I recently wrote about a woman who has few if any cardiac symptoms, no definitive test results, and very little if any reason to believe she might have a heart condition. Yet she is so utterly convinced of her extreme risk for having a heart attack that she actually describes feeling like a “ticking time bomb”.
Her conviction may have something to do with the increasing media coverage of atypical signs of heart disease in women (= a good thing). Or it may have something to do with the possibility that she is “catastrophizing” by looking to snag a nice juicy attention-getting heart disease diagnosis (= a bad thing).
I’ve recently subscribed to medical historian Dr. Jan Henderson‘s fascinating blog called The Health Culture, and that’s where I was once again reminded of a book that may actually help to inform this woman’s case.
It’s called Overdiagnosed: Making People Sick in the Pursuit of Health by Dr. H. Gilbert Welch, who’s a professor of medicine at Dartmouth Medical School and author of another provocatively-titled book, Should I Be Tested For Cancer? Maybe Not and Here’s Why.
Jan offers this simplistic overview of Dr. Welch’s new book:
“We choose to pursue health or to pursue disease.”
For example, she describes Dr. Welch’s take on the wide spectrum of our attitudes toward our own health.
“At one end are those who regard medical care as something to be used when symptoms arise, but not when feeling healthy. One could characterize these people as wanting to stay healthy and well.
“At the other end are those who seek to identify and treat potential problems that they’re currently not aware of. The focus for this group is not health so much as staying alive – doing everything possible to avoid disease and death.”
In his new book, Dr. Welch suggests that overdiagnosis can occur when we seek diagnoses in the absence of any real symptoms. He compares disease seekers with health seekers in this way: (emphasis added)
“I am not suggesting all diseases are curable after symptoms appear, nor am I suggesting that no diagnoses should be made in the absence of symptoms. I’m simply suggesting that we should be most cautious about early diagnosis in those who feel well.
“Some people may prefer to pursue health: to focus on feeling healthy and minimize medical contact while they are well. They may accept a slightly higher chance of death or disability to minimize the chance of medicalization, overdiagnosis, and overtreatment now. They prefer to reserve medical care for problems that are obvious to them.
“Others may want to pursue disease: do everything they possibly can to be healthy in the future and to decrease their chances of experiencing death or disability – even with the knowledge that they are more likely to be diagnosed with disease, more likely to be frequently exposed to medical care, and more likely to suffer harm.
“They prefer to work to avoid death and choose to allow medical care to assume a larger role in their lives. Many view this as the best strategy to stay well. But it is difficult to promote wellness when actively looking for things to be wrong.
“In the effort to find out that everything is okay, people pursue early diagnosis. Ironically, this strategy increases the chances that they’ll be told something is wrong.”
These words made sense to me, and it’s not just because of that woman convinced that her heart attack is imminent – behaviour that’s known as “cardiophobia”. This is an anxiety disorder characterized by repeated complaints of chest pain, heart palpitations, and other somatic sensations accompanied by fears of having a heart attack and of dying.
Amid limited health care resources, overburdened medical staff and long waiting lists, I believe that there are also more sinister issues at work with “disease-seeking” behaviours. As I wrote here in January:
“Those who insist on wasting limited medical resources in search of a high-drama cardiac diagnosis that will never come make it so much harder for those of us who actually are ill to be taken seriously by the medical profession.
“Instead, genuinely ill people with real symptoms are then lumped in with the cardiophobes of the world, dismissed and sent home in mid-heart attack, as I and many other female heart attack survivors have experienced.
“This is an extremely serious issue. We know that female heart patients are under-diagnosed (and then under-treated even when appropriately diagnosed) compared to men. Women under the age of 55, in fact, are seven times more likely than men to be misdiagnosed even in mid-heart attack.
“One wonders how many catastrophizing cardiophobes my exhausted and burned out E.R. doctor encountered before I arrived at his door, and before he sent me home in mid-heart attack with an acid reflux misdiagnosis – just another hysterical middle-aged hypochondriac?”
Dr. Welch, along with his co-authors Dr. Lisa Schwartz and Dr. Steven Woloshin, had already written in the New York Times* a couple years ago that what’s actually making us sick is what they call “an epidemic of diagnoses”. For example:
“This epidemic is a threat to your health. It has two distinct sources.
“One is the medicalization of everyday life. Most of us experience physical or emotional sensations we don’t like, and in the past, this was considered a part of life.
“Increasingly, however, such sensations are now considered symptoms of disease. Everyday experiences like insomnia, sadness, twitchy legs and impaired sex drive now become diagnoses: sleep disorder, depression, restless legs syndrome and sexual dysfunction. While these diagnoses may benefit the few with severe symptoms, one has to wonder about the effect on the many whose symptoms are mild, intermittent or transient.
“The other source is the drive to find disease early. While diagnoses used to be reserved for serious illness, we now diagnose illness in people who have no symptoms at all, those with so-called pre-disease or those “at risk.”
* “What’s Making Us Sick Is an Epidemic of Diagnoses” – New York Times, January 2, 2007
- Are You Being Over-Diagnosed?
- Catastrophizing: Why We Feel Sicker Than We Actually Are
- The Medicalization of Everyday Life
- How To Turn a Condition Into a Disease by “Selling Sickness”
- “We Never Imagined People Would Think of Osteopenia as a Disease”