Hypochondriasis

What is hypochondriasis?

In the past, hypochondriasis was described as a type of somatoform disorder, a mental illness in which a person has symptoms of a medical illness, but the symptoms cannot be fully explained by an actual physical disorder. More recent research indicates hypochondriasis may better be considered an anxiety disorder. In particular it is a form of abnormal health anxiety that may be rather mild or quite severe and disabling. This has important implications for treatment as we will discuss later.

Because hypochondriasis carried a very negative connotation and was considered rather treatment resistant, the newer research holds out more hope. The milder forms of health anxiety do not have worse physical outcomes and do not cost as much money to the health care system as those with well established medical conditions or those with sever health anxiety. By the time DSM V is published, health anxiety may be preferred but currently under DSM IV TR, hypochondriasis remains the diagnosis. This section will consider the terms to be interchangeable.

People with hypochondriasis are very worried about getting a disease or are certain they have a disease, even after medical tests show they do not. Further, these people often misinterpret minor health problems or normal body functions as symptoms of a serious disease. An example is a person who is sure that his or her headaches are caused by a brain tumor. The symptoms associated with hypochondriasis are not under the person’s voluntary control, and can cause great distress and/or can interfere with a person’s normal functioning.

Hypochondriasis can occur at any time of life, but most often begins in early adulthood. It appears to affect men and women equally.

What are the symptoms of hypochondriasis?

Most people with hypochondriasis—sometimes called hypochondriacs—are worried about having a physical illness. The symptoms they describe can range from general complaints—such as pain or tiredness—to concerns about normal body functions—such as breathing or stomach noises. People with hypochondriasis are not faking or lying about their symptoms; they truly believe they are sick.

Warning signs that a person might have hypochondriasis include the following:

• The person has a history of going to many doctors. He or she might even "shop around" for a doctor who will agree that he or she has a serious illness.
• The person recently experienced a loss or stressful event.
• The person is overly concerned about a specific organ or body system, such as the heart or the digestive system.
• The person’s symptoms or area of concern might shift or change.
• A doctor’s reassurance does not calm the person’s fears. They believe the doctor is wrong or made a mistake.
• The person might have had a serious illness as a child.
• The person’s concern about illness interferes with his or her work, family, and social life.
• The person might suffer from anxiety, nervousness, and/or depression.

There is new evidence that intrusive images are very prominent in the more severe cases of health anxiety. Theses intrusive images fall into 4 categories. The individual might envision themselves being told bad news like having an incurable form of cancer. Another image might be of them experiencing the terminal illness with all of the mental and physical suffering. A third type of image is watching themselves die or seeing themselves dead. The fourth image could be them seeing the reactions of family and loved ones to their death. All four types of images can be extremely distressing and cause patients to check with their physicians and others for reassurance. If they think of these images over and over (ruminate), the images will seem more real and troubling. If they are unable to distract themselves from the images, the illness will become more severe. They can traumatize the individual causing great health related anxiety that steals away their time and joy of life.

What causes hypochondriasis?

The exact cause of hypochondriasis is not known. Factors that might be involved in the development of the disorder include the following:

• A history of physical or sexual abuse
• A poor ability to express emotions
• A parent or close relative with the disorder — Children might learn this behavior if a parent is overly concerned about disease and/or overreacts to even minor illnesses.
• An inherited susceptibility for the disorder

How is hypochondriasis diagnosed?

Diagnosing hypochondriasis can be very difficult because people with the disorder are convinced their symptoms are caused by a medical illness.

When symptoms appear, the doctor will begin his or her evaluation with a complete medical history and physical examination. If the doctor finds no physical reason for the symptoms, he or she might refer the person to a psychiatrist or psychologist, health care professionals who are specially trained to diagnose and treat mental illnesses. The psychiatrist or psychologist makes a diagnosis based on his or her assessment of the person’s attitude and behavior, and the fact that physical illness has been ruled out as the cause of the symptoms. The psychiatrist or psychologist might administer a personality assessment to confirm the diagnosis of hypochondriasis or somatoform disorder.

How is hypochondriasis treated?

A main goal of treatment is to help patients live and function as normally as possible, even if they continue to have symptoms. Treatment also aims to alter the thinking and behavior that leads to the symptoms.

As with other somatoform disorders, hypochondriasis can be very difficult to treat. This is due, in part, to the fact that people with this disorder refuse to believe their symptoms are the result of mental or emotional rather than physical causes.

Treatment for hypochondriasis most often includes a combination of the following options:

• Supportive care — In most cases, the best course of action is for the person to stay in regular contact with a trusted health care provider. Within this doctor-patient relationship, the doctor can monitor the symptoms and stay alert to any changes that might signal a real medical illness. The doctor’s main approach is likely to focus on reassuring and supporting the person, and preventing unnecessary tests and treatments. It might be necessary, however, to treat some of the symptoms, such as severe pain.
• Medicines — Antidepressant or anti-anxiety drugs are sometimes used if a person with hypochondriasis also has a mood disorder or anxiety disorder. Selective serotonin reuptake inhibitors and some tricyclic antidepressants are helpful as they are for obsessive compulsive disorder, another anxiety disorder. This may be an additional reason why hypochondriasis is being considered as a health related anxiety with intrusive thoughts.
• Psychotherapy — Psychotherapy (a type of counseling) can be helpful in changing the thinking and behavior that contribute to the symptoms. Therapy also can help the person learn better ways to deal with stress, and improve his or her social and work functioning. Unfortunately, most people with hypochondriasis deny there are any mental or emotional problems, making them fairly resistant to psychotherapy. Cognitive behavioral therapy has proven successful when adapted to the special needs of these patients. This may prove to be the optimal treatment after more research or in combination with the medication described above, but it is currently too early to be certain of that. When an individual learns what initiates and continues their anxiety, they can learn how to reframe their interpretations of the anxiety and how to change behavior to reduce the emotional impact of abnormal images. In time they may be able to control these visions and convert them to more normal thoughts and images fairly efficiently.

What are the complications of hypochondriasis?

A person with hypochondriasis is at risk for repeated episodes of symptoms. He or she also might suffer from reactions or health problems related to multiple tests, procedures, and treatments. In addition to the pain and frustration this disorder often causes to the person and his or her family, repeated episodes also can lead to unnecessary and risky procedures, as well as high medical bills. Further, genuine medical problems can be missed in a person with a long history of having tests with negative results.

What is the outlook for people with hypochondriasis?

Hypochondriasis tends to be a long-term (chronic) condition that can last for years. In many cases, symptoms can recur. In the past, we believed only a small percentage of patients could recover completely. The focus of treatment was on learning to manage and control symptoms, and on minimizing functional problems associated with the disorder. Now their certainly seems more hope, especially for patients with milder symptoms and those who can respond to an adapted form of cognitive behavioral therapy.

Can hypochondriasis be prevented?

There is no known way to prevent hypochondriasis. However, providing the person with an understanding and supporting environment might help decrease the severity of the symptoms and help him or her better cope with the disorder. Years of negative images and extreme fear will be hard to reverse. However when an individual can tell others about the vivid images and get help early, the therapy is likely to be more effective.

References

• Ford CV. Chapter 22. Somatoform Disorders. In: Ebert MH, Loosen PT, Nurcombe B, Leckman JF, eds. CURRENT Diagnosis & Treatment: Psychiatry. 2nd ed. New York: McGraw-Hill; 2008. www.accessmedicine.com/. Accessed December 13, 2011.
• Ropper AH, Samuels MA. Chapter 56. The Anxiety Neuroses, Hysteria, and Personality Disorders. In: Ropper AH, Samuels MA, eds. Adams and Victor's Principles of Neurology. 9th ed. New York: McGraw-Hill; 2009. www.accessmedicine.com/. Accessed December 13, 2011.

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