Hypochondriasis
Hypochondriasis and the other somatoform disorders are among the most difficult and most complex psychiatric disorders to treat in the medical setting. Because of many new developments in this field, diagnostic criteria have been revised to facilitate clinical care and research, and more empirical research is being performed. As with all psychiatric disorders, the somatoform disorders demand creative, intricate biopsychosocial treatment planning by a team that includes psychiatrists, primary care physicians, and many other health professionals. This article briefly describes hypochondriasis and its diagnosis and provides an overview of treatment, with a number of references for details beyond the scope of the article. Finally, the article reviews new developments in psychopharmacologic and psychosocial treatment. Neurochemical deficits associated with hypochondriasis and some other somatoform disorders (eg, somatization, conversion, and body dysmorphic disorders) appear similar to those of mood and anxiety disorders. For example, in 1992, Hollander et al posited an "obsessive-compulsive spectrum" that includes obsessive-compulsive disorder (OCD), body dysmorphic disorder (BDD), anorexia nervosa, Tourette syndrome, and impulse control disorders (eg, trichotillomania, pathological gambling).
This formulation of obsessive-compulsive spectrum disorders, while not a part of the consensus psychiatric diagnostic and classification literature, crosses boundaries of several diagnostic categories in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition-Text Revision (DSM-IV-TR). In addition, it is not unusual to encounter a patient with more than one of the obsessive-compulsive spectrum disorders during his or her life. Although findings from studies of these neurochemical deficits are only preliminary, such deficits may explain why symptoms overlap, why the disorders are commonly comorbid, and why effective treatments parallel one another (eg, selective serotonin reuptake inhibitors [SSRIs]).
- In the US: The prevalence rates for primary hypochondriasis in the primary care setting range from 0.8-4.5% (Magariños, 2002). Some degree of preoccupation with disease apparently is common; 10-20% of people who are healthy and 45% of people without a major psychiatric disorder have intermittent, unfounded worries about illness (Kellner, JAMA, 1987).
- Internationally: Rates are similar to those in the United States.
Hypochondriasis is usually episodic, with hypochondriacal periods lasting from months to years and with equally long quiescent periods. Although formal outcome studies have not been conducted, one third of patients with hypochondriasis are believed to eventually experience significant improvement in their condition. A good prognosis appears to be associated with high socioeconomic status, treatment-responsive anxiety or depression, the absence of a personality disorder, and the absence of a related nonpsychiatric medical condition. Most children are believed to recover by adolescence or early adulthood, but empiric studies have not been performed. Epidemiological studies are lacking, but the characteristics of patients with hypochondriasis appear similar to those of patients with somatization disorder. These individuals use medical care at high rates, including frequent emergency department visits, doctor and other health care provider visits, physical examinations, laboratory testing, and other costly, invasive, and potentially dangerous procedures (Barsky, Med Care, 2001). These high-use patterns differ dramatically from those of nonsomatizing patients, even when comorbid medical conditions and sociodemographic differences are taken into consideration (Barsky, Am J Psychiatry, 2001). Cognitive, social learning, and psychodynamic theories imply that patients have significant psychosocial disturbances in terms of relationship, vocational, and other endeavors. Exacerbations may occur with psychological stressors and in patients with comorbid psychiatric conditions. Patients with hypochondriasis have a high rate of psychiatric comorbidity (Barsky, 1992). In one general medical outpatient clinic, 88% of patients with hypochondriasis had one or more concurrent disorders, the most common being generalized anxiety disorder (71%), dysthymic disorder (45.2%), major depression (42.9%), somatization disorder (21.4%), and panic disorder (16.7%). These patients are 3 times more likely to have a personality disorder than the general population (Barsky, 1992). Substance abuse and dependence are also serious comorbid conditions, particularly abuse or dependence on benzodiazepines. However, epidemiological studies have not been completed to assess the exact frequency of this problem. More information is also needed with regard to hypochondriasis and its relationship to other disorders (eg, neurasthenia, chronic fatigue syndrome, fibromyalgia, multiple chemical sensitivity syndrome). This disorder has not been well studied with respect to race and ethnicity. Hypochondriasis appears to occur equally in men and women. Hypochondriasis can begin at any age, but the most common age of onset is early adulthood.
Hypochondriasis is classified as one of the somatoform disorders, a class that was formulated to accommodate the differential diagnosis of disorders characterized primarily by physical symptoms for which no demonstrable organic cause can be found. The DSM-IV-TR stipulates that the symptoms are not under voluntary control (thus excluding malingering and factitious disorders) and are not fully explained by known physiological causes (excluding psychological factors affecting the medical condition). The disorders in the somatoform class include somatization disorder, conversion disorder, pain disorder, hypochondriasis, BDD, and undifferentiated somatoform disorder.
- The core feature of hypochondriasis is not preoccupation with symptoms themselves, but rather the fear or idea of having a serious disease. The fear or idea is based on the misinterpretation of bodily signs and sensations as evidence of disease. The illness persists despite appropriate medical evaluations and reassurance.
- The diagnosis should be considered strongly if the patient has a history of hypochondriasis (or other somatization disorder) or has had multiple workups and if the patient's complaints are markedly inconsistent with objective findings or the examination yields no abnormal findings. Further psychiatric history should be obtained with regard to a history of hypochondriasis (or corresponding behaviors) in family members or a sudden, unexplained loss of function that spontaneously resolved. Consideration for, and confidence in, a diagnosis of hypochondriasis is also increased if the patient changes emphasis with regard to key symptoms or describes new symptoms inconsistent with others.
- Diagnostic criteria for hypochondriasis include the following:
- The patient has a preoccupying fear of having a serious disease.
- The preoccupation persists despite appropriate medical evaluation and reassurance.
- The belief is not of delusional intensity (as in delusional disorder, somatic type) and is not restricted to a concern about appearance (as in persons with BDD).
- The preoccupation causes clinically significant distress or impairment.
- The preoccupation lasts for at least 6 months.
- The preoccupation is not explained better by another mood, anxiety, or somatoform disorder.
- The absence of physical findings, particularly after serial examinations, supports the diagnosis of hypochondriasis. An examination of the patient's mental status complements the physical examination.
- General appearance, behavior, and speech
- Modestly or well groomed and not grossly disheveled
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Alert; cooperative with the examiner, yet ill at ease and not easily reassured
- Possible signs of anxiety, including moist hands, perspiring forehead, strained or tremulous voice, and/or wide eyes and intense eye contact
- Psychomotor status
- Restless
- Frequent shifts in posture
- Agitation
- Slowed, if sleeping poorly
- Mood (the pervasive and sustained emotion that colors the patient's perception of the world) and affect (what the examiner observes)
- Anxious or worried, depressed, or futile mood
- Restricted, shallow, fearful, or anxious affect, with fluctuations and limited depth
- Spontaneous speaking with occasional abrupt changes in topic within an underlying theme
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Responds to questions but may divert to next worry or revert to an already expressed concern despite reassurance to the contrary
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No latency unless also depressed
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No thought blocking, looseness of associations
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Concrete focus of thought, but with capacity to abstract in a number of areas when encouraged or tested
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May appear distractible and yet can concentrate independently and with encouragement
- Preoccupation with being ill
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Anxious themes concerning what in the body is wrong, how it is wrong, and how it is experienced
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May have guilt, which is not usually linked to the preoccupations
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May have feelings of despair and/or hopelessness, although these are not usually of significant depth unless little relief has come from seeing multiple providers and/or the patient concurrently depressed
- Catastrophizing tendencies
- Inflexibility regarding bodily concerns, but only rarely to the point of a delusion (ie, fixed, false belief), and if so, limited to somatic complaints rather than grandiose or persecutory complaints
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No suicidal ideation, unless concurrently depressed
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Oriented fully to time, place, and person
- Rare difficulties with concentration, memory, and other faculties, but functions in the normative range with refocusing and encouragement
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May have some deficits if concurrently depressed, which also tend to be overcome in response to encouragement
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May have selective attention (eg, patient distressed by an ongoing bodily complaint but not by a newly sprained ankle)
- Able to recognize bodily sensations
- Lacks a full understanding of underlying psychological concerns and how they underpin development and maintenance of bodily complaints; tends to see the "trees" rather than the "forest"
- Some awareness of own feelings about people and events, but not always with the ability to translate that into action, sustained change in mood, or lessening of preoccupations
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- Capable of social greetings and other behaviors
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Because of limited insight, persistent discussion of ongoing preoccupations, accompanied by equally persistent attempts to have them evaluated
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May be impaired if concurrently depressed
Developmental and other predisposing factors consistently indicate the importance of parental attitudes toward disease, previous experience with physical disease, and culturally acquired attitudes relevant to the etiology of the disorder (Ball, 1990). Overall however, few demographic and clinical differences have been found between patients with hypochondriasis and the general population. Social position, education level, and marital status do not appear to be factors in this condition.
- A cognitive model of hypochondriasis suggests that patients misinterpret bodily symptoms by augmenting and amplifying their somatic sensations. Patients also appear to have lower-than-usual thresholds for, and tolerance of, physical discomfort. For example, what most people normally perceive as abdominal pressure, patients with hypochondriasis experience as abdominal pain. When they do sustain an injury (eg, ankle sprain), it is experienced with significant anxiety and is taken as confirmation of their worry about being ill. This may be due to a tendency among patients with hypochondriasis to exaggerate their assessment of vulnerability to disease and their appraisal of the risk of serious illness (Barsky, Am J Psychiatry, 2001).
- The social learning theory frames hypochondriasis as a request for admission to the sick role made by a person facing seemingly insurmountable and insolvable problems. This role may allow them to avoid noxious obligations, postpone unwelcome challenges, and be relieved from duties and obligations.
- The psychodynamic theory implies that aggressive and hostile wishes toward others are transferred via repression and displacement into physical complaints. The hypochondriacal symptoms serve to "undo" guilt felt about the anger and serve as a punishment for being "bad."
- Neurochemical deficits with hypochondriasis and some other somatoform disorders (eg, BDD) appear similar to those of depressive and anxiety disorders. For example, the aforementioned obsessive-compulsive spectrum described by Hollander et al in 1992 includes OCD, BDD, anorexia nervosa, Tourette syndrome, and impulse control disorders (eg, trichotillomania, pathological gambling). Although only preliminary data have been reported on these neurochemical deficits, such deficits may explain why symptoms overlap, why the disorders are commonly comorbid, and why treatments may parallel one another (eg, SSRIs).
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