(2 of 2)
But so did many in the placebo group, which led Fallon to take an even closer look. His conclusion: hypochondriacs may actually represent three different groups whose problems look superficially similar. Those in the first really do have a variant of OCD. Those in the second have a problem more like depression, often triggered by something that makes them feel guilty--an affair, perhaps--or by a loss, like the death of a close relative. And the third group consists of people who somatize--which means they focus an inordinate amount of attention on their bodies. A pain that most people wouldn't even notice feels like a punch in the nose to those in this group.
In all cases, though, the descent into hypochondria takes the form of a self-reinforcing spiral. You notice a symptom, decide it's unusual and begin exploring for more. Since we all have minor twinges from time to time, when you go looking for more, you find them. "You build a case in your own mind that something's wrong," says Barsky. Even if a doctor assures you it isn't true, you have the symptoms to prove to yourself that the doctor is mistaken.
The key to treatment is disrupting the cycle. That can be tough, however, since doctors rarely tell hypochondriacs the truth about their disorder. When Fallon tried to recruit study subjects through their doctors, he got nowhere; physicians evidently didn't want to embarrass or anger their patients by suggesting they might be hypochondriacs.
To avoid stigmatizing their patients, Fallon and Barsky avoid the H word altogether. Fallon calls it "heightened illness concern," and Barsky doesn't use any label at all. "The first thing I do," says Barsky, "is acknowledge the patient's symptoms and say we have no good explanation for them." Then he suggests that the patient do some psychological work, which he tells them is often helpful in such situations.
His preferred technique is cognitive behavioral therapy, in which patients are trained to force their attention away from the symptoms. "Just as focusing on a pain makes it seem more significant, ignoring it can make it seem much less," says Barsky. Patients are also instructed to counter panicky thoughts with self-reassurance, reminding themselves, for example, that stomach pain almost never means stomach cancer. Both cognitive therapy and medication seem to work, and at this point it's hard to say whether one is better than the other. "Nobody's done a comparative trial," says Fallon, "although Barsky and I are working on that."
Both men agree that their primary-care colleagues aren't very well attuned to the problem. "Things are improving," says Barsky, "but there's not a heck of a lot of education about hypochondria in medical school. We teach doctors that their job is to find disease and weed out those who are physically well. They have no time for hypochondriacs." It needn't take as much time as they think, though. "It's not hard to identify a hypochondriac," says Fallon, "if you have the right antenna out." And once a hypochondriac is identified and properly treated, no one is happier than his or her doctor.