- All right, just a quick announcement for this podcast. For whatever reason, my audio recording got a little screwed up, and I sound like a robot intermittently throughout this podcast. It's a little unfortunate, but I still think it's passable and it's fine, it's just not up to the standards that I normally want. So I do apologize for that, but I appreciate you sticking with me. And for those of you who are concerned that I turned into a robot, rest assured, I am not a robot. Thanks so much for listening. Do you worry too much about your health? Could it be possible that your concern for your health is actually making you less healthy? Today, we're gonna discuss an interesting article about health anxiety, and how it may be worse than we previously thought. So let's dive in here. So welcome back to the podcast, everybody. For those of you who haven't met me before, my name is Jordan Wrennke. I'm a dual board certified physician in sports and family medicine. And the goal of this podcast, help keep you active and healthy for life through actionable evidence informed education. So today we're gonna talk about an interesting article here, and let's dive in. So the title of that is, "All Cause and Cause-specific Mortality Among Individuals with Hypochondriasis." So big name in the title there, but let's dive into what specifically we're looking at here. So the importance is, why do we care about this? Well, specifically hypochondriasis, or health anxiety disorder, is common but often underdiagnosed. And it's characterized by persistent worry about having serious or progressive physical illnesses. And the mortality among people is pretty much unknown. And so taking a step back here, this is the formal diagnosis, right? So hypochondriasis is pretty much saying, "Hey, this is a clinically diagnosed someone who has to the next level of health anxiety." So normal health anxiety is kinda, "Hey, I'm worried about this. I'm preoccupied about my health a little bit." But it doesn't really affect day-to-day too much. It's not really causing financial issues. It's not causing big, serious anxiety or medical issues, or not really affecting your day-to-day all that much. But this is the end of that spectrum. So the hypochondriasis, this is like clinically diagnosed, making a significant impact on your life, really, really pervasive and really bothersome and leading to controlling your life, essentially. So that's like there. Health anxiety is kind of more in between where it's your word probably more than you should be. And you might have some more issues with that, but not to the point where it's like clinically causing issue and affecting your life to like nth degree. But I'm making an argument here that maybe the spectrum is more blurred than we thought. So we'll kind of dive in and talk about it a little bit more. But that's kind of why we care about this. And this is looking at like, does having this hypochondriasis, does it actually lead to issues in terms of mortality? So are you more likely to die? Or lead to an earlier death? So the goals of this was to examine the all cause and cause specific mortality in a large cohort of individuals with hypochondriasis. So they're looking at all cause and specific causes, meaning did you die? And then looking at specifically, did you die of these certain conditions as well? And so those are the big things we're looking for the objective. So the design, how do they do this study? Well, this was a nationwide matched cohort study in Sweden. So looking just at Swedish individuals, include about 4,000 individuals who had diagnosed hypochondriasis, right? So diagnosed clinically, that's what, and they exclude individuals diagnosed with body dysmorphic disorder, so there wasn't overlap there. And what they did though, they matched each individual with hypochondriasis to 10 other individuals without hypochondriasis based on demographics, right? So sex, how old they were, country, whatnot. So they found for every one person who was clinically diagnosed here, they found 10 people who were not, and that's kind of a comparative group. So when we look at a cohort study, we have to have one group that we're looking at something. So here are the outcomes specifically is that hypochondriasis and then the other group is our control. And so our control are the 10 to one, essentially 10 of these controls to one person who has a hypochondriasis. So hopefully that makes sense. And then moving on after the design, looking at the exposure, what is the actual exposure? Well, this is a valid ICD-10 diagnosis. So ICD is the codes you use in the doctor's office. So like bill, essentially what is, or any, you know, and obviously this is not in America, so it's not the same thing, you essentially pick a diagnosis on a dropdown saying, this is it. So what that is, they found, they looked in the charts and said, those people had that specific diagnosis, those are people who are eligible to be in the study, specifically in that arm of the group. And it was in the Swedish National Patient Registrar as well. And what were the main outcomes they looked at? Well, the main outcomes they're looking at were all cause and cause specific mortality data obtained from the death registry. So essentially what they did is they looked back and they said, okay, these people who die and there's big death registry, they look at them and compare them overall, but they were looking to see overall, did these people die and what did they die of? That's what we're looking at. And they also had a bunch of covariates. So covariates are things that are kind of intermixed. And when I mean intermixed means it's really hard to tease out these things specifically. So covariates, as you'll see mentioned a couple of times here are age, demographics, education status, all these things that are kind of intertwined to who you are and what makes you and how healthy you are. So it's very hard to tease out specifically someone who has a really high education level versus someone who doesn't. And those are what we know as covariates. And in statistical analysis, you try to tease out those using different algorithms to try to remove those things 'cause we know it's a big factor, right? So socioeconomic status can have a huge impact on overall mortality and health and whatnot. So it's like you try to do ways to take those out so that they don't confound your information. But here they looked at specifically age, sex, country of residence, where they were born, last recorded, latest education level, civil status, all of these things. So lots of stuff going on there. So the main outcomes that we're looking at are the all cause and mortality and in cause specific as well. And then they did run some stats. So they were stratified, Cox proportional hazard regression models, which were employed to estimate hazard ratios for all cause and cause of mortality. That's a lot of words. Really what I wanna take away is we're looking at the hazard ratios, right? Hazard ratios tell you how much more likely someone with hypochondriasis is to die compared to someone with thotib. That's essentially all it is. So hazard ratio is just saying, hey, how much more likely is this group that we're looking at more likely to experience the outcome that we're looking at? So that's what hazard ratios are. And that's why I just wanted to mention it. Not super important that you know, this is a stratified Cox proportional hazard and all that stuff really, that's what it is. And they ran a couple of models too, to try to pull out things like I mentioned, trying to account for things like age, sex, county residents, and then also socioeconomic status. And so that's what I mentioned before, these statistical analysis. They try to do these to eliminate those things to really isolate that one variable, right? So the one variable we're looking at for is hypochondriasis. Does having that condition lead to these outcomes? And it's impossible to know that, right? So this is not a randomized controlled trial. It's a cohort study. So we're looking for observational things. We cannot determine causality, but we use math to try to pull those things out to isolate it a little more if we can. So that's specifically what we're looking at. And then from a results perspective, what do they find? Well, pretty interesting actually. So from a cohort description, what did they find? Well, overall, there were about 4,000 people I've mentioned and then 40,000 ish, some who did not have hypochondriasis. And people who had hypochondriasis were more likely to be born in Sweden, less educated, single, have lower family income and have at least one other lifetime psychiatric diagnosis. So in this group, 85.7% of people with hypochondriasis also had a different psychiatric disorder. And that's gonna be a common theme here. Spoiler alert that it's gonna be really hard to tease that out, right? So there's a lot of intertwining of psychiatric disease and that's very common, right? If you have one thing, you're more likely to have other. Same thing with like autoimmune conditions and stuff. If you have one, you're more likely to have another. So lots of overlap there, but it was interesting that they most likely had a higher risk of having comorbid conditions as well. And so that's specifically what we're looking at there. And then for other all cause and causes of mortality results, what we found was actually pretty interesting. So there were about 268 deaths in the hypochondriasis group versus 1760 in the non-hypochondriac group. And you might be saying, well, that's way more. Yeah, because there were 10 times more people. So we expect to see things. We'll talk about what that actually means. But they did find that those who had the hypochondriasis died at a younger age. So every about 70 years compared to about 75 with those who have not. And then those with hypochondriasis had an 84% higher risk for all cause mortality. And so 84, that makes the hazard ratio 1.84. Hazard ratio we talked about is kind of how much more likely you are to die. And that's what we're looking for there. When it was adjusted though, kind of all that stuff, it came down to about 1.69. So about 69% higher risk of dying. But it's still 69% greater risk of dying in that group who had hypochondriasis versus the other group. That's pretty substantial. And that's definitely why we're talking on this paper 'cause it was kind of eye opening to see that specifically. And overall, there was an increased risk for both natural and unnatural causes of death specifically. So hazard ratio of 1.6 for natural, meaning, you know, you got sick and that happened versus unnatural would be, you know, typically like you suicide or something like that. But that's what we see. We saw trends for both of those as well. And risks were similar for men and women as well. But yeah, it's kind of overall taking those as higher risk for those. And then the role of psychiatric comorbidities specifically they looked at that. And the risks of all cause mortality and death from natural causes remained statistically significant after adjusting for lifetime psychiatric conditions. So that's the big thing there. So all cause mortality and death from natural causes after ruling out psychiatric conditions still was there. The risk of suicide though, was no longer statistically significant after adjusting for depression and anxiety. So what that means is the risk for suicide potentially was explained for with the underlying comorbidity. So underlying depression and anxiety. When you took those out of the model, it turns out there was no higher risk of death from suicide. And so that kind of makes sense if you think about it. But okay, so now let's talk about the discussion section. This is kind of the take on it, which is kind of cool. And this was kind of the first study to investigate causes of death among individuals with a clinical diagnosis of hypochondriasis. And the key findings here, which we kind of already talked about, was individuals with hypochondriasis had a higher mortality rate than those without with a significant increase in all cause mortality. So significant increase in all cause mortality, increased risk of death from both natural and unnatural causes were a big thing. Higher mortality in those who were initially diagnosed with an inpatient. So if this was first caught while you were in the hospital, that is a high risk factor as well. And as we mentioned before, the psychiatric comorbidities played a role, but the risk of suicide kind of were evened out when we took out and took away the preexisting conditions. But overall, it looked like those with this condition had a higher mortality rate than those without, which is very interesting. And what's the cause of this? Well, the first thing is we don't know, right? So if we step back, this is a cohort study, meaning we're looking at observational things. We will not know and we cannot know what causes this based off of this one study. We can look and we can extrapolate and we can guess and we kind of bring up and suggest some things that have mechanistic plausibility, but we won't know that for sure. So, but at the end of the day, what are some of the things they kind of mentioned? Well, here they are. Specifically, they're saying chronic stress. So if you're living in this chronically keyed up stage here, this chronic stress may lead to issues, lots of physiological issues. So things like the HPA axis, which is dealing with your pituitary and your adrenals and your hormones and all that stuff, that may be altered. You may alter your immune function, may alter chronic inflammation, all those things. So if you have chronic inflammation, that increases up your risk for things like cardiovascular disease. If you have issues with immune function, that may lead to issues with infections. If you have abnormal hormones, that may lead to other issues down the line. So they're saying this chronic state of having high anxiety may lead to these physiologic issues. And that's very plausible. That's definitely plausible. Other things as well is that maybe this anxiety led to different changes in lifestyle, versus alcohol and substance use. And maybe there's an under-recognition of hypochondriasis. Maybe it was, there's something else going on underneath in general that it's not really hypochondriasis. That's to take a step back. What they're saying is maybe these people who are worried about their health actually had something going on with them that we couldn't identify with our standard labs, which is very reasonable as well. That's a big takeaway here is, you know, the headline will say, "Oh, these people are at way higher risk." But like, do we know that they just actually didn't have something that we couldn't identify? And that's what the risk factor is. Once again, this is not a randomized controlled trial. So we won't know, we can't know that. But I do want to play devil's advocate saying, you know, if you read the headlines, they'd be like, "Oh, like your anxiety is killing you." Maybe, I don't think that's good for you. I think that's kind of a takeaway I'll talk about a second is that it's certainly not healthy for you. And do I think all those people had some underlying condition that we didn't catch? Probably not. But there could be some people who legitimately had something that we just didn't catch and that led to their early death. So that's something we have to consider as well. But overall, that was really, I thought, kind of interesting. And from a clinical perspective, you know, what are we thinking about this? I think that the importance, it's important to not dismiss symptoms, right? So I think a lot of times people go to the doctor, they could dismiss saying, "Hey, like it's nothing. It's all in your head." And is that a very possible thing that could be happening? Yeah, it could be. But dismissing things just for the sake of dismissing things 'cause we don't want to work things up or we don't want to look into it or we're going to blame the patient saying it's just their symptoms. I think that's a dangerous game to play. And as evidenced here, what if we have people who have these symptoms and we need to dig a little bit further, right? And we just blame them and, "Oh, like, you're just worried. You're just worried." Well, what's that? And based off of this data, actually, this wouldn't make me feel any better if I had hypochondriasis. I wouldn't be like, "Great, this is awesome." No, it's what it's saying is, "Well, maybe my concerns are actually valid. Maybe there's something going on." Is there a real chance that nothing, quote unquote, you know, physiologically is going on? Yes, that's very possible, but it could be both those things. And so that's one of those things as a physician, you know, my role is to listen to patients and, you know, what's the worst that could happen, right? If I miss something, bad thing's going to happen. That's why we always want to, that has to be the last stone we overturn. We say, "Hey, like, this is just like health anxiety." So you got to kind of rule out all the big, bad, scary stuff, go through all the physiological things that could be happening. And then if you don't find anything, then we kind of say, "Hey, okay, what are we missing?" Kind of reevaluate. But overall, clinically, it's important to make sure that we're not belittling or saying, "Hey, just missing any sort of complaints that people have." And I think it's important to reduce the stigma also associated with hypochondriasis and improve its detection and diagnosis. They say in this article that it's grossly underdiagnosed. And so I think it'd be helpful to see that as well. And it's kind of interesting. And from a strength and limitation perspective, every paper is going to have strength and limitations. So this specifically strengths, I thought was kind of cool, is unique access to Swedish records. That's the nice thing about nationalized medicine. You get to see all the records in the death industry. It was a cohort and a long follow-up period of over seven years, which is great. They did a good job trying to adjust for different socio-demographic variables and psychiatric conditions. And it was a big cohort for an important study, which is cool. And then limitations though, there's always new limitations. I think it's easy for people to say, "These are limitations, this is why the study stinks." But overall, everyone will have them, but let's just talk about them. But not really say, "Hey, I think it's a well-designed study." I think the underdiagnosis of hypochondriasis is probably huge. It could lead to an underestimization of true mortality risk, for sure. You could also, we lack primary care data. So where most people with hypochondriasis usually seek help. And you could have a different socio-demographic group. And there's lots of variables that are hard to control for as well. And yeah, so there's lots and lots of things there. There's a couple more, but those are the big ones. And overall, the conclusions from this study though, I think I just want to say is this does provide the first evidence suggesting that increased risk of all causing mortality is seen and associated with people who have hypochondriasis. And the excess mortality that was observed in both natural and unnatural causes with suicide is a significant contributor, usually highlighting though, the potentially preventable nature of these deaths. And overall though, it seemed like people who had this condition were at a higher risk. And most people listening to this don't have that. So I want to like throw it out there. You might be like, well, Jordan, why are we talking about this? I want to talk about this as kind of a bridge into health anxiety in general. I thought it was a cool study saying, hey, when we get so far, it's not good for you. It's definitely a concern. But there's a lot of people who have probably some smoldering health anxiety who aren't necessarily, I mean, clinical diagnosis, you know, outside of that diagnosis, but maybe us having symptoms. And so there's lots of real world issues. I think most people, like I said, don't have this and don't have full blown hypochondriasis, but there's a lot of health anxiety out there. A large percentage of people in the biohacking group probably have some type of health anxiety. Now it's not me calling them out by any means. I'm not saying everybody has hypochondriasis. I'm not saying that. I'm just saying that subset of people or people who just really care about their health tend to have a little more health anxiety. They worry about things, right? They worry about these slight changes in the resting heart rate from day to day. They worry about their HRV changes from day to day. They worry about little changes here and there. And they look about their glucose, this, that. And so they're just looking at every variable every day and worrying about it. And my general approach, once again, to worry about the big things. And if we see trends, then absolutely. We got to nip stuff in the butt and say, "Hey, let's make sure this isn't going somewhere bad." But I think people who are very, very hyper-vigilant on their health can sometimes go too far on that spectrum and worry about things. And that's kind of where I'm at is, it's not always bad to worry about that, but it can be detrimental for some people. And what if you are, what if you're someone who says like, "Man, Jordan, thank you for saying that. I listen to these people online and there's so many gurus who are gonna tell me so many things and I don't know what to do. And every day it seems like I have a new food that I can't eat or a new morning routine I have to do. What do I do?" This is the talk for you. So this is what I wanna kind of reiterate to say, "Hey, how do we slow things down and help you through that?" So every day when you consume content or live your life, that you're not worried about your health. That's the main goal of this talk. And the first thing is recognizing this as a problem, right? So if you feel like this is impacting your life, if you were going home at night or lay down at night and you were worried about your health and you don't have a real reason to, but other than you saw it on social media or you saw the small change in number that you had or the small change in lab, that might be an issue. So first step is identifying, that's key number one. And then two is challenge your own thoughts. Are you worried because of something realistic based on evidence or are you catastrophizing? Are you saying, "Hey, my blood glucose was two milligrams per deciliter higher today than normally is on fasting." Or my HRV was a little bit lower today that was like, "Are you worried or are you catastrophizing?" My goal is to always bring people back to center. Like, "Hey, let's check this out. A couple of days isn't a big deal." But that's a checklist as well. Does this have a mechanistic reason for why you should be worried? Is it just a little bit or are you catastrophizing it? That's what I wanna think about. And then another step I think is really important is limit your health media consumption. By health media, I mean things like this. So, "Hey, don't turn off now, don't turn off now." But after this, stop listening and stop. But no, in all seriousness, it can be overwhelming. You listen to a four-hour podcast on someone who claims to be a guru in this thing and talk to you how this specific thing is the most important thing you can do for your health. And then you hear another person saying the exact opposite on another four-hour podcast and it can be overwhelming. And so, if you just push pause and just like turn it off, you will continue to exist, I promise. It's amazing and you'll survive, it's great. But if you feel yourself getting overwhelmed or you have to listen to these podcasts or you have to read these books, you have to do this, it's okay. I give you permission to just like stop doing that stuff and go live life, like that's okay to do. And if you do that, that is fine. I want you to focus on living your life, not minutia. So I want you to focus on the big things and go live life. If you were worried about, I have to get in the morning sun and listen to my podcast and do my meditation, do all this stuff, are all those things good? They absolutely can be, but they're not good if they're causing you to have pathologic worry about if it's the best thing you can do for your health. And so I really always focus on the big things. And then the last thing is find someone you trust, right? And so this is key. I totally recommend to meet with that person, either in the world we can do virtual, but like your local physician or you can do telehealth or something like that, but find someone you trust and can work with and that's your person. That's your point of contact. I think in this world, we have guru here, guru here, guru here, and everyone kind of go all over the internet, listening to people and they get these little samplings and they kind of have all these ideas, but like they're just kind of driving themselves. And I'm all for taking ownership of your health. Like I want you to own your health and you know, you're gonna be the best person for your health by far. Even if I'm your doctor, you're gonna be the best person 'cause you're with yourself all the time. And I'm just with you a little slice here and there, but find someone you trust, who you feel like their approach clicks with you and who doesn't make you worried unnecessarily. Yeah, like if you come to my office and your A1C is like 13 and you have rip-roaring diabetes, I will appropriately, I will say, yeah, this is, I'm concerned, I'm concerned about your risk of all these things and I'm not trying to scare you, but I need to do that. But if you say, hey, go to the doctor and they say, hey, my resting glucose was 92 today, instead of 87 normally, like what's going on? And they say, you gotta do this and that and the other thing. And if they're causing you more anxiety than when you came in with, that's not an ideal relationship. So find someone you trust and that's, it could be anyone. I'm not saying it's me by any chance. And you might be saying, well, why should I believe you, Jordan, don't believe me, walk around, see what you want. But that's just my approach to it is I wanna find people and help people to not be more stressed. I want them to be healthier and less stress is my ultimate goal. And if me talking to you about these things makes you more stressed, then turn off my podcast. I no harm, I do not take that into any offense at all. Everyone's gonna find a person that clicks for them. And that's the thing, find someone who clicks for you and you can trust. And that's really ultimately what it comes down to. I do think that if you are worried about your health, I think it can lead to actual health issues. That's the big takeaway here. Obviously this was a extreme example of people with diagnosed hypochondriasis, but I would not be, I would not doubt that if you had kind of smoldering levels of health anxiety over a long-term that it could also lead to issues. And that's me kind of speculating. Obviously I don't have a study saying this is it, but if you're worried about your health all the time, I think you benefit from just worrying a little bit less about it. And that's if you're on one end. And I'm not saying like, okay, Jordan says do whatever. And then you eat terrible and never exercise. No, obviously I'm not gonna say that. I'm gonna say do the big things. But if you're doing the big things and you're overall, your markers are pretty darn good and solid, like it's okay to say, I'm good. I'm good here, I'm happy here. I've got a good balance in life, that's fine. In this world of optimization medicine, we're all trying to live to 200 or whatever. It's okay to say, hey, you know what, I'm good here. I'm content, I've got solid relationships in my life. I'm overall really healthy. I'm controlling things that I can control. And to go from there, that's totally fine. I wanna give you permission to do that. So thanks for sticking with me on that little rant there. I appreciate it. But overall, a cool study just indicating that, hey, health is important. I want you to care about it, but I don't want you to absolutely own your life 'cause we're more than just our health, right? We are much, much more than that. We've got, you know, we're mind, body, soul, all that. And so that's just a portion of it. But if you did stick along or with me this long, I appreciate it. Thanks for stopping by. And this will be the end of that. But before you go, if you like this and find it helpful, it'd mean the world if you shared this with someone. Sharing it's the best way to kind of spread the podcast and make it grow a little bit. And that'd be awesome just to get this message out to people if possible. Or if you want to comment, that'd be awesome on the podcast and YouTube or subscribe. That's helpful as well. But I really do appreciate you listening. Now get out, get off your phone and get outside and we'll see you next time. - Disclaimer, this podcast is for entertainment, education and informational purposes only. The topics discussed should not solely be used to diagnose, treat or prevent any condition. The information presented here was created with an evidence-based approach, but please keep in mind that science is always changing. And at the time of listening to this, there may be some new data that makes this information incomplete or inaccurate. Always seek the advice of your personal physician or qualified healthcare provider for questions regarding any medical condition.
