Its difficult enough dealing with episodes of depression, mania and hypomania. Its made even worse when imagined emotional and somatic symptoms inhibit treatment.

Yet these imagined ailments, indicators of hypochondria, are common in those of us with bipolar disorder.

Hypochondria during mania, when feelings of self-esteem and invincibility are high, is rare, although imagined illnesses or threats may spike as manic episodes end. During hypomania or depression hypochondria is much more common.

Perhaps for this reason, people with bipolar disorder 2, who are more prone to hypomania and depression, are more likely to exhibit hypochondria than people with BP 1, who experience more mania.

Hypochondria is the preoccupation with having or acquiring a serious illness, most often a chronic physical illness. It splits into four factors:

Patho-thanatophobia reflects the fears of serious injury or death. Symptom effect describes the effects of symptoms on everyday life and work. Treatment seeking reflects the action of disease treatment and prevention. Hypochondriacal beliefs are the doubts of being healthy despite medical reassurance.

These four factors make up what we know as hypochondria, and all are found with disproportionate frequency in people with bipolar disorder.Two of them, however, are especially pernicious.

Patho-thanatophobia fuels anxiety and is incredibly difficult to treat and reverse. This anxiety provoking fear of injury or death is actually more common in people with BP2 than it is in people with generalized anxiety disorder.

Treatment seeking clogs the healthcare system and reinforces the BP patients emphasis on things that are wrong with them, especially in hypomanic episodes, instead of fostering the promise of good health that is both possible and positive for people with BP.

Hypochondria in people with BP can be predictive in two ways. First, people with high levels of hypochondria are more likely to attempt suicide and suffer poorer outcomes when given standard treatment for BP. Also, increased hypochondriacal ideation often co-occurs with, or even precedes, episodes of hypomania and/or depression.

People in mania experience fewer incidences of hypochondria due to the grandiosity and feelings of invincibility and narcissismcommon in manic episodes.

Its not only physical diseases that people with BP imagine suffering from. Many also believe they exhibit symptoms of mental illnesses unrelated to their own bipolar disorder. I remember during a hospitalization when a staff member unwisely left a copy of the DSM 4 on the coffee table in the day room. Another patient and I scoured the book and compared our experience to any number of recognized disorders.

We were convinced that the doctors were wrong and we both, in fact, should have been diagnosed with borderline personality disorder. We demanded to be reassessed and began to exhibit symptoms of BPD. Much of the progress we had made to that point was lost.

Its no surprise that high levels of neuroticism are correlated with high levels of hypochondria. Its also no surprise that high levels of hypochondria significantly set back gains in treatment and make positive outcomes in BP much less likely.

It takes information, courage and humility to admit youre wrong, especially on feelings about your own health. However, cognitive impairment during episodes of hypomania and depression, or late-stage manic episodes, may make this self-awareness difficult, if not impossible.

The neuroticism that breeds hypochondria is intransigent and eludes easy treatment.

To this end we must be open to the conclusions of medical experts and the evidence against our perceived illnesses. With bipolar disorder we have enough challenges to treat and overcome. Adding imagined ones only makes a very difficult road even more harrowing to navigate.