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Hypochondriasis

  • Author: Glen L Xiong, MD; Chief Editor: David Bienenfeld, MD  more...
 
Updated: Jun 10, 2013
 

Background

Hypochondriasis and the other somatoform disorders are among the most difficult and most complex psychiatric disorders to treat in the general medical setting. On the basis of many new developments in this field, diagnostic criteria have been revised to facilitate clinical care and research. Long-awaited randomized, placebo-controlled treatment approaches have finally emerged. Comparative clinical effectiveness studies are also being developed.

As with all psychiatric disorders, the somatoform disorders demand creative, rich biopsychosocial treatment planning by a team that includes primary care physicians, subspecialists, and mental health professionals.[1]

This article describes hypochondriasis, its diagnosis, and an overview of treatment approaches, with references for details beyond the scope of the article. Finally, the article reviews new developments in psychopharmacologic and psychotherapeutic treatments.

Case study

A 45-year-old white male engineer presents to a primary care clinic armed with multiple internet searches on the topic of cancer. He states that he “just knows” he has a GI cancer, "probably the colon or maybe the pancreas." When asked how long this concern has bothered him he says "for years I have been concerned that I have cancer." You ask about relevant symptoms and he is a bit vague, saying "I get some pain or pressure right here (he points to the left upper quadrant) but it is not there all the time." Upon asking about prior workups he says “I have had ultrasounds and colonoscopies but they could find anything. I was initially relieved but a couple of weeks later started to think that they must have just missed something.”

When you ask about the patient's goals for today’s visit he is emphatic "I think what I really need is another colonoscopy and abdominal CT scan." His examination is unrevealing. When you suggest a less invasive approach, he shows the error rates of the other evaluations and shows literature endorsing how abdominal CT is the criterion standard. He is anxious at baseline and increasingly irritable when you propose less invasive evaluation. He ends the encounter by stating that he will “find another doctor who sees my point and will get me what I need.”

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Pathophysiology

Neurochemical deficits associated with hypochondriasis and some other somatoform disorders (eg, somatization, conversion, and body dysmorphic disorders) appear similar to those of mood and anxiety disorders. See Medscape Reference articles Somatoform Disorders and Conversion Disorders.

For example, Hollander et al posited an "obsessive-compulsive spectrum" to include obsessive-compulsive disorder (OCD)[2, 3] , body dysmorphic disorder (BDD), anorexia nervosa, Tourette syndrome, and impulse control disorders (eg, trichotillomania, pathological gambling).[4] Other authors postulate that somatoform disorders including hypochondriasis may be a learned unconscious behavior that may serve to avoid internal conflicts and external stressors.[5]

This formulation of obsessive-compulsive (OC) spectrum disorders, while not a part of the consensus psychiatric diagnostic and classification literature, crosses boundaries of several diagnostic categories in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition-Text Revision (DSM-IV-TR). In addition, encountering a patient with more than one of the anxiety spectrum disorders during his or her life is not unusual. Although findings of studies of these neurochemical deficits are only preliminary, such deficits may explain why symptoms overlap, why the disorders are commonly comorbid, and why effective treatments parallel one another (eg, selective serotonin reuptake inhibitors [SSRIs]).

In a recent study of biological markers, subjective who met DSM-IV-TR diagnostic criteria for hypochondriasis had decreased plasma neurotrophin 3 (NT-3) level and platelet serotonin (5-HT) levels, compared to healthy control subjects. NT-3 is a marker of neuronal function and platelet 5-HT is a surrogate marker for serotonergic activity.[6]

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Epidemiology

Frequency

United States

The prevalence rates for primary hypochondriasis in the primary care setting are 0.8-4.5%.[7] Some degree of preoccupation with disease is apparently common, because 10-20% of people who are healthy and 45% of people without a major psychiatric disorder have intermittent unfounded worries about illness.[8]

International

International rates are similar to those in the United States.[9]

Mortality/Morbidity

Hypochondriasis is usually episodic, with hypochondriacal symptoms that last from months to years and equally long quiescent periods. Although formal outcome studies have not been conducted, one third of patients with hypochondriasis are believed to eventually improve significantly. A good prognosis appears to be associated with high socioeconomic status, treatment-responsive anxiety or depression, the absence of a personality disorder, and the absence of a related nonpsychiatric medical condition. Most children are believed to recover by adolescence or early adulthood, but empiric studies have not been carried out.

Epidemiological studies are lacking, but patients with hypochondriasis appear similar to those with somatization disorder. These individuals use medical care at high rates, making frequent visits to the emergency department, the doctor, and other health care providers and undergoing frequent physical examinations, laboratory testing, and other costly, invasive, and potentially dangerous procedures.[10]

Cognitive, social learning, and psychodynamic theories imply that patients have significant psychosocial disturbances in terms of relationships, vocational, and other endeavors. Exacerbations may occur with psychological stressors and in patients with comorbid psychiatric conditions.

These high-use patterns differ dramatically from those of nonsomatizing patients and remain true even when comorbid medical conditions and sociodemographic differences are accounted for.[11] The medically unexplained complaint is often a symptom of hypochondriasis[12] and may well be a presentation of associated abnormal illness behavior.[13]

Patients with hypochondriasis have a high rate of psychiatric comorbidity.[14] In one general medical outpatient clinic, 88% of patients with hypochondriasis had one or more concurrent psychiatric disorders, the most common being generalized anxiety disorder (71%), dysthymic disorder (45.2%), major depression (42.9%), somatization disorder (21.4%), and panic disorder (16.7%). These patients are 3 times more likely to have a personality disorder than the general population.[14] Substance abuse or dependence is also a serious comorbid condition, particularly use of benzodiazepines, though epidemiological studies have not assessed the exact frequency of this problem. The long-term prognosis of patients with hypochondriasis is understudied due to the heterogeneity of the disorder. However, higher severity at baseline is likely associated with worse outcome.

Race

This disorder has not been well studied with respect to race and ethnicity. More information is needed, too, with regard to its relationship to other medical disorders needing better definition (eg, neurasthenia, chronic fatigue syndrome, fibromyalgia, and multiple chemical sensitivity syndrome).

Sex

Hypochondriasis appears to occur equally in men and women.

Age

Hypochondriasis can begin at any age, but the most common age of onset is early adulthood.

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Contributor Information and Disclosures
Author

Glen L Xiong, MD Associate Clinical Professor, Department of Psychiatry and Behavioral Sciences, Department of Internal Medicine, University of California, Davis, School of Medicine; Medical Director, Sacramento County Mental Health Treatment Center

Glen L Xiong, MD is a member of the following medical societies: AMDA - The Society for Post-Acute and Long-Term Care Medicine, American College of Physicians, American Psychiatric Association, Central California Psychiatric Society

Disclosure: Received royalty from Lippincott Williams & Wilkins for book editor; Received grant/research funds from National Alliance for Research in Schizophrenia and Depression for independent contractor; Received consulting fee from Blue Cross Blue Shield Association for consulting. for: Received book royalty from American Psychiatric Publishing Inc.

Coauthor(s)

Donald M Hilty, MD Chair and Program Director, Department of Psychiatry, Keck School of Medicine of the University of Southern California

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

Disclosure: Nothing to disclose.

James A Bourgeois, OD, MD, MPA Clinical Professor, Department of Psychiatry, University of California, San Francisco, School of Medicine; Faculty Psychiatrist, Consultation-Liaison Division, Department of Psychiatry, Langley Porter Psychiatric Institute, University of California, San Francisco, Medical Center

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

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: Received consulting fee from Medscape for independent contractor.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

David Bienenfeld, MD Professor, Departments of Psychiatry and Geriatric Medicine, Wright State University, Boonshoft School of Medicine

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

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference 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.

References
  1. Barsky AJ, Klerman GL. Overview: hypochondriasis, bodily complaints, and somatic styles. Am J Psychiatry. 1983 Mar. 140(3):273-83. [Medline].

  2. Fallon BA, Petkova E, Skritskaya N, et al. A double-masked, placebo-controlled study of fluoxeine for hypochondiasis. J Clin Psychopharmcol. December 2008. 6:638-45.

  3. Ravindran AV, da Silva TL, Ravindran LN, Richter MA, Rector NA. Obsessive-compulsive spectrum disorders: a review of the evidence-based treatments. Can J Psychiatry. 2009 May. 54(5):331-43. [Medline].

  4. Hollander E, Stein DJ, Decaria CM, Cohen L, Islam M, Frenkel M. Disorders related to OCD--neurobiology. Clin Neuropharmacol. 1992. 15 Suppl 1 Pt A:259A-260A. [Medline].

  5. Wooley SC, Blackwell B, Winget C. A learning theory model of chronic illness behavior: theory, treatment, and research. Psychosom Med. 1978 Aug. 40(5):379-401. [Medline].

  6. Brondino N, Lanati N, Barale F, et al. Decreased NT-3 plasma levels and platelet serotonin content in patients with hypochondriasis. J Psychosom Res. 2008 Nov. 65(5):435-9. [Medline].

  7. Magarinos M, Zafar U, Nissenson K, Blanco C. Epidemiology and treatment of hypochondriasis. CNS Drugs. 2002. 16(1):9-22. [Medline].

  8. Kellner R. Hypochondriasis and somatization. JAMA. 1987 Nov 20. 258(19):2718-22. [Medline].

  9. Gureje O, Ustum TB, Simon GE:. The syndrome of hypochondriasis: a cross-national study in primary care. Psychol Med;. 1997. 27:1001-10.

  10. Barsky AJ, Ettner SL, Horsky J, Bates DW. Resource utilization of patients with hypochondriacal health anxiety and somatization. Med Care. 2001 Jul. 39(7):705-15. [Medline].

  11. Barsky AJ, Ahern DK, Bailey ED, Saintfort R, Liu EB, Peekna HM. Hypochondriacal patients' appraisal of health and physical risks. Am J Psychiatry. 2001 May. 158(5):783-7. [Medline].

  12. Holder-Perkins V, Wise TN, Williams DE. Hypochondriacal Concerns: Management Through Understanding. Prim Care Companion J Clin Psychiatry. 2000 Aug. 2(4):117-121. [Medline].

  13. Lipowski ZJ. Somatization: a borderland between medicine and psychiatry. CMAJ. 1986 Sep 15. 135(6):609-14. [Medline].

  14. Barsky AJ, Wyshak G, Klerman GL. Psychiatric comorbidity in DSM-III-R hypochondriasis. Arch Gen Psychiatry. 1992 Feb. 49(2):101-8. [Medline].

  15. Ball RA, Clare AW. Symptoms and social adjustment in Jewish depressives. Br J Psychiatry. 1990 Mar. 156:379-83. [Medline].

  16. Jones LR, Mabe PA 3rd, Riley WT. Illness coping strategies and hypochondriacal traits among medical inpatients. Int J Psychiatry Med. 1989. 19(4):327-39. [Medline].

  17. Atmaca M, Korkmaz H, Korkmaz S. P wave dispersion in patients with hypochondriasis. Neurosci Lett. 2010 Nov 26. 485(3):148-50. [Medline].

  18. Smith RC. Somatization disorder: defining its role in clinical medicine. J Gen Intern Med. 1991 Mar-Apr. 6(2):168-75. [Medline].

  19. Stefansson JG, Messina JA, Meyerowitz S. Hysterical neurosis, conversion type: clinical and epidemiological considerations. Acta Psychiatr Scand. 1976 Feb. 53(2):119-38. [Medline].

  20. Toone BK. Disorders of hysterical conversion. Bass C, ed. Physical Symptoms and Psychological Illness. London, UK: Blackwell Scientific; 1990. 207-34.

  21. de Leon J, Bott A, Simpson GM. Dysmorphophobia: body dysmorphic disorder or delusional disorder, somatic subtype?. Compr Psychiatry. 1989 Nov-Dec. 30(6):457-72. [Medline].

  22. Bienvenu OJ, Samuels JF, Wuyek LA, Liang KY, Wang Y, Grados MA, et al. Is obsessive-compulsive disorder an anxiety disorder, and what, if any, are spectrum conditions? A family study perspective. Psychol Med. 2011 May 13. 1-13. [Medline].

  23. van den Heuvel OA, Mataix-Cols D, Zwitser G, Cath DC, van der Werf YD, Groenewegen HJ, et al. Common limbic and frontal-striatal disturbances in patients with obsessive compulsive disorder, panic disorder and hypochondriasis. Psychol Med. 2011 May 5. 1-12. [Medline].

  24. Hollifield M, Tuttle L, Paine S, Kellner R. Hypochondriasis and somatization related to personality and attitudes toward self. Psychosomatics. 1999 Sep-Oct. 40(5):387-95. [Medline].

  25. Fallon BA, Harper KM, Landa A, Pavlicova M, Schneier FR, Carson A. Personality disorders in hypochondriasis: prevalence and comparison with two anxiety disorders. Psychosomatics. 2012 Nov-Dec. 53(6):566-74. [Medline].

  26. Xiong GL, Bougeois JA, Chang CH, Liu D, Hilty DM. Hypochondriasis: common presentations and treatment strategies in primary care and specialty settings. Therapy. 2007. (4):3:323-38.

  27. Salkovskis PM, Rimes KA, Warwick HM, Clark DM. The Health Anxiety Inventory: development and validation of scales for the measurement of health anxiety and hypochondriasis. Psychol Med. 2002 Jul. 32(5):843-53. [Medline].

  28. Campo JV, Di Lorenzo C, Chiappetta L, et al. Adult outcomes of pediatric recurrent abdominal pain: do they just grow out of it?. Pediatrics. 2001 Jul. 108(1):E1. [Medline].

  29. Noyes R Jr, Stuart S, Langbehn DR, Happel RL, Longley SL, Yagla SJ. Childhood antecedents of hypochondriasis. Psychosomatics. 2002 Jul-Aug. 43(4):282-9. [Medline].

  30. Fiddler M, Jackson J, Kapur N, Wells A, Creed F:. Childhood adversity and frequent medical consultations. Gen Hosp Psychiatry. 2004. 26:367-77.

  31. Durso FT, Reardon R, Shore WJ, Delys SM:. Memory processes and hypochondriacal tendencies. J Nerv Ment Dis. 1992. 179(5):279-83.

  32. Gottlieb GL. Hypochondriasis: A psychosomatic problem in the elderly. Adv Psychosom Med. 1989. 19:67-84.

  33. Stein EM. When is hypochondriasis not hypochondriasis? Geriatrics. 2003. 58(3):41-2.

  34. Tyrer P, Cooper S, Tyrer H, et al. CHAMP: Cognitive behaviour therapy for health anxiety in medical patients, a randomised controlled trial. BMC Psychiatry. 2011 Jun 14. 11:99. [Medline]. [Full Text].

  35. Kellner R, Abbott P, Pathak D, Winslow WW, Umland BE. Hypochondriacal beliefs and attitudes in family practice and psychiatric patients. Int J Psychiatry Med. 1983-1984. 13(2):127-39. [Medline].

  36. Speckens AE, Spinhoven P, Sloekers PP, Bolk JH, van Hemert AM. A validation study of the Whitely Index, the Illness Attitude Scales, and the Somatosensory Amplification Scale in general medical and general practice patients. J Psychosom Res. 1996 Jan. 40(1):95-104. [Medline].

  37. Janca A, Isaac M, Bennett LA, Tacchini G. Somatoform disorders in different cultures--a mail questionnaire survey. Soc Psychiatry Psychiatr Epidemiol. 1995 Jan. 30(1):44-8. [Medline].

  38. Harrington P. Obsessive compulsive disorder with associated hypochondriasis. BMJ. 2008 May 10. 336(7652):1070-1. [Medline].

  39. Weck F, Neng JM, Richtberg S, Stangier U. Dysfunctional beliefs about symptoms and illness in patients with hypochondriasis. Psychosomatics. 2012 Mar-Apr. 53(2):148-54. [Medline].

  40. Looper KJ, Kirmayer LJ. Behavioral medicine approaches to somatoform disorders. J Consult Clin Psychol. 2002 Jun. 70(3):810-27. [Medline].

  41. Visser S, Bouman TK. The treatment of hypochondriasis: exposure plus response prevention vs cognitive therapy. Behav Res Ther. 2001 Apr. 39(4):423-42. [Medline].

  42. Kroenke K, Swindle R. Cognitive-behavioral therapy for somatization and symptom syndromes: a critical review of controlled clinical trials. Psychother Psychosom. 2000 Jul-Aug. 69(4):205-15. [Medline].

  43. Visser S, Bouman TK. Cognitive-behavioural approaches in the treatment of hypochondriasis: six single case cross-over studies. Behav Res Ther. 1992 May. 30(3):301-6. [Medline].

  44. McManus F, Surawy C, Muse K, Vazquez-Montes M, Williams JM. A randomized clinical trial of mindfulness-based cognitive therapy versus unrestricted services for health anxiety (hypochondriasis). J Consult Clin Psychol. 2012 Oct. 80(5):817-28. [Medline].

  45. Medical Economics Staff. Medical Economics. Physicians' Desk Reference. 58th ed. Monvale, NJ; 2004.

  46. Kellner R. Prognosis of treated hypochondriasis. A clinical study. Acta Psychiatr Scand. 1983 Feb. 67(2):69-79. [Medline].

  47. olde Hartman TC, Borghuis MS, Lucassen PL, van de Laar FA, Speckens AE, van Weel C. Medically unexplained symptoms, somatisation disorder and hypochondriasis: course and prognosis. A systematic review. J Psychosom Res. 2009 May. 66(5):363-77. [Medline].

  48. Schweitzer PJ, Zafar U, Pavlicova M, Fallon BA. Long-term follow-up of hypochondriasis after selective serotonin reuptake inhibitor treatment. J Clin Psychopharmacol. 2011 Jun. 31(3):365-8. [Medline].

  49. Adler G. The physician and the hypochondriacal patient. N Engl J Med. 1981 Jun 4. 304(23):1394-6. [Medline].

  50. Avia MD, Ruiz MA, Olivares ME, Crespo M, Guisado AB, Sánchez A. The meaning of psychological symptoms: effectiveness of a group intervention with hypochondriacal patients. Behav Res Ther. 1996 Jan. 34(1):23-31. [Medline].

  51. Barsky AJ. Hypochondriasis. Medical management and psychiatric treatment. Psychosomatics. 1996 Jan-Feb. 37(1):48-56. [Medline].

  52. Bouman TK. A community-based psychoeducational group approach to hypochondriasis. Psychother Psychosom. 2002 Nov-Dec. 71(6):326-32. [Medline].

  53. Bursztajn H, Barsky AJ. Facilitating patient acceptance of a psychiatric referral. Arch Intern Med. 1985 Jan. 145(1):73-5. [Medline].

  54. Cetin M, Ebrinç S, Agargün MY, Yigit S. Risperidone for the treatment of monosymptomatic hypochondriacal psychosis. J Clin Psychiatry. 1999 Aug. 60(8):554. [Medline].

  55. Fallon BA, Javitch JA, Hollander E, Liebowitz MR. Hypochondriasis and obsessive compulsive disorder: overlaps in diagnosis and treatment. J Clin Psychiatry. 1991 Nov. 52(11):457-60. [Medline].

  56. Fallon BA, Liebowitz MR, Salman E, Schneier FR, Jusino C, Hollander E. Fluoxetine for hypochondriacal patients without major depression. J Clin Psychopharmacol. 1993 Dec. 13(6):438-41. [Medline].

  57. Fallon BA, Schneier FR, Marshall R, et al. The pharmacotherapy of hypochondriasis. Psychopharmacol Bull. 1996. 32(4):607-11. [Medline].

  58. Ford CV, Long KD. Group psychotherapy of somatizing patients. Psychother Psychosom. 1977. 28(1-4):294-304. [Medline].

  59. Greeven A, van Balkom AJ, Visser S, et al. Cognitive behavior therapy and paroxetine in the treatment of hypochondriasis: a randomized controlled trial. Am J Psychiatry. 2007 Jan. 164(1):91-9. [Medline].

  60. Hamann K, Avnstorp C. Delusions of infestation treated by pimozide: a double-blind crossover clinical study. Acta Derm Venereol. 1982. 62(1):55-8. [Medline].

  61. Hiller W, Leibbrand R, Rief W, Fichter MM. Predictors of course and outcome in hypochondriasis after cognitive-behavioral treatment. Psychother Psychosom. 2002 Nov-Dec. 71(6):318-25. [Medline].

  62. House A. Hypochondriasis and related disorders. Assessment and management of patients referred for a psychiatric opinion. Gen Hosp Psychiatry. 1989 May. 11(3):156-65. [Medline].

  63. Kellner R. Psychotherapeutic strategies in hypochondriasis: a clinical study. Am J Psychother. 1982 Apr. 36(2):146-57. [Medline].

  64. Klimes I, Mayou RA, Pearce MJ, Coles L, Fagg JR. Psychological treatment for atypical non-cardiac chest pain: a controlled evaluation. Psychol Med. 1990 Aug. 20(3):605-11. [Medline].

  65. Lidbeck J. Group therapy for somatization disorders in primary care: maintenance of treatment goals of short cognitive-behavioural treatment one-and-a-half-year follow-up. Acta Psychiatr Scand. 2003 Jun. 107(6):449-56. [Medline].

  66. Pearce MJ, Mayou RA, Klimes I. The management of atypical non-cardiac chest pain. Q J Med. 1990 Sep. 76(281):991-6. [Medline].

  67. Phillips KA. Body dysmorphic disorder: clinical features and drug treatment. CNS Drugs. 1995. 3:30-40.

  68. Reilly TM, Jopling WH, Beard AW. Successful treatment with pimozide of delusional parasitosis. Br J Dermatol. 1978 Apr. 98(4):457-9. [Medline].

  69. Stone AB. Treatment of hypochondriasis with clomipramine. J Clin Psychiatry. 1993 May. 54(5):200-1. [Medline].

  70. Thomson A, Page L. Psychotherapies for hypochondriasis. Cochrane Database of Systematic Reviews 2007, Issue 4. Art. No.: CD006520. DOI: 10.1002/14651858.CD006520.pub2.

  71. Walker J, Vincent N, Furer P, Cox B, Kjernisted K. Treatment preference in hypochondriasis. J Behav Ther Exp Psychiatry. 1999 Dec. 30(4):251-8. [Medline].

  72. Wesner RB, Noyes R Jr. Imipramine an effective treatment for illness phobia. J Affect Disord. 1991 May-Jun. 22(1-2):43-8. [Medline].

 
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Mood, cultural, developmental, and environmental factors that influence hypochondriasis.
Factors that maintain anxiety in patients with hypochondriasis.
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