Shirah Vollmer MD

The Musings of Dr. Vollmer

The Hypochondriac

Posted by Dr. Vollmer on September 11, 2013

Lacey, fifty-seven, insists that no physician can determine the cause of her multiple somatic complaints. Lacey, a physician herself, no longer practices medicine, as she feels disabled by her symptoms which she struggles to explain to others. She is not exactly tired, she says, but she does feel fatigue. She does not have headaches, but she does feel discomfort in her head. Her stomach is not quite right, although she eats a healthy diet and she maintains a healthy weight. She has consulted multiple tertiary care medical centers, all of whom, express confusion over her symptoms. She comes to me, not because she considers her symptoms secondary to her mental state, but because she is despairing that no physician can give her a diagnosis. George Vaillant MD in his article entitled “The Beginning of Wisdom is Never Calling a Patient a Borderline,” speculates that hypochondriacs need to be understood, in terms of their subjective suffering, and through this understanding, their personal trauma will eventually unfold, yielding a platform in which to work through childhood pain. In essence, primary care physicians need to entertain the notion of a hypochondriac as someone who is crying out to be heard, but patience and empathy must be present for a long time, before this will pay off with insight and symptom relief. Psychiatrists often cannot be helpful, as the hypochondriac will feel further dismissed and thereby get more angry. My job with Lacey is to work with her and her primary care physicians, mostly to help her other physicians understand how to work with her. My direct work with Lacey is to help her deal with her frustrations, while cracking the door open, that her symptoms, indeed very distressing, might be as a result of a painful internal mental state which reaches back to childhood trauma and the need to be heard and understood. Sad as it is, Lacey acts as if the only way people will listen to her is if she has medical complaints. It is as if she believes that if she were to say she were sad, anxious or scared, then she would be ignored, but if she insists that she has a serious medical problem, then her friends and family will attend to her. This pathological belief, likely stems from a childhood in which only physical problems yielded nurturing, whereas emotional issues were neglected. Maybe Lacey will come to understand that, but for now, the job is to give her the space to feel heard and understood, with the sensitivity to know that the slightest suggestion that her mind is producing these bodily complaints, will be heard with anger and despair.

4 Responses to “The Hypochondriac”

  1. Michelle said

    I understand that, in your opinion, Lacey is a hypochondriac. However; I went through many doctors and was even told I was drug seeking and I should go to a psychologist before it was found out that i DO ACTUALLY HAVE MEDICAL ISSUES with my body called fibromyalgia. I am not trying to tell you how to do your job. I have a bachelor’s degree in psychology, myself…. But, often medical doctors dismiss thing outside of the small box they learned from. I hope that your work with her is encompassing all aspects of her feelings. I felt horrible knowing there were things wrong with my body but no doctor wanted to see the whole picture and the specific symptoms they tested for were not shown as anything wrong. Dismissing is not always a correct treatment.

    • Hi Michelle,
      Thanks for your comments. As you imply, each situation is different. Of course, I cannot say for sure that Lacey does not have medical problems, but in this fictional example, I am illustrating that it is possible for a patient to strongly believe they have medical problems, when, in fact, their symptoms are a result of childhood trauma. At the same time, there are numerous examples, such as yourself, in which doctors do miss important symptoms and then do not pursue a diagnosis which would explain a complicated case. One must keep an open mind for all possibilities. Both the physician and the patient need to embrace that the mind/body connection is complicated and so there could be multiple explanations for vague, nonspecific symptoms. Plus, the course of the illness is often another means to understanding the nature of the disease process. Dismissing is never a correct treatment, as you say. Taking all points of view into account, is the most thorough approach to each patient. Thanks again for chiming in.

  2. Shelly said

    Very interesting blog, Shirah. I wanted to take issue with two points: “It is as if she believes that if she were to say she were sad, anxious or scared, then she would be ignored, but if she insists that she has a serious medical problem, then her friends and family will attend to her,” you wrote. You, as a psychiatrist are probably the only medical professional who will take Lacey seriously. In my own experience I know that once someone is being treated for anxiety or depression or any type of mood disorder, no-one takes the patient seriously at all. Not even a primary care physician. From experience, I know this true. When I repeatedly came back to my PCP complaining of neck pain, she stated, “Are you sure this isn’t something you’re making up or are imagining?” Shortly thereafter I underwent surgery for a herniated disc in my neck. Secondly, you discuss George Vaillant, MD and his article entitled “The Beginning of Wisdom is Never Calling a Patient a Borderline.” Are you calling Lacey borderline? Why?

    • Yes, Shelly, I agree. Physicians of all stripes are guilty of not taking patients seriously, particularly when they do not feel they have answers to their patient’s complaints. This is the old game of throw the dung back at the patient, rather than analyze it and sit with the smell. Having said that, there are still physicians out there who are capable of understanding that unexplainable pain may be related to a medical problem and/or a mental state. Keeping both in mind is the key to a good diagnostician. I am not calling Lacey a Borderline, but this is the unfortunate title of this article which describes primitive mental states. Thanks.

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