Hypochondriasis Clinical Presentation

  • Author: Glen L Xiong, MD; Chief Editor: David Bienenfeld, MD   more...
 
Updated: Aug 3, 2011
 

History

Hypochondriasis is classified as one of the somatoform disorders, a class that was formulated to accommodate the differential diagnosis of disorders characterized primarily by physical symptoms for which no demonstrable organic explanations or physical findings exist. The DSM-IV-TR stipulates that the symptoms are not under voluntary control (thus excluding malingering and factitious disorders) and are not fully explained by known physiological causes (excluding psychological factors affecting the medical condition). The disorders in the somatoform class include somatization disorder, conversion disorder, pain disorder, hypochondriasis, BDD, and undifferentiated somatoform disorder.

The core feature of hypochondriasis is not preoccupation with symptoms themselves, but rather the fear or idea of having a serious disease (see the image below). The fear or idea is based on the misinterpretation of bodily signs and sensations as evidence of disease. The illness persists despite appropriate medical evaluations and reassurance.

Pathological cycle of bodily concern and anxiety iPathological cycle of bodily concern and anxiety in hypochondriasis.

The diagnosis should be considered strongly if the patient has a history of hypochondriasis (or other somatization disorder) or has had multiple nonproductive clinical workups, and if the patient's complaints are markedly inconsistent with objective findings or the examination yields no abnormal findings. Further psychiatric history should be obtained with regard to a history of hypochondriasis (or corresponding behaviors) in family members or a sudden, unexplained loss of function that spontaneously resolved.

Diagnostic criteria for hypochondriasis include the following (DSM-IV-TR):

  • The patient has a preoccupying fear of having a serious disease.
  • The preoccupation persists despite appropriate medical evaluation and reassurance.
  • The belief is not of delusional intensity (as in delusional disorder, somatic type) and is not restricted to a concern about appearance (as in persons with BDD).
  • The preoccupation causes clinically significant distress or impairment.
  • The preoccupation lasts for at least 6 months.
  • The preoccupation is not explained better by another mood, anxiety, or somatoform disorder.
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Physical

The absence of physical findings, particularly after serial examinations, supports the diagnosis of hypochondriasis. However, the patient must receive a physical examination to make the psychiatric intervention possible. A mental status examination complements the physical examination.

General appearance, behavior, and speech

  • Modestly or well groomed, not grossly disheveled
  • Cooperative with the examiner, yet ill at ease and not easily reassured
  • Possible signs of anxiety, including moist hands, perspiring forehead, strained/tremulous voice, and wide eyes and intense eye contact

Psychomotor status

  • Restlessness
  • Frequent shifts in posture
  • Mild-to-moderate agitation
  • Slowed (if sleeping poorly)

Mood (the pervasive and sustained emotion that colors the patient's perception of the world) and affect (what the examiner observes)

  • Anxious or worried, depressed mood
  • Restricted, shallow, fearful, or anxious affect, with restricted fluctuations and limited depth

Thought process

  • Spontaneous speaking with occasional abrupt changes in topic
  • Circumstantial, scattered at times
  • Responds to questions but may divert to next worry or revert to an already expressed concern despite reassurance to the contrary
  • No latency unless also depressed
  • No thought blocking or looseness of associations
  • Concrete focus of thought, but with capacity to abstract in a number of areas when encouraged or tested
  • May appear distractible and yet can concentrate independently and with encouragement

Thought content

  • Preoccupation with being ill
  • Anxious themes concerning what in the body is wrong, how it is wrong, and how it is experienced
  • May have feelings of despair and/or hopelessness, although these are not usually of significant depth unless little relief has come from seeing multiple providers and/or the patient concurrently depressed
  • Catastrophizing tendencies (focused on dire consequences of various symptoms and obtaining more diagnostic testing)
  • Uninterested in revealing other aspects of daily functioning or general lifestyle topics at length
  • Inflexibility regarding bodily concerns, but only rarely to the point of a delusion (ie, fixed, false belief), and if so, limited to somatic complaints rather than grandiose or persecutory complaints
  • No perceptual disturbances (eg, hallucinations)
  • No suicidal ideation, unless concurrently depressed
  • No homicidal ideation

Cognitive function

  • Attentive
  • Oriented fully to time, place, and person
  • Rare difficulties with concentration, memory, and other faculties, but functions in the normative range with refocusing and encouragement
  • May have some deficits if concurrently depressed; these also tend to be overcome in response to encouragement
  • Interestingly, may have selective attention (eg, the patient is distressed by an ongoing bodily complaint but not by a newly sprained ankle)

Insight

  • Able to recognize bodily sensations
  • Lacking full understanding of underlying psychological concerns and how they underpin development and maintenance of bodily complaints; tends to see the "trees" rather than the "forest"
  • Some awareness of own feelings about people and events, but not always with the ability to translate that into action, sustained change in mood, or lessening of preoccupations

Judgment

  • Capable of social greetings and other behaviors
  • Persistence in discussing and evaluating continuing preoccupations (due to limited insight)
  • May be impaired if concurrently depressed
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Causes

Developmental and other predisposing factors (see the image below) consistently indicate the importance of parental attitudes toward disease, previous experience with physical disease, and culturally acquired attitudes relevant to the etiology of the disorder.[15] Overall however, few demographic and clinical differences have been found between patients with hypochondriasis and the general population. Social position, education level, and marital status do not appear to be factors in this condition.

Mood, cultural, developmental, and environmental fMood, cultural, developmental, and environmental factors that influence hypochondriasis.

A cognitive model of hypochondriasis suggests that patients misinterpret bodily symptoms by augmenting and amplifying their somatic sensations. Patients also appear to have lower-than-usual thresholds for, and tolerance of, physical discomfort. For example, what most people normally perceive as abdominal pressure, patients with hypochondriasis experience as abdominal pain. When they do sustain an injury (eg, ankle sprain), it is experienced with significant anxiety and is taken as confirmation of their worry about being ill. This may be due to a tendency among patients with hypochondriasis to exaggerate their assessment of vulnerability to disease and their appraisal of the risk of serious illness.[11]

The social learning theory frames hypochondriasis as a request for admission to the sick role made by a person facing seemingly insurmountable and insolvable problems. This role may allow them to avoid noxious obligations, postpone unwelcome challenges, and be relieved from duties and obligations.[16]

The psychodynamic theory implies that aggressive and hostile wishes toward others are transferred via repression and displacement into physical complaints. The hypochondriacal symptoms serve to "undo" guilt felt about the anger and serve as a punishment for being "bad."

Neurochemical deficits with hypochondriasis and some other somatoform disorders (eg, BDD) appear similar to those of depressive and anxiety disorders. For example, in 1992, Hollander et al posited an obsessive-compulsive spectrum that includes OCD, BDD, anorexia nervosa, Tourette syndrome, and impulse control disorders (eg, trichotillomania, pathological gambling).[4] Although only preliminary data have been reported on these neurochemical deficits, such deficits may explain why symptoms overlap, why the disorders are commonly comorbid, and why treatments may parallel one another (eg, SSRIs).

Hypochondriasis has been hypothesized to be an anxiety spectrum disorder. P-wave dispersion (the difference between the maximum and minimum P-wave duration on the electrocardiograph) has been found to be significantly higher in patients with panic disorder and in patients with hypochondriasis, compared with healthy control subjects. The elevated P-wave dispersion may be an indicator of cardiac autonomic dysfunction in anxiety disorders.[17]

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Contributor Information and Disclosures
Author

Glen L Xiong, MD  Assistant Clinical Professor, Department of Psychiatry and Behavioral Sciences, Department of Internal Medicine, University of California Davis School of Medicine; Attending Psychiatrist, Sacramento Mental Health Treatment Center; Attending Physician, Sacramento County Primary Care Clinic

Glen L Xiong, MD is a member of the following medical societies: American College of Physicians, American Psychiatric Association, and Sierra Sacramento Valley Medical Society

Disclosure: Lippincott Williams & Wilkins Royalty Book Editor; PGxHealth Consulting fee Consulting; National Alliance for Research in Schizophrenia and Depression Grant/research funds Independent contractor

Coauthor(s)

James A Bourgeois, OD, MD, MPA  Professor, Consultation-Liaison Service, Department Education Coordinator, Vice Chair of Education, Department of Psychiatry and Behavioural Neurosciences, St Joseph's Healthcare, Centre for Mountain Health Services, McMaster University School of Medicine, Canada

James A Bourgeois, OD, MD, MPA is a member of the following medical societies: Academy of Psychosomatic Medicine, American Neuropsychiatric Association, American Psychiatric Association, and Association for Academic Psychiatry

Disclosure: Nothing to disclose.

Peter M Yellowlees, MD, MBBS  Professor of Psychiatry, Director of Health Informatics Program, University of California, Davis, School of Medicine

Disclosure: Medscape Consulting fee Independent contractor

Donald M Hilty, MD  Professor of Clinical Psychiatry, Vice-Chair of Faculty Development, Department of Psychiatry and Behavioral Sciences, University of California, Davis School of Medicine

Donald M Hilty, MD is a member of the following medical societies: Academy of Psychosomatic Medicine, American Association for Technology in Psychiatry, American Psychiatric Association, and Association for Academic Psychiatry

Disclosure: Nothing to disclose.

Specialty Editor Board

Sarah C Aronson, MD  Associate Professor, Departments of Psychiatry and Medicine, Case Western Reserve School of Medicine/University Hospitals of Cleveland

Sarah C Aronson, MD is a member of the following medical societies: American Academy of Family Physicians, American Medical Association, and American Psychiatric Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Harold H Harsch, MD  Program Director of Geropsychiatry, Department of Geriatrics/Gerontology, Associate Professor, Department of Psychiatry and Department of Medicine, Froedtert Hospital, Medical College of Wisconsin

Harold H Harsch, MD is a member of the following medical societies: American Psychiatric Association

Disclosure: lilly Honoraria Speaking and teaching; Forest Labs None None; Pfizer Grant/research funds Speaking and teaching; Northstar None None; Novartis Grant/research funds research; Pfizer Honoraria Speaking and teaching; Sunovion Speaking and teaching; Otsuke Grant/research funds reseach; GlaxoSmithKline Grant/research funds research; Merck Honoraria Speaking and teaching

Chief Editor

David Bienenfeld, MD  Professor of Psychiatry, Vice-Chair and Director of Residency Training, Department of Psychiatry, Wright State University, Boonshoft School of Medicine

David Bienenfeld, MD is a member of the following medical societies: American Medical Association, American Psychiatric Association, and Association for Academic Psychiatry

Disclosure: Nothing to disclose.

Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors Shayna L Marks, BA, MA; Dandan Liu, BA; and Celia Chang, MD to the development and writing of this article.

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Pathological cycle of bodily concern and anxiety in hypochondriasis.
Mood, cultural, developmental, and environmental factors that influence hypochondriasis.
Factors that maintain anxiety in patients with hypochondriasis.
A cognitive model of the development of anxiety with hypochondriasis.
 
 
 
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