P&S Journal: Spring 1995, Vol.15, No.2
Prozac: On Trial For Hypochondria
By Robin Eisner
To Sarah, a pain in the neck meant she had lymphoma.
An opera singer and mother of two grown children, 57-year-old Sarah (not her real name) has suffered from hypochondria for more than 30 years. Throughout her life she would get symptoms, such as head and intestinal aches, and worry she was going to die. "I have this morbid dread and fear," she says.
Sarah relied on her daughter, now 37 years old, to guide her about which complaints to seek medical attention for and which to ignore. "My daughter really tunes in on me," she says.
Unlike other hypochondriacs, who go to many doctors and undergo numerous tests but doubt their reliability, Sarah fears doctors and even newspaper articles on health. Her life, she says, has been one of suffering and terror. But Sarah decided to take a risk, and she enrolled in a clinical trial run by Dr. Brian Fallon'85, assistant professor of clinical psychiatry. The trial tests whether Prozac, or fluoxetine-a drug currently approved by the FDA for depression and obsessive-compulsive disorder-could help hypochondriacs.
This five-year, $500,000, blind, randomized, placebo-controlled trial of 100 patients is the first National Institute of Mental Health-sponsored controlled trial for the treatment of hypochondria. Started in July of 1993, the trial will determine whether Prozac can help hypochondriacs and if patients relapse after medication is withdrawn.
Hypochondriacs come in two types: those who believe they have a severe illness when they do not, like Sarah, or those who worry excessively about an illness they do have. Unlike most people who have temporary fears of illness when they experience a new physical symptom, hypochondriacs persist in their distress for six months and longer, despite medical reassurance. Epidemiologists estimate that about 4 percent to 10 percent of people who visit physicians do so because of hypochondria-based complaints.
Literally, hypochondria means a region below the cartilage of the rib cage. Eventually the region came to be associated with hysteria. Freud believed hypochondriasis was a withdrawal of the libido from the external world onto internal organs. Considered a psychological illness in the 20th century, it has been treated with psychotherapy and with drugs but often with very little success. James Boswell, Samuel Johnson, Alfred Lord Tennyson, Charles Darwin, Leo Tolstoy, and Sara Teasdale all are believed to have been sufferers.
The trial, which has enrolled 25 patients, was developed after Dr. Fallon demonstrated in an earlier open pilot study, published in the Journal of Clinical Psychopharmacology in December 1993, that 70 percent (10/14) of hypochondriac patients benefited from daily Prozac doses ranging from 20 to 80 mgs. Using a psychological test measuring hypochondria, the Whiteley Index, Dr. Fallon showed patient improvement after 12 weeks of drug treatment.
Dr. Fallon first got a hint Prozac might help hypochondriacs when he was a psychiatric resident at CPMC in 1989. A 50-year-old man was referred to him after numerous specialists could not find the basis of his gastrointestinal symptoms. "When he came to see me," says Dr. Fallon, "he was enraged because he believed something medical, not psychiatric, was wrong." After tricyclic anti-depressants failed, the man was given Prozac. He felt dramatically better and was grateful. Although still aware of his physical symptoms, he was no longer as fixated on them.
The fixation of hypochondriacs makes them similar to people with obsessive-compulsive disorder (OCD), explains Dr. Fallon. The difference between hypochondria and OCD, though, is that hypochondriacs excessively fear having a disease while OCDs irrationally fear getting a disease. "But in their obsessions, their compulsions to check, and their failure to be reassured, hypochondriacs are similar to people with OCD."
Prozac, a serotonin receptor reuptake inhibitor, is believed to work in patients with OCD by increasing the amount of serotonin, a neurotransmitter, available to act between neurons. Dr. Fallon says a serotonin deficit might be implicated in hypochondria too.
For more than a year, Dr. Fallon has screened people for the trial at CPMC and at St. Joseph's Hospital in Stamford, Conn. Although he has funding for 75 more patients, he says it is difficult to recruit subjects because hypochondriacs don't want to acknowledge they have a psychiatric illness. Some fear using Prozac, which can cause nausea and anxiety and decrease the sex drive. Reports in the news media about aggression and suicide possibly attributed to the drug have increased patient wariness.
Dr. Fallon says patients eventually enlist because the potential serotonin disorder provides an acknowledgment that they might have something physically wrong. They feel vindicated, he says, and the societal stigma against hypochondria is lessened.
"People make fun of hypochondriacs, thinking they unnecessarily worry and are not really afflicted with a disorder," says Carla Cantor, a Maplewood, N.J., writer and hypochondriac who takes Prozac. To change public perception about the disorder, she is writing a book with Dr. Fallon called "Phantom Illness-Shattering Myths of Hypochondria" (Houghton Mifflin Co., Winter 1996 publication).
Initially, the potential adverse reaction to Prozac disturbed Sarah. "I was freaked out by the possible side effects of Prozac," she says. "But even if Prozac cuts five years off my life due to brain cancer they still don't know about, yet it helps me be happy and comfortable with my own body now, like I see happening to some of my friends, I'm willing to do it." She pauses. "And I want to participate to help other people who suffer."