Is it Ever Okay for Me to Yell at My Kids?

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Reena Ninan
Episode #219: My Kid is a Hypochondriac. What Can I Do?

It’s the time of the school year when it’s like every concert and exams and projects, and I feel like it all just whirls into one, right? We’re entering that period.

Lisa Damour
It does. Do you know what they call May in schools?

Reena Ninan
No, what are they called?

Lisa Damour
100 Days of May. [Laughter]

Like there’s every darn thing, and you want to be there for all of it, and yes, kind of don’t want to be there for all of it. [Laughter]

Reena Ninan
You’ve nailed it. You’ve completely nailed it.

Lisa Damour
You’re so proud. And there’s other stuff that could be done, too.

Reena Ninan
Yeah, and you’re already thinking graduation, and there’s so much going on for high school parents.

Lisa, I want to get into this letter about when should you worry if your kid is just a total hypochondriac? I’m going to get into it:

“Dear Dr. Lisa and Reena, first, it’s hard to convey how much I appreciate your podcast. Here’s my situation: Our son, who has just turned 17, is responsible, hard, working, diligent and kind. He also has a lot of anxiety, and one way it shows up is around health. If his stomach hurts, he’ll convince himself that it’s an ulcer or stomach cancer, and will want us to take him to the doctor. Even when we do, he never seems to get relief and wants to see more doctors. Also, because he has allergies, we found out, and that has led to a deviated septum. So now we’re getting a consultation for that, and he wants to explore a nose job to possibly straighten his nose, which is incredibly handsome as it is. Finally, he has a small scar on his face from when he was six and fell into a coffee table. He wants to look into getting it lasered off. I could just go on and on. Thank you in advance for your help.”

Is being a hypochondriac a real thing?

Lisa Damour
It is real. We don’t call it that anymore in our written literature, right?

Reena Ninan
How come?

Lisa Damour
I don’t know why. Actually, it’s good question, because it’s everywhere in pop culture. That’s basically what we refer to it as, but in the in the most technical term, we call it “illness anxiety disorder.”

Reena Ninan
I’ve never heard of that.

Lisa Damour
Yeah, well, because it’s our kind of inside baseball of diagnostic upgrades or revisions. But yes, I mean, it’s essentially hypochondriasis, yeah.

Reena Ninan
Why do people do it?

Speaker 1
It’s a lot of reasons. Well, let me ask you this first, Reena: Are you hyperchondriacal at all?

Reena Ninan
I think whatever the opposite of that is, because I’m always like, “Oh no no, you’re fine, you’re fine. That’s not a big deal.” And then I’m realizing, like, you know, my son kept getting stomach aches. “You’re fine, you’re fine. No, no, shake it off. You’re fine.” And then I realized he was actually allergic to certain types of— Like, apples need to be warmed up for five seconds, and carrots, and there’s a name for it. But I was very dismissive.

Lisa Damour
Like, skin, like, is it the skin of fruits and nuts?

Reena Ninan
Yes, that’s right.

Lisa Damour
That’s really interesting. Okay, so this is actually one of the challenges for a parent. Sometimes you’re like, “Ah, you’re being a hypochondriac,” and they’re not. So, I mean, I think that that can make it tricky. And it sounds like there’s a little bit of both of this in the letter. That both the kid is complaining about stomach stuff, that’s just stomach stuff and not ulcers, and he legit had allergies. And I think that sometimes the kid’s right, can complicated situations like this. I will tell you, Reena, I come from a long and proud line of hypochondriacs and have a touch of it myself, as does my older daughter. It’s not impairing, and I think that’s the distinction we make in whether it’s a disorder or whether it’s something. But my mom and I joke when we’re going up, “I’ve got a pimple, you think it might be a tumor?” But then I’m like, “I have this worry about, like, I combined this vitamin and this other thing, and maybe I’m gonna die.” Yeah, I can totally go there. And my older daughter, then will text me, and I’ll be like, “Not to worry. Not to worry.” And my husband will be looking at me like, “Look what you have done.” [Laughter]

Reena Ninan
So how common is it, Lisa? Is this pretty rampant?

Lisa Damour
So in terms of, like, straight up diagnosable, impairs-your-life illness anxiety disorder, it’s 1% of the population, which is actually not that rare. Like, one out of 100 people. But, as we say, “Diagnosis does not cleave nature at its joints.” This occurs on a continuum. What I’m describing of people like me and my mother and my older daughter, where we can spend some time looking stuff up and getting ourselves pretty worked up? That is quite a bit more common.

Reena Ninan
Yeah. Well, I mean, Google is just so at your… Everyone’s diagnosing, and now ChatGPT–

Lisa Damour
Yeah. And I think all physicians would like to get rid of “Dr. Google” and all of that, because it can really play into this stuff.

Reena Ninan
So where does this come from?

Lisa Damour
Okay, so sometimes it comes from my mother to me, to my daughter. Sometimes it does get modeled a little bit. Sometimes, and there’s actually a very interesting line of research about this, there was a real issue. There were some studies looking at kids who had congenital heart malformations that needed to be repaired. Big, scary medical stuff, but then it gets repaired and the kid is totally healthy. There’s nothing really for them to worry about, but there can be ongoing anxiety. So that stuff that is really a nothing burger, the kid will be like, “Is this? Is this? Is this?” They’ll worry in that way, which, of course, makes sense, right? If you’ve had this world rocking surgery or diagnosis, you can see how the kid themselves would feel fragile. You could see how the family might feel that the kid is fragile. So that that can play into it, and that’s sometimes where we see it. There’s also a lot of displaced anxiety. Sometimes we’ll see it in kids where maybe, “Mom drinks too much, and I don’t know what to do about that, and I’m super anxious about that. And so I have free-floating anxiety, and then it’s like, but I also have this pain in my leg, and so I’m gonna focus on that and think about that a lot and worry about that.”

Reena Ninan
So is it lack of control? Like something else has happened and it manifests into, “Okay, this is the way I can sort of deal with it with my body?”

Lisa Damour
“I feel helpless about this, so I’ll focus on that.” Or, “If I think about this, I don’t have to think about that.” That’s an operation that happens in people’s minds. “There’s this thing I can’t do anything about, so I’m going to perseverate on this thing I can crowd my mind with so I don’t have to worry about this other big thing that actually feels even worse.”

And then the other explanation that can sometimes be applicable is: In some families, the way that kids get attention is through their bodies. Maybe the parents aren’t able to tune in to upset feelings and be present and available, but if the kid’s like, “I don’t feel well,” that is the moment where they get tenderness and attention. And so then that can kind of ramp up a, “I’m sure there’s something wrong with my body when there’s really nothing wrong with the body,” if it’s functionally reinforced by a good feeling or a good reaction.

This is why I love my field. People are complicated. There’s one outcome that can you can arrive at it through all of these different paths. There’s not usually one right explanation for everybody, or one same explanation for everybody.

Reena Ninan
So, Lisa, how do you address this?

Lisa Damour
Okay, so here’s the thing that’s hard, and you will totally understand this: Say, I come to you, and you’re my physician, and I’m like, “Drd Reena, see this pimple? I’m sure it’s a tumor.” And you’re a good physician, and you’re like, “No, no.” And you’re also thinking, “Clearly, you’re stressed about something. You’re getting stuck on this garden variety pimple.” What do you think you might say to me, if I’m your patient? How would you tell me to deal with this?

Reena Ninan
I think I would explain why it’s not. Because clearly, you’ve gotten in your head that this is something, and I want you to understand medically why it’s not. But I wouldn’t know where to go after that.

Speaker 2
Because I think what you would hesitate to say is: “Lisa, you’re stressed. Go deal with your stress.” I think that is actually what a lot of times we’re thinking. But the challenge for the clinician is it comes off as really dismissive, right? You have this person in front of you, and a pimple’s a little thing, but the kid who’s like, “I’m sure it’s an ulcer, I’m sure it’s an ulcer. I’m sure it’s an ulcer,” which is happening in this letter… So, yeah, our stomachs get all wonky when we’re stressed. But if the kid is absolutely convinced there’s a medical thing, and maybe the kid has actually other legit medical things, like the allergies, for an adult or a physician to be like, “It’s in your head,” does not usually go over very well. So this is tricky to treat. We have ways, but I think that’s the first hurdle everybody gets stuck on, is telling somebody “It’s in your head” when they are freaking out about their health. It’s not usually a very successful conversation.

Reena Ninan
So where do we go from here, then, right? And also, how do you know when it’s a legitimate illness and when you need to have a conversation that you’re creating problems that aren’t there?

Lisa Damour
Okay, so let me start with the second question, because I think that’s really tough: On the one hand, you’re like, “Okay, well I don’t want to sit here and tell my kid “You’re fine, you’re fine, you’re fine,” and then three months later, be like, “Oh, sorry, you were right.” So parents and caregivers have to make a judgment call about, “Okay, let’s go get it checked out and get it cleared that this is not actually a concern that needs to be dealt with medically.” Do that, if it feels like that’s an important thing to do.

Now, the hesitation in my voice: One of the features of hypochondriasis is that reassurance-seeking becomes very reinforcing. You take the kid to the doctor, the doctor says, “Nope, no, ulcer, you’re good to go.” And the kid’s like, “Okay, great, I feel good for 10 minutes.” But because it was never about the ulcer in the first place, they will then shift to something else, or they’ll be like, “Maybe that doctor didn’t really know.” The anxiety will come back and they’ll want to go back to the doctor or see a different doctor to get the same reassurance. What we have to walk, as the person who can take a kid to a doctor is: When is it gonna at least give the adult the confidence that the kid is healthy, but do that at the risk of actually offering reassurance, which is oddly reinforcing, and it can make things worse?

Reena Ninan
So do you not give the reassurance, then?

Lisa Damour
Well, it’s interesting: When we really treat this over time, part of what we help people do is to stop seeking reassurance, because it actually does play into it. But here’s here’s another way to go at this. And this is, again, why I love people who’ve thought this through and really spend time on it: Rather than focusing on the fact that the kid’s worried about their stomach, once you have every confidence that there’s really nothing wrong there, what the adult can do is actually shift the focus to how unpleasant it is for the kid to worry so much about these pains. And the analogy here, Reena: Either of your kids, were they ever scared of monsters under the bed?

Reena Ninan
Of course, we had monster spray.

Lisa Damour
You had monster spray?

Reena Ninan
Oh, yeah. My mother-in-law got a little spray bottle that she filled with water and put a picture of a monster on it and said, “If you spray it right before you go to bed they all go away.”

Lisa Damour
That’s awesome. And it worked?

Reena Ninan
Oh, totally worked.

Lisa Damour
Cool. Again, control. Like, “There, I did the magic thing. I did the ritual.” It’s fantastic. Now, there’s some kids who don’t have a grandma who comes up with a solution like that that works, and they remain convinced there’s a monster under the bed. And the parent is showing them that there’s nothing there, and they’re getting out the flashlight or whatever, and the kid just stays totally, “Yeah, you’re just not good at finding monsters. I remain scared.” The solution in that moment is not to continue to seek out, like, “See, there’s no monsters.” Because, of course, there was never a monster. Instead, it’s to say: “It must be so scary to worry that there is a monster under your bed.” Because what you’re doing is you’re basically saying “There isn’t,” in so many words, but you’re empathizing with how tortured they are, and you try to address that. Because that’s the actual problem; they are torturing themselves mentally over something that is not real.

So that same framework can shift over to health concerns. The best approach that we have right now is psychoeducation for illness anxiety disorder. To put that in garden variety terms is to say to your kid, “Okay, the doctor has said you don’t have an ulcer. But honey, it is so unpleasant for you to worry this much about your body. You’ve got these worries that are just keeping you up at night. Let’s try to get them under control.” That seems to be a way in that doesn’t feel dismissive and actually helps address the problem.

Reena Ninan
I get it. So when you’re sort of stepping back and saying, “I get it, you’ve got all of these worries,” how do you get to the root of what the problem might be? Or is that not necessarily, what happens when you do this?

Lisa Damour
No, that’s a key question. Okay, so the first thing I would have the loving adult do is, “Okay, this kid is worried about something that’s not real. Is there something real that needs to be addressed?” Because if it’s that mom’s drinking too much, yes. If there’s a way to solve that problem, and we do see this clinically, suddenly the kid’s worries about their body die down. So if you can fix it, fix it. If it is a displaced anxiety, go address the real problem, if you can.

But sometimes it’s just that the kid has gotten themselves stuck, and we see this in a reinforcing cycle that keeps the health anxieties alive. So they do things like they worry, and then they go check online, like we were talking about, and then they find 14 new things that could be wrong with them and that that exacerbates the worry. So the intervention is you worry, and then it triggers these behaviors that actually, in the short term, are meant to make you feel better, but in the long term are making you feel much worse. Can we take those behaviors down a few notches? Taking the kid really seriously, like this is miserable for them. But instead of taking it as a medical thing or just saying “It’s all in your head,” approaching it from the standpoint of “This is real for you, and it even has a name. It’s illness anxiety disorder. And here’s the good news: We can do all sorts of things DIY at home to help bring this down to size.”

Reena Ninan
So having that conversation is an approach that works. Is there anything else that you think parents should think about when they worry that they have got a child who’s a hypochondriac?

Lisa Damour
Start with a really tender… Like, “It may not be the stomach, but it is the fact that you are losing sleep about your stomach, and we can help you with that. I think that you then want to look for reinforcing things, like going to doctors repeatedly.” The reassurance is reinforcing in the short term, and so then as soon as the anxiety comes back, they’re like, “Take me back. I want that short term relief.”

There’s actually courses people can take on illness anxiety disorder, and again, that course model is way less pathologizing than like, “You need to go see a psychologist.” That can feel so dismissive. But there are courses available, and I actually found an online one that we’ll put in the show notes that people can download and do at home. It’s super cool. And one of the things that it talks about is where your attention goes. Because the other thing that we see in hypochondriacal behavior: So say a kid is worried that there’s a pain in their leg, that something is wrong. Then they’ll keep poking at it and bugging it. And then it will kind of start to hurt because they have palpated it so much. And so the other thing that we help kids do is shift attention. “When you’re locked in on this worry about your body, that locked in concern, and then you mess in with it, not thinking about anything else, makes it bigger. Here’s a strategy to shift your attention to help the feelings die down.” So this is all a very long way of saying we can come at this with tenderness. We could come at this without being dismissive and saying, “That’s in your head. Knock it off.” We can come at this saying, “This is a real thing to have outsized worries about illness.” And the resource I found, I just love this so much. The Government of Western Australia put on their website a downloadable workbook for managing illness anxiety disorder. It’s great. It’s totally cool. If you are listening to this and you’re like, “This is my kid,” download this thing, take a look. Either it’ll give you very specific guidance for more conversations, like the ones we’re talking about, or even you and your kid could do this workbook together.

Reena Ninan
Oh, I love a good workbook. That’s that’s really wonderful. So Lisa, as we sort of step back and look at this and look at this letter, one thing that stood out is the talk about a potential nose job and the scar concern. Is this really a hypochondriac? Is this a superficial teen?

Lisa Damour
Yeah, what is this? Okay, so that stuff is not straight down, straight up, hypochondriacal. It’s more in the category of what we would call “body dysmorphic disorder,” which is another disorder, also an anxiety disorder. And again, diagnosis does not cleave nature in its joints. All of these can be overlapping. So body dysmorphic disorder, when it’s full blown, and I don’t think that’s what’s happening here, is when a person becomes preoccupied that there’s something wrong with their appearance. And, like in hypochondriasis, focuses on it really heavily, is messing with it all the time, and it can start to shape behavior: Like they’re sure their nose is ugly and so they won’t leave the house. They will only wear a mask if they go outside. It can become very, very torturous. What I hear in this letter is, I worry about the online stuff around appearance, and I worry that a kid who’s got a scar that they don’t love, if they search a little bit in their social media or their YouTube, that they’re gonna find a whole bunch of people who have all sorts of great ideas about what you could do about that scar and normalize the need for intervention on that. What do you think?

Reena Ninan
You’re saying that just by being online, you’re just bombarded by all of this imagery, and that it’s easy to fall down that rabbit hole,

Lisa Damour
100%. And I feel like I get into algorithms where, if I were vulnerable to it, and maybe at some point I will be, I would become convinced that I need all sorts of treatments and cosmetic interventions that I wouldn’t have otherwise even known about. So I worry about that in this letter, that kids who are already a little anxious and a little bit insecure about appearance or something, combine that with an algorithm that tells them just how to fix the thing, and you can be off to the races.

Reena Ninan
One of the questions we ask on this podcast often is: When do I need to worry as a parent? So with this type of disorder, when do you need to worry? When is there no need to worry, and when do you need to take action immediately?

Lisa Damour
Great questions, Reena. The nice thing is, you can start small with some home interventions. If what I’m recommending here isn’t enough to help. go check out the Government of Western Australia’s awesome website. They will have more help.

When we make a diagnosis of illness anxiety disorder or body dysmorphic disorder, in order to actually meet criteria for the diagnosis, it has to interfere with functioning. A person might not like their nose, but if it doesn’t mess up their lives or get in the way of their day, it’s uncomfortable for them. It’s not nothing, but it’s not a disorder.

Reena Ninan
But if they refuse to go hang out with their their friends because they’re like, “I don’t want them to see my nose,” and that becomes an obsession, then it’s time to worry.

Lisa Damour
So if it interferes with their lives, it’s time to worry.

Reena Ninan
So Lisa, what do you have for us for Parenting to Go?

Lisa Damour
You just got me thinking about a really interesting question in diagnosis and psychology, which is: How do you know when a kid is having real trouble? And the reason it’s so hard is kids do stuff that is totally normal for them, but at other ages in life would be really problematic. Like if I tell you a person threw themselves on the floor in a tantrum, if this is a 20-year-old, something is really up. If this is a three year old, that’s a Wednesday. [Laughter] The behavior itself is not diagnostic. You need more context. Kids do a lot of stuff that at other times of life would be grounds for concern, but in that developmental moment, that’s normal.

The definition of when to worry about a kid, my favorite actually comes from Anna Freud, who was Sigmund Freud’s daughter, and who worked out a lot of child and adolescent psychology. And her definition is: If there’s an interference with progressive development. Kids’ jobs are to be developing, and they’re developing on multiple lines at once: socially, emotionally, self-care, intellectually… They’re supposed to be growing. And so if something halts development or sends it backwards. So your example: It’s one thing to not like your nose. It’s another thing to refuse to hang out with your friends because of your nose. Now we’re seeing an interference with progressive development on the developmental line of social development. Then it’s time to worry. So that’s for me a go-to if you’re like, “Should I worry?” Well, if it’s getting in the way of the kid’s growth, and they have one job, which is to grow, yes.

Reena Ninan
Then it’s time to worry. A lot here to unpack, Lisa. Thank you for walking us through all this. I’ll see you next week.

Lisa Damour
I’ll see you next week.