eMedicine Specialties > Pediatrics: Developmental and Behavioral > Medical Topics

Hypochondriasis

Author: Maria Sandra Cely-Serrano, MD, Developmental and Behavioral Pediatrician, Florida Hospital
Coauthor(s): Anna Maria Wilms Floet, MD, Assistant Professor, Assistant Professor of Pediatrics, Department of Pediatrics, Behavior and Developmental, University of Maryland School of Medicine
Contributor Information and Disclosures

Updated: Nov 5, 2008

Introduction

Background

Hippocrates used the term hypochondrium in the 4th century BC to refer to the anatomic area below the ribs. Later, the term hypochondriasis emerged to refer to the ill effects upon the psyche and soma of humors or fluids that emanate from the hypochondrium and cause disease.

The Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) defines hypochondriasis as the preoccupation with fears of having, or the belief that one has, a serious disease based on misinterpretation of bodily symptoms. In hypochondriasis, this preoccupation lasts at least 6 months and persists despite appropriate medical evaluation and reassurance. Hypochondriasis causes clinically significant distress or impairment in social, occupational, or other areas of functioning. These diagnostic criteria were initially described for adults, and the same basic criteria are applied to children and adolescents.

Because the literature about hypochondriasis in children and adolescents is limited, this review includes adult studies that describe the most recent advances in the subject of hypochondriasis.

Frequency

United States

Hypochondriasis is rare in childhood and occurs more frequently in adolescence. The precise prevalence in children is unknown because of lack of epidemiologic studies.

As many as 69.2% of children in a psychiatric-based outpatient clinic reported somatic symptoms. More than 12% of adolescents and young adults reportedly have at least one somatoform condition during their lifetime. Somatoform disorder symptoms may begin in early childhood, and the full disorder generally emerges in people aged 8-12 years.

In adults, prevalence rates of hypochondriasis vary according to the population studied and the diagnostic interview used. A prevalence rate of 0.8% was described from a large sample in 15 centers worldwide, and a rate of 3% was described in a primary care adult sample.

Hypochondriasis was found in 7.7% of first-degree relatives of patients with hypochondriasis. These relatives also had a high rate of comorbid anxiety and depressive and other somatoform disorders. The relatives reported substantial physical and psychological impairment, including diminished work performance and disability. In addition, these relatives reported greater use of health care services but less satisfaction with that care. These relatives showed most of the same characteristics found in earlier studies of patients who are hypochondriacal.

International

In adults, prevalence rates of hypochondriasis vary according to the population studied and the diagnostic interview used. A prevalence rate of 0.8% was described from a large sample in 15 centers worldwide.

An epidemiologic German study conducted in 2007 revealed a 0.4 % prevalence rate of DSM IV hypochondriasis.¹

Race

Hypochondriasis exhibits no racial predilection.

Sex

Musculoskeletal pain is associated with depression in both girls and boys. Some data suggest that somatic symptoms are strongly associated with emotional disorders in girls and occur with increased frequency in boys with disruptive behavior disorders. For girls, musculoskeletal pain or the combination of stomachache and headache is associated with anxiety and depressive disorder. For boys, stomachache is associated with oppositional defiant disorder and with attention deficit hyperactivity disorder (ADHD). These data may reflect a degree of referral bias because more boys are referred for psychiatric evaluation for disruptive behavior disorders symptoms than are girls for their more common internalizing symptoms.

Age

Hypochondriasis can begin in people of any age; the most common age at onset is thought to be early adulthood. The clinician should consider a diagnosis of hypochondriasis in older teenagers who have a history of prolonged preoccupation with having a serious illness.

Clinical

History

The key feature of hypochondriasis is abnormal concern that one is developing or has a serious illness. These persons may not claim particular symptoms but are often preoccupied with health and avoiding germs. They may focus excessively on minor bodily signs and are most troubled by their tendency to believe that these signs imply development of a severe condition. Despite of their concerns about having illnesses undiagnosed by physicians, these patients do not tend to show typical anxiety nor do they seem to have poor health despite excessive use of health remedies. They seem to overinterpret bodily signs and are not relieved by reassurances that they are healthy. Patients with hypochondriasis believe good health is defined as a relatively symptom-free state.

The onset of hypochondriasis can occur in people of any age and is associated with dissatisfaction with medical care, doctor shopping, and deteriorating interpersonal relationships. Hypochondriasis can occur as an independent disorder, considered primary hypochondriasis, or as secondary hypochondriasis when it is part of another underlying psychiatric disorder (eg, depression, anxiety disorder).

Children with a somatization disorder have heightened risk for psychiatric disorders, family dysfunction, functional impairment, and frequent use of health services. Headache is the most frequent somatic symptom, occurring in 50% of affected children and adolescents. Younger children show higher rates of abdominal symptoms than adolescents. A nonclinical sample of students reporting frequent headaches also reported additional symptoms of somatization, as well as depression and anxiety.

Children with depression or anxiety report significantly higher rates of somatic symptoms (eg, headache) than children with other mental disorders. Unexplained somatic symptoms can indicate an undiagnosed anxiety or depressive disorder. Multiple somatic symptoms are associated with anxiety, lowered self-esteem, family conflicts, health problems, and obesity. Data also suggest that higher levels of family stressors and parental somatic symptoms predict higher levels of somatic symptoms in children.

Patients with hypochondriasis believe good health to be relatively symptom free and consider more symptoms indicative of sickness. This may contribute to some of the clinical features of hypochondriasis, including the numerous somatic symptoms, bodily preoccupation, resistance to reassurance, and pursuit of medical care.

• Assessment aims include the following:
  • Determine that no other disorder, either physical or psychiatric, better accounts for the symptoms.
  • Establish a thorough account of the psychopathology and arrive at a psychological formulation of the problem. Determination of the most suitable mental health intervention for the patient is also necessary.
  • Initiate a successful therapeutic relationship with the patient. The patient should feel that an empathic and competent therapist conducted the assessment in a satisfactory and complete manner.
• Assessment should elicit the following information from the patient:
  • A brief description (ie, history) of the problem, including onset, severity, and duration
  • Triggers, both internal and external
  • Mood state, particularly anxiety and depression
  • Effects of the problem on school, work, or both and on social relationships
  • Medical interventions and how the interventions were interpreted by the patient
  • Previous treatment and reason, if any, of failure
  • Previous episodes of health concern
  • History of physical illness in the patient or a relative or friend
  • Patient's expectation of treatment
  • Cognitive factors
    • Thoughts, images, or both that trigger health anxiety
    • Intrusive negative thoughts, images, or both
    • Evidence for faulty beliefs
    • Dysfunctional assumptions
    • Selective attention or memory for information about health
    • Preoccupation with health or illness
    • Increased body focus
  • Behavioral factors
    • Behaviors that trigger health anxiety
    • Abnormal illness behaviors (eg, checking, avoidance, reassurance-seeking)
  • Physiologic factors
    • Physical symptoms that trigger health anxiety
    • Physical symptoms of anxiety
    • Physical symptoms caused by increased bodily focus and repetitive body checking
• Assessment should include information from other sources such as relatives, medical records, and involved professionals. Assessment measures include the following:
  • Diaries of intrusive negative thoughts
  • Diaries of physical symptoms
  • Baseline ratings of health anxiety, need for reassurance, and disease conviction
  • Standardized questionnaires (eg, Illness Behavior Questionnaire, Illness Attitude Questionnaire)

The Multidimensional Inventory of Hypochondrial Traits (MITH) was developed as a 4-component instrument consisting of affective, cognitive, behavioral, and perceptual scales, which reliably and validly measures hypochondriasis. The MITH was developed for research and is not intended as a diagnostic instrument. This tool is the first attempt to build a differentiated model of hypochondriasis and to construct a valid measure based on the model. This tool was developed primary with adult patients. The correlated 4-factor model provides a coherent theoretical foundation upon which future research can be built.

Causes

Different theories help explain the origin of somatoform disorders such as hypochondriasis.

• Biologic causes: Genetic or familial factors play a significant role in predisposing an individual to somatoform disorders. These disorders may be associated with the following characteristics:
  • Low pain threshold
  • Impaired verbal communication
  • Patterns of information processing characterized by distractibility, impulsiveness, and failure to habituate to repetitive stimuli
• Psychodynamic theories: These theories explain that an unconscious intrapsychic conflict, wish, or need is converted into somatic symptoms that symbolically express some aspect of the conflict and, at the same time, protect the individual from conscious awareness of it. By keeping the wish unconscious, the symptom minimizes anxiety and thus provides primary gain. A secondary gain is that the symptom provides an escape from unwanted consequences or responsibilities.
• Trauma and abuse: According to some studies, an association among childhood physical or sexual abuse and conversion, somatization, and dissociative disorders is observed.
• Learning theory: A child with an injury or illness quickly learns the benefits of the sick role and may be reluctant to recover. Symptoms are reinforced by increased parental attention and avoidance of unpleasant responsibilities (eg, attending school). Having a role model in the family for the illness has been correlated with somatoform disorders.
• Emotion and communication
  • Children who have difficulty expressing emotions verbally use symptoms to communicate distress.
  • High-achieving children who try to meet parental expectations may be unable to admit to themselves or to their parents that they are under too much pressure.
  • Physical symptoms may be used to express emotions in families in which overt emotional expression is discouraged.
  • Anxious or depressed children may express somatic symptoms to express their feelings.
• Family systems: In this theory, somatization is initiated by specific family patterns; the child's symptoms maintain homeostasis in the family. The family may display the following 4 characteristic patterns:
  • Enmeshment or blurring of interpersonal boundaries
  • Overprotection, demonstrated as limiting the child's involvement in age-appropriate activities
  • Rigidity, demonstrated by difficulty with life transition events (eg, puberty)
  • Lack of conflict resolution because of aversion to conflict and finding ways to avoid points of disagreement
• Environmental and social influences: Cultural factors influence the tendency to somatize and the choice of symptoms. In some cultures, somatic symptoms often are the initial symptoms for underlying anxiety or depressive disorders.
• Interpersonal model: There is a growing literature that links childhood adversity to adult hypochondriasis. Noyes et al (2002) found in an adult study that hypochondrial patients more frequently report more traumatic events and substance abuse in the family members compared to controls.² In addition, parental overconcern about child's health was positively correlated with adult hypochondriasis, and maternal care was negatively correlated with somatic symptoms.
• Association with other disorders: In an experimental analysis of hypochondriasis, subjects were exposed to personally relevant health-related stimuli under one of two conditions: (1) subsequently performing safety-checking behaviors or (2) subsequently being instructed not to perform such behaviors.³ For subjects who performed safety-checking behaviors, feelings of anxiety were reduced. For patients who did not, a more gradual reduction of anxiety and urges was observed. These findings are relevant to hypochondriasis possible relationship to panic disorder and obsessive compulsive disorder.

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