When a hypochondriac walks into a GP, the doctor's heart sinks. What can be done to help them, asks Conor Pope.
A retired watchmaker becomes convinced he has mouth cancer and is going to die. He visits his GP, who can't find anything wrong. So he visits another doctor, and another, and within two years has seen 28 GPs, four dentists and an ear, nose and throat specialist. They all declare him perfectly healthy.
He remains unconvinced and is referred to Prof Ingvard Wilhelmsen, a Norwegian specialist in hypochondria. After two sessions, the watchmaker has accepted that it is probable - but not certain - that the 33 medics are right and he is wrong.
People like him are known as "heartsink" patients by many GPs whose hearts sink when they enter the surgery and in the world outside medicine, they are often dismissed as attention-seeking health dilettantes.
The first question Prof Wilhelmsen asked the watchmaker was whether he had "real cancer or imagined cancer" and pointed out that if it was merely the thought of cancer, then it wasn't very dangerous.
"A thought is a thought. A thought of cancer is okay as long as you don't value it as valid," he says. His patient eventually recognised the distinction and the thought slowly disappeared.
According to the professor, full-blown hypochondria is experienced by 1 per cent of the population, or more than 40,000 people in the Republic. The symptoms can be easy to identify - an intense fear of imminent death, repetitive checking for symptoms, the elevation of every minor twinge into a catastrophic illness and repeat GP visits.
While every hypochondriac has different fears, the root of the problem often stems from a desire to control their mortality. One of the first things Prof Wilhelmsen does is to get his patients to explain their attitude to dying. Many tell him that they feel they cannot die now, they have too much left to do or children who depend on them.
He has to convince patients that attempts to control death are a waste of energy. This is the key to unlocking the condition, he believes. Some health professionals think it is a modern malaise with its origins in the fact that many do not come into contact with death as frequently as their ancestors and, as a result, have lost essential coping mechanisms.
"Patients have to reflect on death and they have to take a new point of view and decide if they are willing to be mortal or not. They cannot just go along as they did, they have to make a commitment either to be willing to be mortal or to not believe catastrophising thoughts."
He accepts that while it is not easy to accept your mortality "when you think about it, you understand that your former point of view is impossible". Hypochondriacs do not, he says, make a conscious decision to rail against their mortality but drift into it. They do, however, "have to make a conscious decision to get out of it".
Hypochrondia is a serious problem. Recent studies in Germany estimate that 3-5 per cent of all doctors' visits are from hypochondriacs, while a US study in the 1980s put the figure at closer to 10 per cent. If these estimates are applied here - the Department of Health and Children has no statistics - hypochondria is costing at least tens of millions of euro annually.
"There isn't a GP in the country without patients who could be classed as hypochondriacs," says Dr Ronan Boland, a member of the IMO's GP committee and editor of medical advice website, www.mygp.ie. "It's a problem, primarily for the patient obviously, because if someone has such excessive worries, it is almost inevitable it interferes with that person's quality of life.
"It's a problem for the doctor in that the normal rules of medicine are often inadequate," as negative test results followed by reassurance make little difference.
At its worst, hypochondria can, he says, lead to unnecessary referrals, investigations and procedures but GPs probably know the signals better than anyone else and play a "gatekeeper role". While stressing that you can't assume an ailment is derived from a bout of hypochondria, familiarity with patients can "ensure that unnecessary referrals are not taking place".
"I'm not saying that GPs always get it right," Dr Boland says, "but by virtue of the continuous relationship with someone they are better placed to pick certain things up."
Prof Wilhelmsen says: "There is a misunderstanding that hypochondriacs are attention-seekers, that they are producing symptoms. But actually they are just afraid. It is more like an honest anxiety. You don't make up symptoms - you feel things and misinterpret them and feel scared."
To be a hypochondriac, "you have to be very creative", he says. "If you are very down to earth you never get any anxiety disorders. The thoughts never occur to you and if they do, you just dismiss them immediately."
Frequently, he says, he has to deal with specific imagined diseases like heart disease head on. "People who believe they have heart disease don't dare to do anything. They won't train or have sex. They have to take a new stand and say 'okay I am going to trust my heart' and they have to behave as if they mean it."
Fionnula McLiam, a clinical nurse specialist in cognitive behavioural therapy (CBT) with the Health Board Area 2 Mental Services, says she treats a small number of patients with excessive health anxiety annually. Not all hypochondriacs need therapy, she says, and it depends on the level of interference it causes.
She believes one of the reasons the number of patients she treats is comparatively small is that many hypochondriacs are so convinced they have a physical illness that they exhaust all other options first.
"They'll be referred to all sorts of specialists," she says. "They'll very rarely come to a psychologist and it's difficult for them to accept this is something that can be treated by a psychologist because they are absolutely convinced they have an actual physical illness."
She uses CBT, a therapy based upon the premise that our emotions, thoughts and behaviour are all linked. "Sometimes people can get into a cycle of very negative thinking" so therapists "look at the interlinking of thoughts, emotions and behaviour", she says.
According to a report last year, patients suffering from hypochondria found their symptoms and anxieties reduced when they participated in CBT sessions. Some 102 patients took part in CBT while a further 85 were assigned medical care only. After 12 months, the CBT patients had significantly lower levels of hypochondriacal symptoms, beliefs and attitudes.
CBT may help but reassurance rarely does and is not even entirely possible. "I can't give patients 100 per cent certainty they will survive," says Prof Wilhelmsen. "But I can ask them what kind of life they want until they die. Do they want to spend most of their energy on not dying or on living?"
He asks patients to make sure their "interpretations of symptoms, and their life and their uncertainty is fairly realistic" and asks them to choose one that "helps them in life rather than ruins their life".