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.

• 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 

• 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

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.) 

• 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 

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.

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.

Laboratory studies to rule out undetected medical conditions are necessary but extensive medical testing and hospitalization should be avoided as much as possible.

Psychological evaluation to rule out other psychiatric disorders.

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.

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.

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.

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). 

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 

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.)

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.
  
  

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.

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.

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.

• 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. 

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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