Hypochondriasis

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Definition

The primary feature of hypochondriasis is excessive fear of having a serious disease. These fears are not relieved when a medical examination finds no evidence of disease. People with hypochondriasis are often able to acknowledge that their fears are unrealistic, but this intellectual realization is not enough to reduce their anxiety. In order to qualify for a diagnosis of hypochondriasis, preoccupation with fear of disease must cause a great deal of distress or interfere with a person's ability to perform important activities, such as work, school activities, or family and social responsibilities. Hypochondriasis is included in the category of somatoform disorders in the Diagnostic and Statistical Manual of Mental Disorders ( DSM-IV-TR ), which is the reference handbook that clinicians use to guide the diagnosis of mental disorders. Some experts, however, have argued that hypochondriasis shares many features with obsessive-compulsive disorder or panic disorder and would be more appropriately classified with the anxiety disorders.

Description

The fears of a person with hypochondriasis may be focused on the possibility of a single illness, but more often they include a number of possible conditions. The focus of the fears may shift over time as a person notices a new symptom or learns about an unfamiliar disease. The fears appear to develop in response to minor physical abnormalities, like fatigue , aching muscles, a mild cough or a small sore. People with hypochondriasis may also interpret normal sensations as signs of disease. For instance, an occasional change in heart rate or a feeling of dizziness upon standing up will lead a person with hypochondriasis to fears of heart disease or stroke . Sometimes hypochondriacal fears develop after the death of a friend or family member, or in response to reading an article or seeing a television program about a disease. Fear of illness can also increase in response to stress . Individuals with hypochondriasis visit physicians frequently; and when told there is nothing physically wrong, they are likely to seek a second opinion since their fears are not soothed. Their apparent distrust of their physicians' opinions can cause tensions in doctor-patient relationships, leading to the patient's further dissatisfaction with health care providers. Physicians who regularly see a patient with hypochondriasis may become skeptical about any reported symptom, increasing the danger that a real illness may be overlooked. People with hypochondriasis also run the risk of undergoing unnecessary medical tests or receiving unneeded medications. Although they are usually not physically disabled, they may take frequent sick days from work, or annoy friends and family with constant conversation or complaints about illness, reducing their ability to function effectively in some aspects of life.

Causes and symptoms

Causes

AMPLIFICATION OF SENSORY EXPERIENCE. One theory suggests that people with hypochondriasis are highly sensitive to physical sensations. They are more likely than most people to pay close attention to sensations within their bodies (heart rate, minor noises in the digestive tract, the amount or taste of saliva in the mouth, etc.), which magnifies their experience of these feelings. While many people fail to notice minor discomfort as they go about their regular activities, the individual with hypochondriasis pays constant attention to inner sensations and becomes alarmed when these sensations vary in any way. This heightened scrutiny may actually increase the intensity of the sensations, and the intensity of the experience fuels fears that the sensations signal an underlying illness. Once the fears are aroused, preoccupation with the symptom increases, further enhancing the intensity of sensations. The tendency to amplify may be either temporary or chronic; it may also be influenced by situational factors, which helps to explain why hypochondriacal fears are made worse by stress or by events that appear to justify concerns about illness. Some researchers have observed that heightened sensitivity to internal sensations is also a feature of panic disorder, and have suggested that there may be an overlap between the two disorders.

DISTORTED INTERPRETATION OF SYMPTOMS. Another theory points to the centrality of dysfunctional thinking in hypochondriasis. According to this theory, the internal physical sensations of the person with hypochondriasis are not necessarily more intense than those of most people. Instead, people with hypochondriasis are prone to make catastrophic misinterpretations of their physical symptoms. They are pessimistic about the state of their physical health, and overestimate their chances of falling ill. Hypochondriasis thus represents a cognitive bias; whereas most people assume they are healthy unless there is clear evidence of disease, the person with hypochondriasis assumes he or she is sick unless given a clean bill of health. Interestingly, research suggests that people with hypochondriasis make more realistic estimations of their risk of disease than most people, and in fact underestimate their risk of illness. Most people simply underestimate their risk even more. Some studies indicate that people with hypochondriasis are more likely to have suffered frequent or serious illnesses as children, which may explain the development of a negative cognitive bias in interpreting physical sensations or symptoms.

Symptoms

The primary symptom of hypochondriasis is preoccupation with fears of serious physical illness or injury. The fears of persons with hypochondriasis have an obsessive quality; they find thoughts about illness intrusive and difficult to dismiss, even when they recognize that their fears are unrealistic. In order to relieve the anxiety that arises from their thoughts, people with hypochondriasis may act on their fears by talking about their symptoms; by seeking information about feared diseases in books or on the Internet; or by "doctor-shopping," going from one specialist to another for a consultation. Others may deal with their fears through avoidance, staying away from anything that might remind them of illness or death. Persons with hypochondriasis vary in their insight into their disorder. Some recognize themselves as "hypochondriacs," but suffer anxiety in spite of their recognition. Others are unable to see that their concerns are unreasonable or exaggerated.

Demographics

According to DSM-IV-TR , hypochondriasis affects 1%–5% of the general population in the United States. The rates of the disorder are higher among clinical outpatients, between 2% and 7%. One recent study suggests that full-blown hypochondriasis is fairly rare, although lesser degrees of worry about illness are more common, affecting as many as 6% of people in a community sample.

Hypochondriasis can appear at any age, although it frequently begins in early adulthood. Men and women appear to suffer equally from the disorder. DSM-IV-TR notes that people from some cultures may appear to have fears of illness that resemble hypochondriasis, but are in fact influenced by beliefs that are traditional in their culture.

Diagnosis

Hypochondriasis is most likely to be diagnosed when one of the doctors consulted by the patient considers the patient's preoccupation with physical symptoms and concerns excessive or problematic. After giving the patient a thorough physical examination to rule out a general medical condition, the doctor will usually give him or her a psychological test that screens for anxiety or depression as well as hypochondriasis. If the results suggest a diagnosis of hypochondriasis, the patient should be referred for psychotherapy . It is important to note, however, that patients with hypochondriasis usually resist the notion that their core problem is psychological. A successful referral to psychotherapy is much more likely if the patient's medical practitioner has been able to relate well to the patient and work gradually toward the notion that psychological problems might be related to fears of physical illness.

Specific approaches that have been found useful by primary care doctors in bringing psychological issues to the patient's attention in nonthreatening ways include the following:

Whenever possible, the doctor should draw connections between the patient's current physical symptoms and recent setbacks or upsetting incidents in the patient's life. For example, the patient may come in with health worries within a few days of having a problem in other areas of life, such as their car needing repairs, a quarrel with a family member, an overdue bill, etc.
The doctor may consider asking the patient to keep a careful diary of his or her symptoms and other occurrences. This diary may be useful in guiding the patient to see patterns in his or her worries about health.
The doctor may want to schedule the patient for regular but short appointments. It is also better to see the patient briefly than to prescribe medications in place of an appointment, because many patients with hypochondriasis abuse medications.
Another approach is to conduct routine screening tests during a yearly physical for patients with hypochondriasis, while discouraging them from scheduling extra appointments each time they notice a minor physical problem.
The doctor should maintain a realistic but optimistic tone in his or her conversation with the patient. He or she may wish to talk to the patient about health-related fears and clarify the differences between normal internal body sensations and serious symptoms.

In order to receive a DSM-IV-TR diagnosis of hypochondriasis, a person must meet all six of the following criteria:

The person must be preoccupied with the notion or fear of having a serious disease. This preoccupation is based on misinterpretation of physical symptoms or sensations.
Appropriate medical evaluation and reassurance that there is no illness present do not eliminate the preoccupation.
The belief or fear of illness must not be of delusional intensity. Delusional health fears are more likely to be bizarre in nature— for instance, the belief that one's skin emits a foul odor or that food is rotting in one's intestines. The preoccupations must not be limited to a concern about appearance; excessive concerns that focus solely on defects in appearance would receive a diagnosis of body dysmorphic disorder.
The preoccupation must have lasted for at least six months.
The person's preoccupation with illness must not simply be part of the presentation of another disorder, including generalized anxiety disorder , obsessive-compulsive disorder, panic disorder, separation anxiety, major depressive episode, or another somatoform disorder.

DSM-IV-TR also differentiates between hypochondriasis with and without poor insight. Poor insight is specified when the patient does not recognize that his or her concerns are excessive or unreasonable.

Treatments

Traditionally, hypochondriasis has been considered difficult to treat. In the last few years, however, cognitive and behavioral treatments have demonstrated effectiveness in reducing the symptoms of the disorder.

Cognitive therapy

The goal of cognitive therapy for hypochondriasis is to guide patients to the recognition that their chief problem is fear of illness, rather than vulnerability to illness. Patients are asked to monitor worries and to evaluate how realistic and reasonable they are. Therapists encourage patients to consider alternative explanations for the physical signs they normally interpret as disease symptoms. Behavioral experiments are also employed in an effort to change the patient's habitual thoughts. For instance, a patient may be told to focus intently on a specific physical sensation and monitor increases in anxiety. Another behavioral assignment might ask the patient to suppress urges to talk about health-related worries with family members, then observe their anxiety level. Most people with hypochondriasis believe that their anxiety will escalate until they release it by seeking reassurance from others. In fact, anxiety usually crests and subsides in a matter of minutes. Cognitive therapy effectively reduces many symptoms of the disorder, and many improvements persist up to a year after treatment ends.

BEHAVIORAL STRESS MANAGEMENT. One study by Clark and colleagues compared cognitive therapy to behavioral stress management. This second form of therapy focuses on the notion that stress contributes to excessive worry about health. Patients were asked to identify stressors in their lives and taught stress management techniques to help them cope with these stressors. The researchers taught the patients relaxation techniques and problem-solving skills, and the patients practiced these techniques in and out of sessions. Although this treatment did not focus directly on hypochondriacal worries, it was helpful in reducing symptoms. At the end of the study, behavioral stress management appeared to be less effective than cognitive therapy in treating hypochondriasis, but a follow-up a year later found that the results of two therapies were comparable.

EXPOSURE AND RESPONSE PREVENTION. This therapy begins by asking patients to make a list of their hypochondriacal behaviors, such as checking body sensations, seeking reassurance from physicians or friends, and avoiding reminders of illness. Behavioral assignments are then developed. Patients who frequently monitor their physical sensations or seek reassurance are asked not to do so, and to allow themselves to experience the anxiety that accompanies suppression of these behaviors. Patients practice exposing themselves to anxiety until it becomes manageable, gradually reducing hypochondriacal behaviors in the process. In a study comparing exposure and response prevention to cognitive therapy, both therapies produced clinically significant results. Although cognitive therapy focuses more on thoughts and exposure therapy more on behaviors, both appear to be effective in reducing both dysfunctional thoughts and behaviors.

Prognosis

Untreated hypochondriasis tends to be a chronic disorder, although the intensity of the patient's symptoms may vary over time. DSM-IV-TR notes that the following factors are associated with a better prognosis: the symptoms develop quickly; are relatively mild; are associated with an actual medical condition; and are not associated with comorbid psychopathology or benefits derived from being ill.

Prevention

Hypochondriasis may be difficult to prevent in a health-conscious society, in which people are constantly exposed to messages reminding them to seek regular medical screenings for a variety of illnesses, and telling them in detail about the illnesses of celebrities and high-ranking political figures. Trendy new diagnostic techniques like full-body MRIs may encourage people with hypochondriasis to seek unnecessary and expensive medical consultations. Referring patients with suspected hypochondriasis to psychotherapy may also help to reduce their overuse of medical services.

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th edition, text revised. Washington, DC: American Psychiatric Association, 2000.

Botella, Cristina, and Pilar Martinez Narvaez. "Cognitive behavioural treatment for hypochondriasis." In International Handbook of Cognitive and Behavioural Treatments for Psychological Disorders, edited by V. E. Caballo. Oxford, UK: Pergamon, 1998.

Pilowsky, Issy. Abnormal Illness Behavior. Chichester, UK: John Wiley and Sons, 1997.

PERIODICALS

Barsky, Arthur J., David K. Ahern, E. Duff Bailey, Ralph Saintfort, Elizabeth B. Liu, and Heli M. Peekna. "Hypochondriacal patients' appraisal of health and physical risks." American Journal of Psychiatry 158, no. 5 (2001): 783-787.

Clark, D. M., P. M. Salkovskis, A. Hackman, A. Wells, M. Fennell, J. Ludgate, S. Ahmad, H. C. Richards, and M. Gelder. "Two psychological treatments for hypochondriasis: A randomized controlled trial." British Journal of Psychiatry 173 (1998): 218-225.

Looper, Karl J. and Laurence J. Kirmayer. "Hypochondriacal concerns in a community population." Psychological Medicine 31 (2001): 577-584.

Neziroglu, Fugen, Dean McKay, and Jose A. Yaryura-Tobias. "Overlapping and distinctive features of hypochondriasis and obsessive-compulsive disorder." Journal of Anxiety Disorders 14, no. 6 (2000): 603-614.

Visser, Sako and Theo K. Bouman. "The treatment of hypochondriasis: Exposure plus response prevention vs cognitive therapy." Behaviour Research and Therapy 39 (2001): 423-442.

Danielle Barry, M.S.