Description

• Preoccupation with fears of having, or idea that one has, serious disease based on misinterpretation of bodily symptoms  
• One in a group of disorders (including somatization, somatoform and pain disorders) characterized by patient complaints of physical symptoms without apparent cause
• Distinguishing features of hypochondriasis include 
    — Preoccupation with fear of a particular disease 
    — Interpretation of minor physical complaints as a sign of severe or catastrophic illness 
    — Fear persists despite evaluation and reassurance by one or more health-care providers. 
    — Patients may frequently change health-care providers.

ICD-9 codes

• 300.7 Hypochondriasis

Organs involved

• No organic illness related to symptomatology (by definition)

Prevalence and risk factors

• Estimated prevalence in the general public (United States and Europe) varies from <1% to 6%, depending on the specific population studied and the exact criteria used.
• No difference in incidence by gender or age (although older female patients in general are more likely to be affected by somatization disorders)
• May be associated with history of significant illness in the patient or patient’s family during childhood


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Causes

• May be associated with a history of traumatic personal experience
• Worsening of symptom(s) often associated with patient anxiety/fear

Associated conditions

• Obsessive compulsive disorder
• Depression
• Anxiety
• Panic disorder

Patient history

• Patient complaints are usually 
    — Described as physical sensations having ambiguous characteristics 
    — Focused on specific bodily functions or benign physical abnormalities 
• Medical/social history often significant for  
    — Patient self-description as being “conscientious” or “a worrier” 
    — Extensive searching of Internet for health information
    — Self-medication with multiple herbal remedies 
    — “Body hypervigilance” (checking the body/bodily functions)
    — Transient, limited reduction in anxiety with provider reassurance, and frequent “doctor shopping”

Making the diagnosis

• Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV) criteria 
    — Preoccupation with fears of having, or idea that one has, serious disease based on misinterpretation of bodily symptoms 
    — Preoccupation persists despite appropriate medical evaluation and reassurance. 
    — Exclude diagnosis if belief of delusional intensity or restricted to circumscribed concern about appearance. 
    — Distress or impaired functioning 
    — Duration longer than six months 
• Some psychiatric literature suggests diagnosis can be made based on such factors as “illness worry,” functional impairment, and excessive use of health-care resources. 
• Consider alternative psychiatric diagnoses, including 
    — Depression/anxiety disorders 
    — Personality, delusional, malingering, or factitious disorders 
    — Somatization or psychogenic pain disorder 
• Exclude true, organic illness (e.g., actual MI with complaint of chest pain).

Prognosis

• Disease is typically chronic and characterized by periodic remissions and exacerbations (usually associated with an identifiable stressor). 
• Worse outcomes are generally associated with a history of more severe symptoms, longer duration of illness, and other concurrent psychiatric illnesses.

Medical/pharmacological treatment

• Thorough medical evaluation and management by (ideally) a single primary-care clinician  
• Type of interaction with health-care provider is important and should stress  
    — Reassurance (although may not necessarily be helpful)  
    — Warm empathetic manner 
    — Subtle encouragement to express feelings 
    — Education about physiologic and psychophysiologic processes 
    — Using less stigmatizing terms for hypochondriasis, such as illness anxiety or health anxiety disorder  
• Some evidence for efficacy of serotonin-specific reuptake inhibitors (especially fluoxetine [Prozac]), but evidence regarding pharmacotherapy is generally limited. 

Counseling

• Medical and psychiatric literature contains extensive evidence demonstrating efficacy of psychotherapy for improvement in symptoms of hypochondriasis. For example: 
    — Recent Cochrane review (2007) found various forms of cognitive and behavioral therapy to be associated with significant alleviation of symptoms. 
    — Cognitive behavioral therapy (CBT) 

    • 2004 study found that six weeks of CBT resulted in significant improvement in social functioning and ability to carry out activities of daily living.  
    • 2007 study suggested that 16 weeks of CBT may be superior to both paroxetine (Paxil) and placebo.  
    • 2008 study found short course of CBT resulted in significant reduction in “health anxiety,” generalized anxiety, and depression.

    — Older (1998) study found that cognitive therapy may reduce “health anxiety” better than behavioral stress management or no therapy.  
    — 2002 study found that group cognitive-educational approach seemed to be effective for 21 patients with hypochondriasis. 

• Explanatory therapy (education, reassurance, and facilitation of patients’ learning to perceive somatic symptoms free of anxiety) reported to reduce health-care utilization (2000 study). 

For complete references, see www.ebscohost.com/dynamed/.