Hypochondriasis Clinical Presentation

Updated: Aug 02, 2016
  • Author: Debra Kahn, MD; Chief Editor: David Bienenfeld, MD  more...
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Presentation

History

Hypochondriasis is no longer a diagnosis according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Instead, approximately 75% of individuals previously diagnosed with hypochondriasis are subsumed under the diagnosis of somatic symptom disorder. The remaining 25% have high health anxiety in the absence of somatic symptoms and are classified as having illness anxiety disorder. Both somatic symptom disorder and illness anxiety disorder are classified in the DSM-5 under Somatic Symptom and Related Disorders. [73] The disorders in this class include somatic symptom disorder, illness anxiety disorder, conversion disorder, and factitious disorder.

The health preoccupation diagnostic interview has been determined to have sufficient inter-rater reliability for somatic symptoms disorder and illness anxiety disorder (kappa of 0.85; n=104). [79] According to the DSM-5, somatic symptom disorders all share a common feature: the prominence of somatic symptoms associated with significant distress and impairment. [73]

The core feature of somatic symptom disorder is the presence of one or more somatic symptoms that are distressing or result in significant disruption of daily life.

The core feature of illness anxiety disorder is a preoccupation with having or acquiring a serious, undiagnosed medical illness.

Diagnostic criteria (DSM-5)

The DSM-5 criteria for illness anxiety disorder are as follows: [73]

  • The individual is preoccupied with having or acquiring a serious illness.
  • Somatic symptoms are not present or, if present, are only mild in intensity. If another medical condition is present or there is a high risk for developing a medical condition (eg, strong family history is present), the preoccupation is clearly excessive or disproportionate.
  • The individual has a high level of anxiety about health, and is easily alarmed about personal health status.
  • The individual performs excessive health-related behaviors or exhibits maladaptive avoidance.
  • The individual has been preoccupied with illness for at least 6 months.
  • The individual's preoccupation is not better explained by another mental disorder.
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Physical

The absence of physical findings, particularly after serial examinations, supports the diagnosis of illness anxiety disorder. 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

See the list below:

  • 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

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

Mood and affect

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

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

Thought process

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  • 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

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  • 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

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  • 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

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  • 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

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  • 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 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 illness anxiety disorder and the general population. There are some findings that risk factors for illness anxiety disorder include a lower educational level, lower income, and a history of childhood illness or abuse. [7]

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 illness anxiety 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 illness anxiety to exaggerate their assessment of vulnerability to disease and their appraisal of the risk of serious illness. [11]

The social learning theory frames illness anxiety disorder 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 somatic symptoms serve to "undo" guilt felt about the anger and serve as a punishment for being "bad."

Neurochemical deficits with illness anxiety disorder 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).  Additionally, 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 illness anxiety, 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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