Is it possible to drive yourself crazy?

Fear of illness: no trivial matter

Hypochondriac disorders cause considerable suffering and lead to increased consultation of medical institutions.

When celebrities like the entertainer Harald Schmidt profess to be “hypochondriac”, people smile about it. Because hypochondriacs are considered sensitive and hysterical, and they are said to drive themselves crazy for no reason. For those affected themselves, for their environment and the health system, “fear of illness”, as a moderately to moderately pronounced hypochondria has recently been called, is by no means funny, but a heavy burden.

Compulsive checking and panic attacks common

The hypochondriac disorder or fear of illness is a somatoform disorder. In contrast to the typical representatives of this form of disorder, the focus is not on suffering from physical complaints without an organic cause, but rather on the fear or conviction that physical complaints could be signs of a serious illness or that a serious illness is present, above all cancer. Fear of illness is also often associated with panic attacks and compulsive checking of the body for signs of illness. For these reasons, it is also placed between somatoform, anxiety, panic and obsessive-compulsive disorders.

The number of people affected can hardly be estimated because the disease is relatively rarely examined scientifically and because many people affected do not seek professional help out of shame. In addition, the disease is often not taken seriously - the number of unreported cases is therefore probably high. According to more recent representative studies, the full picture of hypochondria occurs extremely rarely, but subliminal syndromes can be observed more often. But even minor manifestations of the disease are clinically relevant, as they cause considerable suffering and lead to increased consultation of medical institutions. Men and women are affected about equally often. The disease can start at any age and will persist unless adequate treatment is given. Low level of education, old age, severe symptoms, long duration of illness and frequent use of the health system are associated with the disorder and its perpetuation.

The causes of fear of illness have not yet been well researched. It is assumed that a genetic disposition, the personality trait “neuroticism”, an insecure or negative attachment style and alexithymia play a role. In addition, a style of upbringing seems to contribute to the development in which parents pay close attention to physical symptoms in themselves and their children, react fearfully and overprotectively to them, and reward being sick, for example by sparing duties. Experiences with serious illnesses or injuries and other traumatic experiences in childhood and adolescence are also possible causes. Another central aspect seems to be the tendency to pay special attention to physical sensations, to experience them as intense, harmful and impairing and to regard them as abnormal.

Fear of illness is probably triggered by stress in everyday life and negative experiences with the health system. The latter result, for example, from misdiagnosis or failure to recognize an illness in the person concerned, in people from their immediate environment or in celebrities. If this also has serious consequences or leads to death, distrust and fears are increased.

Those affected quickly get into a vicious circle: It begins with the fact that they notice a physical process or a slight abnormality (for example redness, swelling, palpitations, perspiration, slight pulling) and perceive it as uncomfortable and interpret it as a possible sign of illness. They will then pay increased attention to that part of the body, which in turn increases the likelihood that they will notice something again. The sensations that occur are in turn misinterpreted in the sense that they are an indication of a serious illness. Observations and examinations continue to increase and include, among other things, weight checks, measurements as well as intense touching and feeling, which can lead to the sensations becoming even more unpleasant or to the fact that symptoms of the disease only arise or are intensified. For example, frequent palpation of the lymph nodes with strong pressure can lead to swelling of the tissue, which in turn is interpreted by the person concerned as a sign of lymph node cancer. The person concerned is confirmed by such processes, his behavior is reinforced and increasingly fears develop. To calm himself down, he seeks reassurance that he is not suffering from the disease he is dreading. If he finds out that he is not seriously ill, his anxiety will be reduced in the short term. This positive experience, in turn, reinforces his security-seeking behavior, and he shows it more and more often. Reinsurance is mostly obtained from doctors, but also from friends, relatives, acquaintances with a medical education and through the media, in particular through the Internet. Since the Internet is easily accessible and quickly supplies a wealth of information, it is becoming more and more common to search for and share information about diseases of all kinds with the help of this medium. However, it also harbors some dangers, because the large amount of unfiltered information can cause those affected to worry even more and to worsen the clinical picture (see box).

Television, especially doctor's series, has a similar effect. Various polls showed that after watching Doctor and Hospital series, viewers felt sicker and were more afraid of getting sick and being hospitalized. Frequent consultation of doctors also helps to increase fear of illness rather than calming it down. The above-mentioned ways of thinking and behaving also lead to a decrease in tolerance for physical discomfort as well as the ability to differentiate between harmless and threatening sensations and an increase in body-related awareness. In addition, a pronounced avoidance behavior can be observed. For example, those affected consult doctors, but also avoid them because they are ashamed and because they fear that they will not be taken seriously or that their self-diagnosis could be confirmed. They also avoid topics such as illness and death, avoid hospitals, illness reports on television, physical stress or discussions about illnesses and suppress dangers and risks. All factors together lead more and more into the disease.

Cognitive-behavioral psychotherapy is primarily used to treat anxiety about illness. Recently, experiments have been carried out with extensions, modifications and individual techniques of this form of psychotherapy as well as with other procedures, for example with attention-based cognitive-behavioral psychotherapy, problem-solving and stress management training, bibliotherapy and motivational conversation. There are also initial studies on the effectiveness of psychotropic drugs, especially SSRIs (fluoxetine, paroxetine). It can currently be assumed that cognitive behavioral therapy is an effective therapeutic method. No reliable statements can yet be made about the effectiveness of other procedures.

Treatment with cognitive behavioral therapy

Cognitive behavioral therapy for fear of illness has several goals. Among other things, it is intended to help the patient to find alternative explanations for his or her abnormal sensations, to change the probability of assumptions about the illness, to reduce behavior that seeks security and to improve his quality of life. The most important point, however, needs to be tackled right from the start: the motivation for therapy. "Most disease-anxious patients initially have an ambivalence as to whether psychotherapy is really the method of choice for the problem," says the clinical psychologist and psychotherapist Dr. Gaby Bleichhardt from the University of Marburg and her colleague Prof. Dr. Alexandra Martin from the University of Erlangen-Nuremberg. On the one hand, the patients suffer from their fears and feelings of shame due to frequent visits to the doctor, but on the other hand they also derive some advantages from the disease. You will receive a lot of attention and care, you are the focus, always have a topic of conversation, you can spare yourself and avoid annoying obligations and have a job.

Show normal body sensations

If the psychotherapist and patient can agree that the fear of illness should be better managed, then therapy can begin. An important, educational component of the therapy is to show the patient which bodily processes and sensations are completely normal, harmless and present in every person, such as heartbeat, perspiration or movements of the digestive system. In addition, it is conveyed which physical side effects, for example, stress and fear have, because these can be considered as alternative explanations for paresthesia. For support, for example, biofeedback and behavioral experiments can be used so that the patient can observe for himself how he physically reacts, for example, to several cups of coffee or to a sauna visit. The patient is then instructed to realistically weigh the likelihood of being seriously ill. Attempts are also made to reduce the aversiveness of body sensations and fears of illness, for example by further thinking and questioning fear-laden thoughts. This is followed by behavioral exercises in which the patient learns to largely forego various types of security-seeking behavior or at least to limit them in a targeted manner. Various techniques can be used for this, such as paradoxical intensification of behavior, keeping protocols, reducing the number of visits to the doctor to once a quarter, reducing reinsurance for relatives and via the media, and various exposures. Since the comorbidity with depression, anxiety, panic, obsessive-compulsive and somatization disorders is high, the treatment should be tailored accordingly.

Despite all efforts, relapses cannot be ruled out. It is also to be expected that fears and fears will suddenly revive, for example when new physical symptoms set in or due to reports of illness in the patient's social environment or in the media. According to the current state of knowledge, a complete remission of the disease should not be assumed. Therapy can therefore be ended when the patient is at least able to cope better with fears and complaints.

The treatment should be supported by the involvement of treating physicians and relatives. With the help of the doctors, it can be clarified whether an adequate medical diagnosis has been carried out. It is also a matter of working with them to reduce patient reinsurance and repeated diagnostic measures, and to seek joint treatment. The relatives can help to reduce security-seeking behavior, excessive care, protection and thus the secondary gain from illness for the patient and instead to strengthen his self-efficacy. A solution-oriented discussion should take place with the relatives about their burdens, for example about obligations and lifestyle restrictions resulting from the patient's illness.

No one hundred percent security

The question that remains is whether the diagnosis of “fear of illness” and adequate psychotherapeutic treatment do not increase the risk of overlooking serious illnesses. According to Bleichhardt and Martin, there is always a residual risk, but it is low, since most of those affected have been very well examined in terms of organ medicine; in addition, the likelihood of serious illnesses is relatively low. Nevertheless, the topic should be addressed in therapy. The patient should be taught that there is no such thing as one hundred percent security and that all people - including psychotherapists - have to endure this fact.

Dr. phil. Marion Sonnenmoser

Contact: Dr. Gaby Bleichhardt, Department of Psychology, University of Marburg, Gutenbergstrasse 18, 35037 Marburg, email: [email protected]

Cyberchondria

The term “cyberchondria” is a combination of “cyber” and “hypochondria” and refers to a condition or the risk that fear of illness will be triggered or intensified by information from the Internet. The Internet is problematic as a source of information because it offers a confusing variety of information about diseases. There are well-founded sources as well as dubious and speculative ones. In addition, there are personal illness reports, opinions, comments and messages that are exchanged via chats, blogs, newsgroups, health portals, e-mail and other forms of media communication. The information on the Internet is useful, on the one hand, because it is used for clarification and education and enables laypeople to roughly classify their symptoms and to seek appropriate treatment. On the other hand, their effect on people with existing fear of illness or with an increased vulnerability to fear of illness is questionable. Because those affected use the Internet for reinsurance, but without always being able to objectively assess the sources, the intentions and the truthfulness of the information. This can lead to those affected becoming insecure and confused and experiencing even more fears, worries and panic attacks than already; the illness is triggered or exacerbated by internet use. In addition, there is a potential risk of addiction resulting from frequent and long hours of use of the Internet. ms

Contact points

  • University of Mainz, Outpatient Clinic for Psychotherapy, treatment focus on hypochondria and anxiety, Wallstrasse 3, 55122 Mainz, Dipl.-Psych. Maria Gropalis, email: [email protected], Internet: www.psychotherapie-mainz.de/krankheitsangst.html
  • Central Institute for Mental Health Mannheim, Outpatient Clinic for Fear of Illness and Hypochondria, J 5, 68159 Mannheim, E-Mail: [email protected], Internet: www.zi-mannheim.de/ambulanzhypochondrie.html
  • University of Frankfurt am Main,
    Institute for Psychology, Behavioral Therapy Outpatient Clinic, Varrentrappstrasse 40–42, 60486 Frankfurt am Main, email: vt-ambulanz @ psych. uni-frankfurt. de, Internet: http://user.uni-frankfurt.de
Bleichhardt G, Martin A: Hypochondria and fear of illness. Göttingen: Hogrefe 2010.
Hart J, Björgvinsson T: Health anxiety and hypochondriasis. Bulletin of the Menninger Clinic 2010; 74 (2): 122-40. MEDLINE
Hartman TO et al. Medically unexplained symptoms, somatization disorder and hypochondriasis. Journal of Psychosomatic Research 2009; 66 (5): 363-77. MEDLINE