- Author: Glen L Xiong, MD; Chief Editor: David Bienenfeld, MD more...
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.
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.
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.”
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). Other authors postulate that somatoform disorders including hypochondriasis may be a learned unconscious behavior that may serve to avoid internal conflicts and external stressors.
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.
The prevalence rates for primary hypochondriasis in the primary care setting are 0.8-4.5%. 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.
International rates are similar to those in the United States.
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.
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. The medically unexplained complaint is often a symptom of hypochondriasis and may well be a presentation of associated abnormal illness behavior.
Patients with hypochondriasis have a high rate of psychiatric comorbidity. 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. 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.
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).
Hypochondriasis appears to occur equally in men and women.
Hypochondriasis can begin at any age, but the most common age of onset is early adulthood.
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