"Study Discovers Help for Hypochondriacs" headlined an article in the Dallas Morning News. "Advancement in Hypochondriac Therapy" announced a shorter article in USA Today. Both articles make the point that this condition is "mental not physical."
A quarter of the patients in the study dropped out after being told the problem is in their heads. Of the patients who were willing to attend 6 therapy sessions: 57% showed significant improvement and felt their quality of life was better (This is not to say normal.). 32% of patients assigned to the usual medical treatments had a similar outcome. These news reports were based on an article appearing week in the March 2004 Journal of the American Medical Association. The interpretation given for the patients who didn’t complete all their sessions or didn’t attend any was that "the treatment didn’t fit with their belief that their illnesses were real."
The problem I have with these reports is that it represents one of the most important issues in medicine. The idea that the mind and body are two different things is the old paradigm. This mind/body dualism goes back 3 1/2 centuries to Descartes. The new paradigm is that there is no mind without brain, and brain is part of the body.
Recently a patient of mine went through a life threatening illness and eventually heart surgery. He had a past history of serious depression, well controlled for years with maintenance medication, an antidepressant. He was so sick that he forgot to continue his meds, and his doctors did not see fit to prescribe for him or contact me. I explained to him that depression – which developed during his medical illness to the point that he said, "all I thought about was death" for several weeks – increases the risk of dying from serious illness 2 to 3 fold.
His response was, "I guess they took good care of me physically but not mentally." My response was "What’s the difference?"
So what difference does all this make? Why didn’t his doctors make sure he stayed on his antidepressant? His doctors increased his risk of dying. Why? Because many if not most physicians are still stuck in the old paradigm.
"For every twisted thought, there’s a twisted molecule; straighten the molecule and you’ll straighten the thought." But, responded the cognitive therapy oriented people – "If you straighten the thought, you straighten the molecule."
So, which is right? Both. There are numerous studies now for obsessive compulsive disorder and depression that adequate cognitive behavior therapy (CBT) can change the chemistry and functioning of the brain. Scans of brain functioning can be seen to return to normal for some patients. The right medication(s) at the right dose frequently return the brain to normal. Some patients do better on one approach and not the other. Some patients would do equally well on either, and some need both.
Why would anyone choose medication if cognitive therapy would work? The problem is that CBT therapy takes longer, costs more, takes a lot more time, it’s hard to find people who know how to do it, and it may not work. Medication is simple, quicker, cost less money and less time.
