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Overview |
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Definition |
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Hypochondriasis is defined as a condition in which the patient has an
overwhelming fear of and preoccupation with having a serious disease. These
feelings are based on a misinterpretation of bodily sensations that are
generally normal. This fear and preoccupation persist in spite of medical
evidence and reassurance by a physician that no illness exists. In fact,
patients with hypochondriasis believe that an underlying illness still exists
but remains undetected. They may even believe the physician is incompetent since
he or she has not been able to identify the disease. While mild and occasional
preoccupation with disease is quite common, severe, persistent and recurrent
preoccupation, as seen with hypochondriasis, is classified by the Diagnostic
and Statistical Manual of Mental Disorders (DSM-IV) as a somatoform
disorder; by definition, it impairs social and occupational functioning. Most
patients are fairly easily reassured by their physicians. However, as many as
10% to 20% of "normal" and 45% of "neurotic" patients have intermittent,
seemingly unfounded, worry. An estimated 9% doubt reassurances provided by their
physicians.
It is estimated that 75% to 85% of cases of hypochondriasis are secondary to
another psychiatric disorder such as anxiety or depression. In approximately 15%
of cases, however, there is no associated psychiatric illness (primary
hypochondriasis). Hypochondriasis is often confused with somatization disorder,
a preoccupation with multiple physical symptoms rather than a specific disease.
Both hypochondriasis and somatization disorder are classified as somatoform
disorders; this class of disorders shares the commonality of symptoms suggesting
a physical disorder without demonstrable organic findings or physiologic
mechanisms. The two disease processes do not necessarily share etiology or
pathophysiologic mechanism. People with somatoform disorders such as
hypochondriasis do not cause symptoms intentionally, as with factitious
disorders, and generally do not have a secondary gain, as with malingering.
Somatoform disorders significantly impair a patient's quality of life; patients
spend an average of 4.9 to 7.0 days in bed per month while people with major
medical problems only spend an average of 1 day per month in
bed. |
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Etiology |
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- Amplification theory—patients over-interpret
normal bodily sensations and erroneously attribute pathological origins to these
sensations
- Psychodynamic theories—hypochondriasis as a
defense against guilt; a morbid preoccupation with self; conflicted dependency
needs; need to suffer and be loved at the same time; masochistic dynamics; pain
and suffering become atonement for past real or imagined wrongdoing; disturbed
object relations; repressed hostility displaced to the body
- Social learning theory—patients have learned
the "benefits" of the sick role (e.g., attention from a parent)
- Syndromic variant theory—hypochondriasis is
seen as a variant of some other psychiatric disorder, such as depression,
anxiety, or certain personality disorders including obsessive compulsive
disorder (OCD); research, though, does not support that hypochondriasis is a
variant of depression
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Risk Factors |
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- A prolonged childhood illness or prolonged illness in another family
member that teaches the benefits of the sick role
- Typically originates in early adulthood
- Family history of hypochondriasis
- A psychosocial stressor, such as death of a close friend or relative,
may precipitate hypochondriasis
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Signs and Symptoms |
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The following is a summary of the diagnostic criteria for hypochondriasis as
stated in the
DSM-IV:
- Preoccupation with fears of having a serious illness, often based on
an over-interpretation of normal bodily sensations
- Despite physician reassurance and medical evidence that does not
identify a serious medical condition, the fear of disease persists
- The preoccupation about illness is not delusional nor is it concerned
with body image (as in another somatoform disorder called body dysmorphic
disorder); the absence of delusion means that patients with hypochondriasis are
able, at times, to acknowledge the possibility that their concerns are
unfounded
- Clinically significant distress or impairment of social, occupational,
or other important areas of function
- Presence of the preoccupation with disease or illness for at least 6
months
- There is no other appropriate psychiatric diagnosis with which to
label this preoccupation, such as generalized anxiety, obsessive compulsive
disorder, panic attacks, separation anxiety, major depressive episode, or
another somatoform disorder
- Some patients are unable to recognize, during most of an episode, that
their preoccupation with having a serious illness is unreasonable. (These
patients are classified by the DSM-IV as having "poor insight," differentiated
from delusional thinking because they are able to recognize unreasonable
behavior between episodes.)
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Differential
Diagnosis |
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- First, any physical disease must be ruled out. There are times when a
patient appears hypochondriacal but has an as yet undetected underlying medical
condition (e.g., multiple sclerosis, myasthenia gravis, thyroid disease,
parathyroid disorder, systemic lupus erythematosus, occult malignancies, HIV,
acute intermittent porphyria)
- Normal health concerns of the elderly
- Psychiatric disorders (e.g., anxiety disorder, obsessive-compulsive
disorder, panic disorder, major depressive disorder, separation-anxiety
disorder, schizophrenia); hypochondriasis may closely resemble OCD or a
psychiatric disorder because of the predominant presence of
preoccupation.
- Another somatoform disorder (e.g., somatization disorder, conversion
disorder, pain disorder, body dysmorphic syndrome, undifferentiated somatoform
disorder, and somatoform disorder not otherwise specified -- NOS). All
somatoform disorders are characterized by physical symptoms that are not
explained by neurologic or medical disorder, but cause significant distress and
functional impairment for the patient.
- Factitious disorders
- Malingering
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Diagnosis |
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Physical Examination |
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Physicians must schedule a complete physical examination and diagnostic tests
to rule out any serious medical illness, particularly the disease on which the
patient has become focused. Because these patients often have medical histories
of many complaints without evidence of disease, the physician-patient
relationship often becomes strained with both the patient and physician becoming
angry and frustrated. |
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Pathology/Pathophysiology |
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According to one study conducted by Gramling et. al. (1996), interpretation
of a patient response may be complicated by possible differences in the
subjective and objective reactions of hypochondriacal patients to pain and
stress. In the small, controlled study, hypochondriacal subjects demonstrated
less tolerance to adverse conditions through their behavior (e.g., withdrawing
from a cold stimulus more readily than nonhypochondriacal subjects), and also
had significantly increased objective measurements in response to a physical
stressor compared to controls, including:
- Elevated heart rate
- Decreased hand temperature
The authors conclude that hypochondriacal behavior may be partly mediated by
objective differences in physiologic reactivity. |
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Laboratory Tests |
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Laboratory studies to rule out undetected medical conditions are necessary
but extensive medical testing and hospitalization should be avoided as much as
possible. |
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Other Diagnostic
Procedures |
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Psychological evaluation to rule out other psychiatric
disorders. |
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Treatment Options |
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Treatment Strategy |
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If another treatable psychiatric disorder (e.g., anxiety or depression)
exists, successful treatment of that underlying condition with psychotherapy and
appropriate medication generally results in resolution of the hypochondriasis as
well. Even in the absence of such comorbidity, referral to a psychiatrist should
be attempted and handled sensitively, emphasizing that the disease is serious
and that the psychiatric evaluation will be an adjunct to, not a substitute for,
continued medical care. The patient may be more likely to accept referral for a
comorbid condition. Good results have been reported for group therapy, behavior
modification, and cognitive therapy approaches. Often, despite attempts for
adjunctive care, the treatment remains solely in the care of the primary care
practitioner (PCP) because of persistent resistance by the patient to see a
psychiatrist. The focus during a visit with the PCP should gradually and gently
shift from physical complaints to interpersonal problems. |
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Drug Therapies |
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Drugs, to date, are only specifically indicated for comorbid conditions.
Preliminary reports suggest that selective serotonin reuptake inhibitors (SSRIs)
may be efficacious in the absence of depression, anxiety, or other underlying
disorders. |
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Surgical Procedures |
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Unnecessary exploratory surgeries should be avoided whenever possible.
Other Therapies
The cognitive-behavioral model was developed in 1990; results of a
study of the model were first published in 1996. Cognitive approaches include:
- Identifying psychological factors contributing to the preoccupation of
illness
- Challenging the patient's misinterpretations of signs and
symptoms
- Helping patients construct more realistic interpretations of bodily
sensations
- Modifying dysfunctional assumptions
The behavioral aspect of this model consists of body focusing to induce
symptoms and intentionally dwelling on fearful thoughts, as well as increasing
involvement in activities usually avoided because of beliefs about illness.
Homework assignments include daily record keeping of negative thoughts and
rational responses. The unique aspect of this model has to do with the focus on
helping patients recognize that their problem is health anxiety (worrying about
illness rather than any illness itself) and not on reassurance about negative
medical tests.
Behavioral stress management teaches stress management and relaxation
techniques, thereby helping patients avoid becoming focused on their health
during stressful situations. When compared to cognitive-behavioral therapy in a
controlled clinical trial, both groups had equal improvement; however, the study
suggests that changes from cognitive-behavioral therapy may be longer
lasting. |
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Complementary and Alternative
Therapies |
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As outlined already, the cornerstones of treatment in hypochondriasis are:
- Cognitive therapy
- Stress management
Other treatment techniques or approaches to consider include:
- Music therapy—a case report in
International Journal of Arts Medicine discusses the successful treatment
of a woman with somatization disorder (also classified as a somatoform disorder,
as described earlier) using music therapy in conjunction with psychotherapy and
medication (Fagen and Wool 1999).
- Regularly scheduled appointments with a CAM practitioner may help
alleviate the fears of a patient with hypochondriasis, particularly if the
healthcare provider's environment is supportive and empathetic (see section on
Patient Monitoring).
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Nutrition |
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The role of nutrition in hypochondriasis specifically has not been evaluated
by scientific investigation. It is possible, though, that patients with
concomitant anxiety or depression might benefit from reductions in alcohol
consumption and caffeine intake. In addition, a patient with hypochondriasis
might benefit from general nutritional guidelines for optimal health. In the
case of hypochondriasis, the patient should only make one dietary change at a
time, allowing for physical and psychological adjustment. A step-by-step
approach may help improve compliance for this particular group as well as reduce
hypervigilance about potential side effects from foods or supplements. Consider
referral to a registered dietitian who may encourage some of the following:
- Maintaining a whole foods diet—one that is
low in sugar, dairy, and refined, processed foods and rich in fresh fruits,
vegetables, and whole grains
- Drinking at least eight glasses of water each day to reduce
constipation and other gastrointestinal complaints
- Eating small, frequent meals throughout the day to help stabilize
blood sugar and normalize digestion; the former may improve mood while the
latter may reduce awareness of peristalsis and other normal bodily sensations
perceived as abnormal by the patient with hypochondriasis
Although not specifically studied for hypochondriasis, the following
supplements may be considered for reduction of symptoms, general health and
well-being in an effort to reassure the patient, and, in the case of vitamin B
complex, for possible reduction of the effects of stress:
- Multivitamin (MVI), as directed
- Mineral supplement, including calcium 500 mg to 1,000 mg qd with
magnesium 200 mg to 400 mg qd. (Note: Taking too much calcium can lead to
constipation in susceptible individuals and too much magnesium can lead to gas,
bloating, and diarrhea (Jellin et al. 2000; De Franceschi et al.
1997).)
- Vitamin B complex, including pantothenic acid (B5) 250 mg
qd and pyridoxine (B6) 100 mg qd. (This amount of pyridoxine and
pantothenic acid may not be found in a standard MVI and additional vitamin B
supplements may be needed. Caution should be exercised with niacin
[vitaminB3], however, as it may cause flushing of the
skin, perspiration, and a prickly feeling in susceptible individuals (Institute
of Medicine 2000; Ward et al. 1998; Jungnickel et al. 1997).)
- Lactobacillus acidophilus, to decrease bowel
symptoms
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Herbs |
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Herbs that are used as stress relievers may enhance an individual's
resilience during periods of particular pressure and anxiety. Theoretically,
they may help a person with hypochondriasis alleviate preoccupation about
nonexisting disease which tends to worsen during stressful times. Some of the
herbs mentioned may also reduce certain symptoms and, in the process, diminish
fixations by the person with hypochondriasis. A combination of the following may
be recommended by an herbalist:
- Echinacea (Echinacea augustifolia, E. purpurea, E. pallida) to
reduce frequency and/or duration of colds (Blumenthal et al. 2000)
- Kava kava (Piper methysticum) for anxiety with restlessness;
should not be used with prescription psychotropic medications (Blumenthal et al.
2000)
- Lemon balm (Melissa officinalis), for calming stress reactions
particularly with associated gastrointestinal symptoms or insomnia (Blumenthal
et al. 2000)
- Oats (Avena sativa) to assist convalescence and strengthen a
weakened constitution (Blumenthal et al. 2000)
- Passionflower (Passiflora incarnata) for restlessness, nervous
stress, anxiety, and sleep disorders; can also alleviate tachycardia related to
anxiety (Blumenthal et al. 2000)
- Skullcap (Scutellaria laterifolia) for relieving nervous
tension
- St. John's Wort (Hypericum perforatum) for symptoms of
depression, anxiety and nervous unrest (Blumenthal et al. 2000). (Note: This
herb should not be used in conjunction with SSRIs, MAO inhibitors, or other
medications for depression or with indinavir. It may be advisable for physicians
to warn patients of a possible photosensitivity reaction to this herb. Spotting
has also been reported when St. John's wort has been used in conjunction with
oral contraceptives.)
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Homeopathy |
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This modality has not been examined scientifically for its use in the
treatment of hypochondriasis specifically, but many clinicians propose that
homeopathy lends itself to a greater overall sense of well-being and may
alleviate comorbid anxiety or improve depression. An experienced homeopath
considers the individual's constitution and particular combination of symptoms.
Some remedies that the specialist might consider, depending on the individual
clinical picture, include the following:
- Arsenicum album—for anxiety and fear
of dying; the type of patient appropriate for this remedy tends to call the
doctor often and is difficult to reassure.
- Lycopodium—for anxiety about health
and generalized fears;the person for whom this treatment is most appropriate
typically manifests stress in gastrointestinal complaints.
- Phosphorus—for diffuse anxiety
centering around concern for health; patients for whom this is appropriate
generally have a fear that something bad will happen (sense of impending doom)
but tend to be easily
reassured.
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Acupuncture |
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Several studies suggest the value of acupuncture for hypochondriasis.
Acupuncture is believed to have equilibrating effects that balance a system that
is in either an excessive or deficient condition. Such a balancing effect might
be beneficial in patients with altered reactivity and sensitivity to bodily
sensations. In addition, acupuncture may be useful for:
- Relieving chronic fear and apprehension (Helms 1995)
- Reducing psychoemotional symptoms (Kochetkov et al. 1983)
- Diminishing perception of stress and pain (Kochetkov et al. 1983;
Romoli and Giommi 1993)
- Regulation of sleep patterns (Kochetkov et al. 1983)
- Improvement in work capacity (Kochetkov et al.
1983)
Some experts feel that not only might acupuncture be a useful adjunctive
treatment for psychosomatic illnesses such as hypochondriasis, it may also help
elucidate the pathophysiology of these disease processes. |
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Massage |
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Some hypothesize that regular visits, attention, and reduction of stress,
which are all features of massage, may help reduce symptoms of hypochondriasis.
It is also theoretically possible, however, that massage could draw attention to
physical complaints, thereby increasing hypochondriacal symptoms. Research is
needed before conclusions can be drawn about the value of massage in this
population. |
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Patient Monitoring |
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In spite of the fact that no medical illness exists, healthcare providers
should suggest regularly scheduled appointments to continue to monitor patients
for presumed illnesses; this may help to allay patients' fears that they are not
receiving the proper care and provide them with a supportive, empathetic
environment. Regularly scheduled appointments may help reduce phone calls and
inquiries by the patient between visits because it gives the person the
reassurance that he or she will be seen and his or her questions will be
answered. It is helpful for the healthcare provider to remember that the patient
does not necessarily want or expect to get better. In addition, it is important
not to miss future medical problems by completely dismissing the patient.
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Other
Considerations |
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Complications/Sequelae |
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- Family life and social relationships are often adversely affected by
the hypochondriac's attention-seeking behavior.
- Often many sick days are taken from work. In severe cases, individuals
may become completely disabled.
- Costly medical evaluations
- Other mental disorders, such as anxiety and depression, and particular
personality disorders such as OCD may accompany hypochondriasis.
- Addiction to medications given inappropriately may
develop.
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Prognosis |
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Hypochondriasis is usually a chronic, relapsing condition with symptoms that
are episodic over a lifetime. Psychosocial stress may exacerbate the illness.
Some reports suggest that one-fourth of patients with hypochondriasis do poorly,
one-third to one-half improve over time, and one-tenth may recover completely.
These statistics, though, are not entirely reliable as they are difficult to
gather and interpret. A good prognosis is generally associated with the
following:
- Early referral for psychiatric evaluation and treatment
- Acute onset
- Medical comorbidities
- A high socioeconomic background
- Strong motivation to change
- Absence of secondary gain
- Absence of a personality disorder or an organic
disease
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References |
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Copyright © 2000 Integrative Medicine
Communications This publication contains
information relating to general principles
of medical care that should not in any event be construed as specific
instructions for individual patients. The publisher does not accept any
responsibility for the accuracy of the information or the consequences arising
from the application, use, or misuse of any of the information contained herein,
including any injury and/or damage to any person or property as a matter of
product liability, negligence, or otherwise. No warranty, expressed or implied,
is made in regard to the contents of this material. No claims or endorsements
are made for any drugs or compounds currently marketed or in investigative use.
The reader is advised to check product information (including package inserts)
for changes and new information regarding dosage, precautions, warnings,
interactions, and contraindications before administering any drug, herb, or
supplement discussed herein. | |