BASICS
DESCRIPTION
- In DSM-5 75% of patients with hypochondriasis are classified in the new diagnostic category of somatic symptom disorder (300.82) and 25% of patients with hypochondriasis are now classified in the new diagnostic category of illness anxiety disorder (300.7) (1).
- 6 months existence of the following:
- ≥1 physical symptoms associated with the belief that these physical symptoms are a manifestation of an underlying serious illness.
- Fear and anxiety that a serious illness is present in the body and, unless treated, may cause significant harm and lead to death or serious impairment and disability.
- Standard medical workup and reassurance that such a serious illness is not present is not effective in curing the fear.
- The patient's beliefs have an obsessive quality.
- The patient typically is engaged in behaviors seeking a physical diagnosis that would explain his or her somatic symptoms.
- Synonym(s): hypochondriacal neurosis; hypochondria; health anxiety; cyberchondria.
EPIDEMIOLOGY
Incidence
- Predominant sex: male = female; women tend to seek help more frequently than men.
- Predominant age: Most common onset is in the 3rd to 4th decade of life.
Prevalence
- In the United States, 1-4.5% of the general population
- 4-6% of medical outpatients meet criteria for hypochondriasis.
- In 25-50% of all primary care visits, no physical cause is found to explain the patient's presenting symptoms (2)[A].
ETIOLOGY AND PATHOPHYSIOLOGY
- Biologic: Some evidence suggests that patients with hypochondriasis may have a lower threshold and a lower discomfort tolerance. Recent studies suggest that hypochondriacal patients have smaller pituitary volumes.
- Childhood events: The experience of numerous or serious actual medical illnesses during childhood may predispose to hypochondriasis at a later age.
- Life events: Experience of life-threatening medical diseases may predispose some to become overly sensitive to physical symptoms and overly worried about the recurrence of an acute relapse of chronic illness. These illnesses may be experienced by the patient or by a close family member or friend.
- Psychodynamics: Some view hypochondriasis as the patient's psychodynamic manifestation of coping with intrapsychic subconscious emotions of guilt, shame, low self-esteem, and a narcissistic overindulgence with self; others, as a manifestation of an individual's need for attention by overly identifying with the sick role, which offers an acceptable way of alleviating anxiety by seeking valid reassurance from a medical authority
- Anxiety/depression: Some patients with an underlying anxiety or depressive disorder experience their psychiatric illness in the form of physical symptoms, which in some patients may become a chronic behavior, turning into a full-blown hypochondriasis even after their underlying anxiety or depression has been alleviated.
- Sociocultural: Some cultures view mental and emotional symptoms in a pejorative way, blaming the patient for the illness when the symptoms are mental and feeling more empathy when the symptoms are physical. In such cultures, patients with physical symptoms get more attention, empathy, and respect and are not blamed for causing their illness.
- Cognitive: Patients with hypochondriasis overestimate their risk of developing a serious illness. They also tend to minimize their past experiences and behaviors of good health.
Genetics
Some studies show an increased prevalence of hypochondriasis in families, especially among identical twins and first-degree relatives.
RISK FACTORS
- Exposure to life-threatening medical conditions in self or others and multiple medical procedures in childhood, adolescence, or adult life
- Being raised by an overprotective parent who is obsessed with excessive worries about health and illness
- Family history of hypochondriasis
COMMONLY ASSOCIATED CONDITIONS
- Anxiety disorders
- Depressive disorders: up to 40%
- Obsessive-compulsive disorder
- Somatization disorder
- Conversion disorder
- Pain disorder
- Body dysmorphic disorder
- Undifferentiated somatoform disorder
- Personality disorders
DIAGNOSIS
According to DSM-5, hypochondriasis is classified in the Somatic Symptom and Related Disorders section. Somatic symptom disorder and illness anxiety disorder are now the new diagnostic home for hypochondriasis.
- Somatic symptom disorder (300.82)
- ≥1 distressing somatic symptoms that result in significant disruption in daily life
- Excessive thoughts, feelings, and behaviors related to the somatic symptoms as manifested by at least one of the following:
- Excessive and persistent thoughts focused on the seriousness of symptoms
- Persistent high anxiety about one's health and symptoms
- Excessive time and energy devoted to such symptoms or health concerns
- The state of being symptomatic is persistent for >6 months.
- Patients previously diagnosed with a pain disorder should be classified as having a somatic symptom disorder with predominant pain.
- Illness anxiety disorder (300.7)
- Preoccupation with having or acquiring a serious illness
- Somatic symptoms are not present or very mild.
- High level of anxiety and worry about one's health
- Performing excessive self-exams, checking for signs of disease or maladaptive avoidance of doctors, labs, health clinics, and hospitals
- Preoccupation with illness has been present for >6 months.
- The illness-related anxiety and preoccupation is not better explained by another mental disorder such as somatic symptom disorder, panic disorder, generalized anxiety disorder, body dysmorphic disorder, obsessive-compulsive disorder, or delusional disorder-somatic type.
- The diagnosis of illness anxiety disorder should specify whether the patient has a care-seeking type or a care-avoidant type of this diagnosis.
HISTORY
- Patient may report the following common concerns:
- Worry about sensations associated with normal body functions, such as heartbeat or diaphoresis, intestinal peristalsis, hiccups, flatulence, and so forth.
- Minor physical abnormalities, such as a small rash or rare cough
- Vague physical sensations
- Attributes symptoms to a disease of concern
- May focus on multiple systems or a single disease
PHYSICAL EXAM
A thorough physical exam reveals no abnormalities or findings that are compatible with the reported symptoms and their severity.
DIFFERENTIAL DIAGNOSIS
- Any patient suffering from hypochondriasis, as with any other psychiatric disorder, is not immune from developing a medical/organic disease. Organic diseases that affect many organ systems, such as connective tissue diseases and autoimmune diseases, as well as more focused single-organ-type diseases, always must be considered as a possibility in these patients.
- Underlying clinical depression
- Schizophrenia
- Delusional disorders
- Conversion disorder
- Anxiety, panic, or obsessive-compulsive disorders
- Factitious disorder with physical symptoms
- Body dysmorphic disorder
- Malingering
- M ¼nchausen syndrome
DIAGNOSTIC TESTS & INTERPRETATION
Initial Tests (lab, imaging)
- Lab tests are used to rule out organic diseases.
- Regular follow-up appointments, including a physical exam, are helpful to reassure the patient that no new disease has emerged.
Follow-Up Tests & Special Considerations
Such patients have the tendency to request unnecessary lab and radiology tests.
Diagnostic Procedures/Other
- Care to avoid nonessential tests; do not perform tests solely to provide reassurance because the reassurance is likely to be short-lived (3)[A].
TREATMENT
The goals of treatment should focus on improving the patient's quality of life, symptom relief, and protecting the patient from the potential hazards of unnecessary and excessive laboratory and radiologic procedures.
GENERAL MEASURES
- Treatment should focus on a careful history and physical exam, with clear and straightforward explanations of any findings.
- Regular medical appointments with clear goals and repeated reassurance with adequate explanation
- Patients may perceive referral to a psychiatrist as dismissive of concerns.
- Some evidence suggests cognitive-behavioral therapy (CBT) is helpful to improve hypochondriacal concerns and overall functioning:
- Explains that focusing on a symptom tends to increase its intensity
- Describes anxiety or depression as worsening physical symptoms
- Teaches distraction techniques
- Group therapy using a CBT model can help to reduce hypochondriacal concerns and anxiety for at least 1 year after treatment (4)[B].
- A good doctor-patient relationship is essential:
- Physicians should be careful with their words: Avoid suggestions of possible diseases.
- Schedule regular appointments even if no new symptoms or findings are present.
MEDICATION
No specific medications have been proven to be curative for hypochondriasis (5)[B].
First Line
- Antidepressants and antianxiety medications are most successful in patients who have a preponderance of anxiety or depressive symptoms (6)[A].
- Selective serotonin reuptake inhibitors (SSRIs) are commonly used (7)[A]:
- Citalopram (Celexa): 20 to 60 mg/day
- Escitalopram (Lexapro): 10 to 40 mg/day
- Fluoxetine (Prozac, Sarafem): 20 to 80 mg/day
- Fluvoxamine maleate (Luvox CR): 100 to 300 mg/day
- Paroxetine (Paxil CR): 10 to 75 mg/day
- Sertraline (Zoloft): 50 to 200 mg/day
Second Line
- Clomipramine (Anafranil): 100 to 250 mg/day
- Desvenlafaxine (Pristiq): 50 to 100 mg/day
- Duloxetine (Cymbalta): 30 to 120 mg/day
- Venlafaxine (Effexor): 37.5 to 300 mg/day
ISSUES FOR REFERRAL
Consult with a psychiatrist when
- Patients do not respond to your treatment.
- Patients become suicidal.
- Comorbid psychiatric illness is present.
ADDITIONAL THERAPIES
Psychotherapy focused on a therapeutic alliance using supportive interventions with reassurance is very important. In addition, CBT, mindful meditation, guided imagery, and family therapy have also been found helpful.
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Protect the patient from unnecessary and excessive laboratory and radiologic tests.
Patient Monitoring
- Patients should be seen on a regular basis.
- Appointments should be scheduled regardless of whether the patient has new symptoms.
- Avoid the use of hospitalizations and unnecessary lab workups.
DIET
Healthy nutrition
PATIENT EDUCATION
- Clear explanations of all test results and their significance.
- Patients may benefit from watching the following movies:
- Hannah & Her Sisters (1986)
- Send Me No Flowers (1964)
- Up in Arms (1944)
PROGNOSIS
The natural history of this condition is usually chronic. 50-70% will continue to meet diagnostic criteria after 1 year.
COMPLICATIONS
Risk of repeated and unnecessary laboratory and diagnostic procedures
REFERENCES
11 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013:309-327.22 olde Hartman TC, Borghuis MS, Lucassen PL, et al. Medically unexplained symptoms, somatisation disorder and hypochondriasis: course and prognosis. A systematic review. J Psychosom Res. 2009;66(5):363-377.33 H ¶fling V, Weck F. Assessing bodily preoccupations is sufficient: clinically effective screening for hypochondriasis. J Psychosom Res. 2013;75(6):526-531.44 S ¸rensen P, Birket-Smith M, Wattar U, et al. A randomized clinical trial of cognitive behavioural therapy versus short-term psychodynamic psychotherapy versus no intervention for patients with hypochondriasis. Psychol Med. 2011;41(2):431-441.55 Barsky AJ. Clinical practice. The patient with hypochondriasis. N Engl J Med. 2001;345(19):1395-1399.66 Creed F, Barsky A. A systematic review of the epidemiology of somatisation disorder and hypochondriasis. J Psychosom Res. 2004;56(4):391-408.77 Schweitzer PJ, Zafar U, Pavlicova M, et al. Long-term follow-up of hypochondriasis after selective serotonin reuptake inhibitor treatment. J Clin Psychopharmacol. 2011;31(3):365-368.
ADDITIONAL READING
- Hanly C. Narcissism, hypochondria and the problem of alternative theories. Int J Psychoanal. 2011;92(3):593-608.
- Hedman E, Lj ³tsson B, Andersson E, et al. Effectiveness and cost offset analysis of group CBT for hypochondriasis delivered in a psychiatric setting: an open trial. Cogn Behav Ther. 2010;39(4):239-250.
- Nakao M, Shinozaki Y, Nolido N, et al. Responsiveness of hypochondriacal patients with chronic low-back pain to cognitive-behavioral therapy. Psychosomatics. 2012;53(2):139-147.
- Neng JM, Weck F. Attribution of somatic symptoms in hypochondriasis. Clin Psychol Psychother. 2015;22(2):116-124.
- Starcevic V. Hypochondriasis and health anxiety: conceptual challenges. Br J Psychiatry. 2013;202(1):7-8.
- Taylor L, Brooks B. Strategies to manage the patient with health anxiety. JAAPA. 2013;26(1):61-62.
- Weck F. Treatment of mental hypochondriasis: a case report. Psychiatr Q. 2014;85(1):57-64.
- Weck F, Neng JM, Richtberg S, et al. Dysfunctional beliefs about symptoms and illness in patients with hypochondriasis. Psychosomatics. 2012;53(2):148-154.
- Williams MJ, McManus F, Muse K, et al. Mindfulness-based cognitive therapy for severe health anxiety (hypochondriasis): an interpretative phenomenological analysis of patients' experiences. Br J Clin Psychol. 2011;50(4):379-397.
CODES
ICD10
- F45.21 Hypochondriasis
- F45.22 Body dysmorphic disorder
- F45.29 Other hypochondriacal disorders
- F45.20 Hypochondriacal disorder, unspecified
ICD9
- 300.7 Hypochondriasis
- 300.82 Undifferentiated somatoform disorder
SNOMED
- Hypochondriasis (disorder)
- body dysmorphic disorder (disorder)
- Hypochondriacal pain (disorder)
CLINICAL PEARLS
- Hypochondriasis is the preoccupation with fears of having, or the idea of having, a serious disease that persists despite appropriate medical evaluation and reassurance.
- The natural history of hypochondriasis is usually chronic: 50-70% of patients will continue to have symptoms after 1 year of treatment. Most patients require lifelong follow-up and reassurance.
- Although no specific medications have been proven effective, antidepressants and antianxiety medications (especially SSRIs) are most successful in hypochondriasis patients who have a preponderance of anxiety or depression symptoms.
- Some evidence suggests that CBT is helpful in improving hypochondriacal concerns and overall functioning.
- Patients respond best in a stable and trusting relationship with a physician whom they perceive as caring, kind, nonjudgmental, patient, reassuring, understanding, and able to deal appropriately with areas of uncertainty in the practice of medicine.
- Set up regular outpatient office visits regardless of the patient's symptoms; appointments should be kept even if patients report an improvement.
- During the appointment, the physician should perform a complete physical examination and report the results to the patient focusing on the use of positive reassuring words.