therefore undertreated.
‘We have to take stress and anxiety very seriously’
Diagnosing an illness anxiety disorder requires sensitivity, especially in a world where patients’ actual physical ailments – e.g pain of women – can be wrongly rejected. Ideally, doctors don’t tell patients to take comfort in the idea that “it’s all in your head.” Instead, they recognize mental health challenges as part of the bigger picture.
When doctors see that a patient is seeking excessive care, they may decide to refer the patient to a therapist.
Dr. Jessie Borelli, a clinical psychologist and professor at the University of California, Irvine, says she gets these referrals “often.” She has heard some “horror stories” about that transfer, but she has also seen doctors handle it carefully. “I think the best way they do this is to talk about the stress that comes with health problems or health anxiety – how much stress and problems that causes, and the need for extra support to deal with that,” says Borelli. “People are usually receptive to that conversation.”
Fortunately, experts say treatments for the condition are very effective, especially cognitive behavioral therapy. For example, therapists and patients can work together to identify behaviors rooted in anxiety and work through them through gradual exposure to the situations that worry them.
If a patient wants to undergo additional medical screening, says Dr. Nora Brier says, “we’ll talk about it together” to determine if it’s necessary or a fear-based decision. If the latter, “the exposure would be not making the appointment and not Googling or double-checking, and tolerating the anxiety of just sitting at home and thinking ‘maybe I should have gone to that appointment go,’” says Brier, a psychologist and assistant professor of clinical psychiatry at the University of Pennsylvania. Medications, including the antidepressants known as SSRIs, can also be helpful.
Patients with fear of illness can continue to seek physical care, but this can also be done in combination with therapy. And not everyone comes to therapy through his or her doctor. For example, patients may refer themselves for therapy if they are too afraid of a diagnosis to see a doctor and recognize that they need help overcoming that fear.
It all goes to the heart of fear in a broader sense: the struggle to live with not knowing. “Hypochondria in some ways challenges medicine’s need for certainty,” said Dr. Catherine Belling, associate professor of medical education at Northwestern University. The best doctor in the world cannot be 100% sure that there is nothing physically wrong with a patient. Not only the patient must tolerate this, but also the doctor.
It takes a doctor to say, “Well, I don’t know. We have to wait and see, but in the meantime, we can do something about your anxiety,” Belling added. In fact, doctors themselves are familiar with these concerns: Medical students are known for suddenly realizing in their first years that they have every condition there is.
One big threat to people with health anxiety right now: spending hours on the internet. One of the key elements of illness anxiety disorder is seeking reassurance, Mataix-Cols says, and with Google, we’re all self-diagnosing medical students. There is even a term for it: cyberchondria.
The pandemic also brought health concerns to the forefront (although it’s too early to say with certainty that it has increased the prevalence of the condition itself, Brier says). a 2021 study warned of a growing risk of excessive health anxiety amid Covid, with a very real disease on our minds all the time, and a Iranian study published last year pointed to greater health fears among people whose relatives had had Covid.
Mataix-Cols hopes that his research, which has attracted international press, will get more patients into treatment by improving diagnosis and communication between doctors and psychotherapists.
Borelli, who was not involved in the Swedish study, also sees some hope in it. “In the case of something like illness anxiety, where it’s quite clear that there is no underlying serious illness, it’s also the case that being very concerned about your health can actually lead to significant health problems, as this study shows,” she says. .
“We know we have to take stress and anxiety very seriously. And the way we take it seriously is to shine a light on it.”