Pediatric Hypochondriasis Differential Diagnoses

Diagnostic Considerations

The differential diagnosis of somatoform disorders and hypochondriasis should consider any possible medical or psychiatric illness. Somatoform disorders or hypochondriasis can occur concurrently with medical or psychiatric illnesses. Also, according to the DSM-IV, psychological factors affecting a medical condition imply the presence of a general medical illness.

Medical Illnesses

Patients with medical conditions with an insidious or long-term progression (eg, multiple sclerosis, hemiplegic migraine) may present with a somatoform disorder. These medical conditions have repeated, nonspecific signs and symptoms that could be interpreted as a somatoform disorder. In hemiplegic migraine, patients present with hemiplegia or hemiparesis, with or without a speech and/or language disturbance, which clears in minutes to hours. Diagnosis can be made with repeated, stereotyped episodes and complete clearing between episodes, particularly in the presence of a positive family history. In multiple sclerosis, patients have multiple symptoms that are difficult to describe initially, but the symptoms resolve subsequently. The symptoms affect different parts of the body at different times.

Patients with organic brain disorders, such as delirium or dementia of any etiology (eg, toxic, metabolic, infectious), can present with somatic symptoms.

Psychiatric Illnesses

Other somatoform disorders

Conversion disorder is the presence of symptoms or deficits in sensory or motor function that indicate an organic medical or neurologic disorder, apparently due to stress or psychological issues. Symptoms are nonintentional and have no evident pathophysiology. Most frequent symptoms are neurologic in origin (eg, blindness, seizures, paralysis, seizures).

Pain disorder is the presence of pain with no explainable etiology; the 2 types are (1) predominant psychological pain and (2) a combination of psychological factors with a medical condition.

Body dysmorphic disorder is an imagined structural defect in a person who appears normal to the expert observer.

Affective disorders

Patients with depression or mania can present with multiple symptoms such as change of appetite and sleep patterns. Depression and hypochondriasis may overlap, especially when the morbid ideation of depression takes the form of disease phobias.

Anxiety disorders

The most common symptoms in children with anxiety disorder are headaches, stomachaches, nausea, and vomiting. Symptoms are often associated with an anxiety-provoking situation.

Hypochondriasis and panic disorder are both characterized by prevalent health anxieties and illness beliefs. Panic patients have more comorbidity with agoraphobia while hypochondriac patients are more closely associated with somatization. Patients with hypochondriasis plus panic have higher levels of anxiety, more somatization, more general psychopathology, and a trend towards increased health care utilization.

Psychoses

Psychosis can be differentiated by involvement of thought processes, social withdrawal, and impaired functioning.

Obsessive-compulsive disorders

Patients with obsessive-compulsive disorder and/or hypochondriasis often share the comorbidity of intense fears of illness, injury, or contamination. The lifetime prevalence of obsessive-compulsive disorders in a series of adult patients with hypochondriasis was 4 times more than in a comparison group (ie, 8% versus 2%). In contrast to those with hypochondriasis, patients with obsessive-compulsive disorder view their fears as abnormal, attempt to suppress them, and avoid publicizing their symptoms, which are frequently observed as shameful.

Personality disorders

A high prevalence of personality disorders is noted in patients with hypochondriasis, particularly obsessive compulsive disorder (OCD). In one study, 76.5% from a total of 88 patients with hypochondriasis had OCD.^[4] This suggests that consideration of personality features is important in assessment and therapeutic interventions for hypochondriasis.

Malingering and Factitious Disorders

Malingering is the intentional production of symptoms or signs of illness or disability in order to obtain a specific goal (eg, avoiding school, acquiring drugs or money).

Factitious disorder is the intentional production of symptoms to maintain a nonspecific patient role (eg, maintaining a dependency role in the family over time).

In somatoform disorders, symptoms are not produced voluntarily, thus differing from factitious disorders and malingering in which symptoms are produced intentionally.

Adolescents who present with unexplained neurologic symptoms in the primary care setting may be suffering from a clinically significant behavioral health disorder or some other form of psychological distress. If no adequate medical cause can be found to explain the patient's presenting symptomatology, it is important for the primary care provider to conduct a careful assessment of the patient's psychosocial functioning.