Public Health, Public Hypochondria

By Catherine Belling

We used to feel reassured by the possibility that medicine might soon be able to find any disease hidden inside our bodies before it could do real harm, and remove it before we even began to feel sick. “Disease awareness” and “early detection” became public health buzzwords. We have been encouraged to get screened for diseases we probably don’t have (but just might). Some began paying for full body CT scans in the hope of catching and fixing all possible anomalies and pathologies the instant they appeared. What could possibly be wrong with such diligent vigilance?

Hypochondria is based on two beliefs that are, on the face of it, perfectly rational: our bodies probably contain hidden diseases, and medicine should be able to find those disease and fix them. Yet when these two beliefs begin to dominate someone’s thoughts and activities, when s/he reads every sensation as the symptom of something serious needing urgent medical attention, we call him or her a hypochondriac, meaning both that s/he is mentally ill and the comical object of annoyance and scorn.

Perhaps hypochondria is so disturbing because it has so much in common with medicine. Hypochondriacs detest uncertainty, so does medicine. As the technological capacity to find disease (or predispositions to disease, or risk of disease) increases, so does the pressure to use that technology to find disease earlier in larger populations. Public health exhibits the hypochondriac’s relentless need to track down disease rather than tolerate the insecure sense that things may be okay (for now).

But this may be changing. Lately we’ve been learning more about the risks of routine mass screening as a means of preventing cancer deaths. Public health guidelines are what your primary care physician consults in deciding whether to refer you for a mammogram or colonoscopy, when you show no symptoms of the conditions these tests seek. Over the last few years, US Preventive Services task forces have announced modifications to many of their guidelines for disease screening, adjustments that herald a solid challenge to the assumption that knowing more is necessarily better.

Perhaps the most controversial changes were to guidelines for seeking early breast cancer. The 2009 Task Force recommended against routine screening mammograms for women between forty and fifty. This came as a great shock to many, seeming to contradict decades of advice to healthy women in their forties to be scrupulous in hunting down breast anomalies.

This May, controversial new guidelines recommended against mass prostate cancer screening, saying the harms solidly outweighed the benefit of lives saved. (See editorial by the chair of the task force, opinion in this week’s Annals of Internal Medicine, and critique of the task force in this week’s Annals.) Last month, a review article in the Journal of the American Medical Association showed that only by limiting screening for lung cancer to high-risk subjects (like heavy smokers) could enough lives be saved to justify the harms.

These are difficult calculations to make. Even one saved life seems to trump most other considerations. There are also disparities in awareness of and access to screening. There is a cost here too. Guidelines that recommend less screening can be misinterpreted as rationing health care, where what is needed is a more even distribution of prudent screening for age- and risk-groups where evidence exists to show that benefits outweigh risks.

Screening entails harm to individuals: repeated radiation exposure from scans and positive results leading to invasive follow-up procedures. A significant number of those positives turn out to have been false alarms; others, while accurate, are the overdiagnosis of cancers so small and slow-growing they pose no meaningful threat within a patient’s lifetime. But once a diagnosis is made, the imperative to treat takes over. There are mental health harms, too. The anxiety and distraction of waiting for results and, if a positive finding emerges, the stress of undergoing more, often increasingly invasive, exploration.

Screening may also be harmful to the overall mental health of its populations. Screening teaches us that, as responsible health citizens, we must imagine our bodies as harboring diseases even when we feel perfectly well. It encourages us to think of ourselves as containing ticking time-bombs, hidden threats that can turn lethal in an instant. This pathology of the imagination, even if such fears are realistic, is a form of cultural hypochondria.

The idea that our bodies harbor hidden disease when we don’t feel sick is, historically, comparatively new. For a long time, the absence of symptoms was a conclusive (and rare) sign of health. This is because symptoms themselves constituted disease. Relieving them meant cure.

This was before the science of pathological anatomy worked out causal connections between hidden internal lesions and recognizable symptoms, teaching us to think of symptoms as signs of disease, warning of underlying pathology. This is why illnesses consisting of symptoms unexplained by visible pathology (like fibromyalgia or chronic fatigue) are such a challenge to medicine. It is also why relieving hypochondriacs’ symptoms, removing valuable clues to hidden danger, can exacerbate anxiety.

But routine population screening changes the symptom-disease relationship again; disease becomes something that only medical technology can find. The subjective component of distinguishing between sickness and wellness is reduced to the anxious anticipation of test results. Waiting for symptoms seems irresponsible. Health, by this model of disease, is quite simply unattainable.

Of course the catch is that in a way this is true. The fact of our eventual and inevitable mortality has its seeds in all our bodies already. Hypochondria is no defense against death. So we have a choice: accept cultural hypochondria as a kind of mental health, both adaptive (there’s a small chance it will save your life) and ethical (vigilance is a virtue, complacency a vice, and we’re all responsible for keeping death rates down) — or recognize that such grasping after unattainable omniscience is misguided.

As the JAMA article on the risks and benefits of lung cancer screening concludes, “uncertainty exists.” In the face of this blunt fact, we need to work out when it is wisest to tolerate not-knowing. The counterintuitive acceptance of a degree of cheerful ignorance may be the best thing we can do for our collective — public — health.

Catherine Belling is the author of A Condition of Doubt: The Meanings of Hypochondria. She is on the faculty of the Program in Medical Humanities and Bioethics at Northwestern University’s Feinberg School of Medicine in Chicago. She came to the United States from South Africa on a Fulbright grant to complete her PhD in English, on representations of anatomy and physiology in Renaissance drama, at Stony Brook University, New York, where, on graduating, she took up a position in the medical school before moving to Chicago in 2007.

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