Look for Horses, Not Zebras

I was recently quite ill for four days. I had severe fatigue, loss of appetite, and shooting pain in my head. Two at-home Covid tests were negative and a third Covid test administered by the ER was negative. After the ER visit ruled out Covid but did not identify the cause of my illness, my imagination filled in the blanks. My anxiety briefly suggested that I may be dying of an incurable disease.

Then, I found a rash on my skin. I quickly texted my niece, who fortunately for me, is a Physician Assistant.

Me: “What is this? Red blotches that aren’t going away. Don’t tell me I’ve got monkeypox.”

My niece: “Do they hurt?” No.

“Are they all in the same area?” No.

“Itch?” No.

“Swollen lymph nodes?” Yes.

“Time to see your doctor. Maybe urgent care. But seriously, where would you have come into contact with monkeypox?”

So, I get an appointment with a doctor.

Me: I describe all of my symptoms, explain my ER visit, and show him my rash.

Doctor: “You know what that is, right?

Me: “Yes. Monkeypox.” In a world with Covid, anything is possible.

The doctor was kind enough not to laugh at my disaster scenario. He then told me I have Lyme disease and gave me antibiotics. Fortunately, my disease was found early, and I should be fine. If discovered late, it could cause death.

Physicians are taught, “When you hear hoofs, look for horses, not zebras.” (Coined in the late 1940s by Dr. Theodore Woodward, professor at the University of Maryland School of Medicine.) The principle is that the odds are the patient has a more common diagnosis than a rare, improbable one. My doctor was certain of his diagnosis and could rule out monkeypox based on the configuration of my rash. Photos of monkeypox are drastically different from my rash.

I periodically have these fleeting worst-case scenario thoughts, or hypochondriasis traits, also known as health anxiety. Hypochondriasis is defined as excessive worry about having a serious illness. I’m not alone. One study has shown it to affect about 3% of the visitors to primary care settings and 5 to 7 percent of the general population. For hypochondriasis to be considered an illness, it must disrupt the patient’s normal functioning and quality of life. Women are ten times more likely to have hypochondriasis than men.

Cognitive Behavioral Therapy (CBT) would ask, “What’s the realistic likelihood that the worst-case scenario is true.” One way to reduce health anxiety is by reducing reassurance-seeking through internet searches and statistics. Reassurance seeking is the act of continuously trying to gather information. This is because while reassurance-seeking might reduce distress in the short term, it doesn’t reduce health-related worry in the long term. It increases worry over time. It can become debilitating. Hypochondriasis puts you at risk for financial struggles due to medical bills and missed work, medical disability and unemployment, and unnecessary medical tests and potential test complications.

If you know someone with disaster medical scenarios, there are things you should not say.

• “It’s all in your head.” No matter how bizarre their belief is, be compassionate. They are truly worried.
• Don’t ruminate with a hypochondriac on what’s making them anxious. It could fuel their fears.
• “I’m sure you’re fine” is dismissive and will prevent them from sharing their fears with you again.

What should you do? Refer them to appropriate medical care and encourage them to think horse, not zebra.