The hypochondriac's epitaph: "I told you I was sick."

A colleague sent a paper published last week [1] in JAMA Psychiatry, one of the Big Five psychiatric journals. It was a long-term follow-up study of people given a diagnosis of what is now known as "Illness Anxiety Disorder," formerly as hypochondriasis as well as dozens of other names. In DSM5, it gets a couple of pages, not under the chapter for Anxiety (p189-233) but under Somatic Symptom Disorder, p315-8. For a condition that is said to account for about 3% of out-patient consultations and emergency centre visits, that's not much. In fact, it says more about psychiatry than it does about the patients, but we need to be clear what we're talking about.

Everybody has a relative or knows someone who is constantly worrying about their health, yet as far as anybody can tell, there's nothing wrong with them. They go for lots of appointments, have heaps of tests, Xrays and scans, and nothing is ever found. But that doesn't reassure them: for a while after the latest normal scan, they may be quiet, then it starts again: "I'm sure there's something wrong, I don't feel right. I don't think they did the right tests at the hospital, I think I need to see someone else..."

To the physicians of ancient Greece, it was hypochondriasis, referring to the soft area under the ribs where most of the worries seemed to focus. It was closely related to hysteria, a condition affecting women in which the womb becomes detached and wanders around inside the body, biting different organs. That is, hysteria for women, hypochondriasis for men; same symptoms, different "disease." These days, most of the worries are about the heart or nervous system but the priniciple is the same: the patients are preoccupied with the notion that they have a significant illness that nobody can diagnose - or even take seriously. Poor people who worry about their health get batted from one hospital department to another, finally ending up in psychiatry because nobody else wants them. The rich go in and out of expensive private hospitals for tests that show nothing and operations that change nothing, because nobody will tell them the truth in case they take their wallets elsewhere.

The study, which came from Sweden, was designed to see what happens to people who get this diagnosis. It was based on their superb national health statistics, comparing just over 4,000 people who were given the diagnosis between 1997and 2020, with ten times as many matched controls who weren't diagnosed. The authors had access to the death certificates and looked at all causes of death. Over the study period, the death rate for people diagnosed with hypochondriasis was over 50% higher than for the control group. This was true for all causes of death (cardiovascular, respiratory, etc) except malignancy, including a suicide rate four times higher than the rest of the population. For a diagnosis that the medical profession regards as a cross between a joke and a nuisance, that's significant.

The history of this condition is long and complicated but doesn't get as much attention as, say, psychosis because it isn't so dramatic. However, as the suicide rate shows, life as a worrywort can be pretty miserable. Traditionally, people who worried over their health went to the village herbalist (often the village midwife) who gave them various concoctions that probably didn't do much good but, compared with modern pharmacy, didn't do much harm either. The rich, of course, could afford to travel to various centres which offered the rest cure with or without hot mud baths. Different cultures had different ways of looking at the problem. In Thai Buddhist culture, what westerners called "neurosis," meaning "an excess of nervous activity," was seen as an imbalance of inner winds and was treated by massage. The first medical school in the world was opened in Bangkok in 1843 to teach this treatment and it's still there. In India, ayuvedic medicine goes back thousands of years and the same is true of Chinese traditional medicine. The problem of people worrying about their health is universal, and so is the lack of effective treatment.

Naturally enough, effective treatment depends on a clear understanding of causes, and this is where it goes wrong. Consider a historical example, the death of Gen. George Washington. In his time, malaria was rife on the east coast of what became the US but, as the name implies, people believed it was caused by breathing bad air ("mal aria") from swamps. The fever was thought to be caused by too much hot blood, so treatment followed from that belief: remove some of the blood. If that didn't work, then obviously the patient had a bad attack and needed to lose more blood. And more, until he expired, which is what happened to the unfortunate Mr G Washington.

The general rule is: Treatment flows from your understanding of the condition. Bleeding the patient had no effect on malaria but quinine did, so it was made into a tonic, which was then combined with gin and proved very popular among the idle classes. At the end of the nineteenth century, the parasite was discovered which eventually led to better treatment and, slowly, to better public health measures but malaria is still a terrible disease. Well over half a million people, 75% of them children under five, die of it each year, and it remains a huge burden of chronic illness for people in slums or agricultural workers. The point is that if you don't understand the cause, then treatment will be hit-or-miss, based mainly on prejudice.

With Western psychiatry, the prejudice is that each mental disorder is caused by a distinct physical disturbance of the brain. Each one starts with some sort of unique genetic defect which causes a characteristic "chemical imbalance of the brain," which translates into a particular cluster of mental symptoms. This leads to the concept of mental disorder as a long list of separate categories of disturbance. In turn, this leads to a research program looking for defects in the brain and genome, and treatment (drugs, ECT etc) to change brain chemistry. It says that the cause of mental disorder is brain-based, so it does not look at upbringing or life experiences because the theory says these are irrelevant. Anything the patients believe is neither here nor there so nobody bothers to listen to them.

Trouble is, there's not a shred of evidence to support the idea. It is an ideology of mental disorder, not a science. There are no categories of mental disorder, there is no cut-off point between normal and abnormal and, after a hundred years and untold research money, not a single sign of a brain defect to explain mental disorder. Just look at the DSM system: it puts "health anxiety disorder" in a separate category from anxiety in general. Why? Why aren't they considered variations on the same theme? Because that's not what the theory says. There is thus no hope that Western psychiatry will ever say anything useful about all the people who worry excessively over their health. This is also true of massaging people to shift the patterns of inner wind (it feels good at the time but it doesn't last) and most of the herbal and other remedies used around the world.

But if it's not biological, what could it be? Er, maybe it's psychological? Maybe a mental problem has a mental cause? No way, this is too radical. The basis of Western science is that we can only study things that can be counted, measured and weighed, and minds can't be seen or stuck in a bottle, therefore they don't exist. But mainstream psychiatry is reaching the end of the line, as this quote from the former director of the US National Institute for Mental Health shows:

I spent 13yrs at NIMH really pushing on the neuroscience and genetics of mental disorders, and when I look back on that, I realise that while I think I succeeded at getting lots of really cool papers published by cool scientists at fairly large costs - I think $20billion - I don't think we moved the needle in reducing suicide, reducing hospitalisations, improving recovery for the tens of millions of people who have mental illness.

That's a lot of money, lot of hype to achieve nothing, especially when the solution to the ancient problem of hypochondriasis is staring us in the face. Anxiety is the response to the perception of a threat. A threat is in the future, coming at us. The closer it gets, the more dangerous it seems and the more anxious we become. This is true of all animals capable of experiencing anxiety, which is practically everything bigger than an amoeba: a cat seeing a dog, a baboon seeing a leopard, a fish seeing a shark, a robin seeing a hawk, and so on.

The anxiety response is universal and ancient: it exists to make us deal with a threat ("fight or flight") in order to save our lives. Anxiety is immensely powerful: it can override all other emotions, hunger, tiredness, pain, sexual arousal, greed, you name it, anxiety, always wins. Anxiety never abates until it gets what it wants. Other emotions wear out but not anxiety, it gets more and more intense until you do what it wants, such as run away.

Normally, we think of threats as "out there" but humans are a bit different in that we can think of threats "in here," meaning one's health. I can worry about what that twinge or that lump means, or what I'm coughing and so on. If, however, I worry about the effects of anxiety themselves, like my heart racing, trembling, feeling dizzy, my stomach gurgling, and so on, then they become the threat, and I am caught in a vicious circle. The essence of any anxiety state is that sufferers fear the effects of anxiety (and it affects every organ of the body); the more they fear them, the worse the effects get, on and on without relief. That's all. There is nothing wrong with the brain, no genetic defects or chemical imbalances. Anxiety is the body doing what it is intended to do, warn us of danger, but the racing heart and so on only seem dangerous. They're not really, except the sufferer doesn't know this. He knows his heart jumps around and he is sure it means danger, so he goes back and back, looking for something to relieve it. This breeds anger and frustration on both sides, as the only thing that can do so comes from within: realising that anxiety is normal, so don't fear it. It's all psychological.

This is self-evident but since psychiatrists don't believe in the causative powers of the mind, they can never see this elementary truth. Instead, they spend billions on biological research that tells us nothing, prescribing drugs that don't address the central problem (drugs don't work on beliefs) and then blaming the patient when things don't improve. But like the physicians slowly bleeding Washington to death, what is needed is a radical change of perception of the problem. Unfortunately, the history of science tells us that dramatic change almost never comes from within the profession.

1. Mataix-Cols D et al (2023). All-Cause and Cause-Specific Mortality Among Individuals With Hypochondriasis. JAMA Psychiatry. doi:10.1001/jamapsychiatry.2023.4744 . Published online December 13, 2023.

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I will have a break over the Christmas week so will wish readers a peaceful Christmas and New Year, with the hope that perhaps our "leaders" will start to get some sense and wind down the disasters engulfing the world.

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