				Using the search form

If you prefer to view this article in PDF form, click here.

Hypochondriasis: Meeting the management challenge

Patients who remain convinced they are ill despite all medical evidence to the contrary are among the most difficult to care for in all of medicine.

J. Glenn Forister, MPAS, PA-C; Billy James, PhD

Glenn Forister is Assistant Clinical Professor, Department of Physician Assistant Studies, and Billy James is Assistant Professor, Departments of Physician Assistant Studies and Emergency Health Sciences, both at the School of Allied Health Sciences, University of Texas Health Science Center at San Antonio. The authors have indicated no relationships to disclose relating to the content of this article.

The days when patients used to obtain most of their health information from physicians—and only limited information at that—have long since passed. Now, the medicolegal requirements of informed consent and the pressures of consumer demand have increased the amount of information clinicians relay to patients. Information can also be accessed 24 hours a day via health-oriented television channels, news reports, and Web sites spotlighting even the most obscure and rare health conditions.

Although most people absorb and filter health information in an adaptive way, some are not able to assess their own personal risk of illness and therefore misapply the information. At one extreme are people who ignore life-threatening warning signs, such as chest pain; their delay in seeking medical attention may have catastrophic results. The other end of the spectrum consists of those who obsess over normal physical stimuli, constantly seek reassurance, and cannot be convinced that they are not seriously ill. The latter may have hypochondriasis.

The prevalence rate for hypochondriasis is between 2% and 7%,^1,2 and it increases to 19% in primary care patients presenting with medically unexplained symptoms.^1,3 Hypochondriacal patients are quite frustrating to deal with, and PAs are very likely to encounter them at some point in clinical practice.

WHAT IS HYPOCHONDRIASIS?

Health anxiety becomes hypochondriasis (a somatoform disorder) when the patient becomes preoccupied with fears of having a serious disease based on misinterpretation of bodily sensations or changes in bodily sensation.¹ A number of symptoms are associated with the central feature of fear of having a disease, including repeated bodily checking and persistently seeking medical assurance. The DSM-IV-TR takes a descriptive approach to psychiatric illness and therefore does not address causal explanations for a given psychiatric condition. While the etiology of hypochondriasis is elusive, the cognitive model provides clinicians with a starting point for evaluation and treatment.^2-4

Proposed mechanism Although the etiology of hypochondriasis is not well understood, some characteristics have emerged in the literature and are important in understanding how the condition is manifested. Hypochondriasis can be conceptualized as a multifactorial mental illness with four dimensions: (1) affective: worry about health; (2) cognitive: conviction that one is ill despite contrary evidence; (3) behavioral: seeking reassurance to allay illness fears; and (4) perceptual: somatic absorption with body sensations.^2,5-7 These characteristics will be noticed during clinical assessment of a patient with hypochondriasis. Additionally, these four dimensions provide an opportunity to disrupt the mental events maintaining hypochondriasis.^2,4,6

It has been suggested that to develop hypochondriasis, a person must be psychologically predisposed to selectively attend to bodily sensations and to misinterpret these sensations. Additionally, persons with hypochondriasis amplify their worry and concern about illness as well as the potential for catastrophic disease. Therefore, the mechanism that maintains hypochondriasis appears to be a psychological predisposition coupled with information processing errors (ie, logical errors).

DIAGNOSIS

The diagnosis of hypochondriasis relies heavily on the psychosocial history and mental status examination. During the assessment, the PA should attend to elements that support the DSM-IV-TR criteria for hypochondriasis¹ (see Table 1).

Symptoms of hypochondriasis overlap with those of other conditions, including anxiety disorders (obsessive-compulsive disorder, generalized anxiety disorder [GAD], and panic disorder), somatoform disorders (somatization disorder, body dysmorphic disorder, and conversion disorder), and depressive disorders (major depression, adjustment disorder, and others). Fink and colleagues suggest that the DSM-IV-TR diagnostic criteria should be revised to allow “division of cases into (two categories) mild and severe.”⁸ Dividing patients in this way may be prognostically important.

In addition, it is important to distinguish hypochondriasis from anxiety disorders. Patients with either condition may experience a catastrophic misinterpretation of sensations. However, patients with anxiety disorders—specifically panic disorder or GAD—will misperceive the catastrophe as an immediate threat and will have a symptomatic presentation of autonomic arousal. In contrast, the hypochondriacal patient will more often present with a less immediate or distant threat and symptoms that are less likely to be associated with autonomic arousal. Thus in general terms, hypochondriasis can be differentiated from anxiety disorders by the proximity of the threat and the extent to which symptoms are related to autonomic or central nervous system arousal.^1,9

Somatization is a word that is sometimes used to describe the over-reporting of medical symptoms. Somatization disorder is something else entirely and involves symptoms in four domains (pain, GI, sexual, and pseudoneurologic symptoms). Both somatization disorder and hypochondriasis involve fear of having a disease, but hypochondriasis is not diagnosed if a person meets the criteria for somatization disorder. In other words, somatization disorder takes precedence over hypochondriasis, although somatization disorder occurs much less frequently. Furthermore, the conditions differ in terms of chronicity, age of onset, and gender distribution¹ (see Table 2).

Finally, depressive disorders can produce somatic complaints (for example, abdominal pain). A determination of depressive disorder takes precedence over a diagnosis of hypochondriasis, and hypochondriasis would be diagnosed along with depression only when hypochondriacal symptoms occur outside of the depressive syndrome (such as when hypochondriasis symptoms preceded the depressive symptoms).¹

History The PA should take care not to appear rejecting, dismissive, or rushed when taking the history. Standing while the patient is seated, avoiding eye contact, or glancing at a watch are nonverbal clues to the patient that may impair the ability to establish a good rapport.

Close attention should be given to psychosocial elements and recent family history. Ask if a close contact has had a recent catastrophic illness or died because this might suggest a more acute and transient form of hypochondriasis. Ask about the patient’s general and specific concerns. Certain common fears may also emerge, such as concern over possible malignancy, an ill-defined sense of dread, or paranoia about the possible adverse effects of medication.^2,10 Look for errors in the patient’s logic. Try to discover if there is a trigger or specific time pattern related to the symptoms. Is there a temporal relationship of the symptoms to life stressors? Constructing a timeline of events is helpful. A pattern of “doctor-shopping” in search of reassurance may emerge. Often patients will relate stories of negative interactions with previous providers, and they may describe their prior caregivers as uncaring, untrustworthy, disrespectful, or unfriendly.¹¹ Explore the possibility of a sleep disorder, depression, anxiety, panic, or substance abuse that may take precedence over a diagnosis of hypochondriasis or may at least complicate the treatment plan.^1,8

Performing a thorough review of systems serves to uncover a recognizable pattern of illness behavior or a large number of positives. Determine if the complaints can be explained by normal physiology, such as numbness and tingling of the extremities related to hyperventilation. Determine if the patient feels autonomic mediated responses such as sweatiness, tremor, palpitations, chest pain, or shortness of breath at specific times. Ask if the patient has a health diary, medical records, or printed literature from the Internet. Also assess how the condition interferes with level of function and the patient’s relationship with others. Finally, while taking the history, maintain an objective, nonjudgmental demeanor.

Examination If possible, perform a complete physical examination. Do this in the usual manner, but do not verbalize any medical jargon related to minor physical variances. For example, announcing that you note xeroderma rather than simply saying dry skin can cause a patient to misinterpret significance. Informing the patient of a physiologic split of the second heart sound or an innocent murmur can likewise be counterproductive. When seeing a patient on multiple occasions, perform a problem-focused examination for new complaints. Patients with established hypochondriasis may occasionally have an organic cause of new symptoms.

Testing Avoid excessive testing. Overdiagnosis occurs when screening reveals inconsequential findings that are unlikely to result in later disease. The tests ordered should be selected for their sensitivity and be based on objective findings. Proceed with caution when ordering panels of tests or invasive diagnostic procedures. Ordering a test with low sensitivity will generate a greater number of false-positive results.¹² The patient with hypochondriasis might seize on a false-positive test result as confirmation of disease when the disease is not truly present. This is especially true for conditions that have a low prevalence in the population.

Communicating the diagnosis When a patient clearly meets the diagnostic criteria for hypochondriasis, the diagnosis should be communicated cautiously. A central manifestation of hypochondriasis is the conviction that one has a disease in spite of a negative evaluation. Keep in mind that the patient may not accept a psychological explanation of symptoms. If this occurs, reframe the conversation to focus on how the patient will cope with the symptoms rather than pushing the patient to accept a diagnosis of hypochondriasis.

TREATMENT

A central manifestation of hypochondriasis is the need for reassurance.^1,2 Although reassurance from the clinician may temporarily allay fear of an occult disease process, providing ongoing reassurance at the patient’s request can become addictive. Just as nicotine reduces anxiety and agitation in a smoker, reassurance reduces anxiety and worry in the person with hypochondriasis. The anxiety reduction is a temporary fix, however, and does not change the underlying structure or dimensions of the patient’s illness worry. Therefore, the effect of reassurance will wear off in a very short time.

A better approach may involve limited reassurance and limited access to the PA.^2,4,6 The PA should validate the somatic symptoms (“the muscles in your neck are tense and causing you pain”), build rapport to increase credibility (“these symptoms must be disruptive for you”), be honest in the therapeutic relationship ( “I don’t believe there is a physical explanation for all of your symptoms, and I don’t think we can expect to eliminate all the symptoms you’re experiencing”), and provide guidance (“what we can do is help you to cope better with the symptoms that you have”). Other important strategies are to reorient (focus on improving how the patient copes with the symptoms rather than on removing the symptoms); limit prescriptions (in the absence of comorbid conditions, medications have not been shown to be superior to cognitive methods and carry higher risks); and consult (a mental health professional can be helpful in severe cases of hypochondriasis or when the patient is receptive to trying additional treatment strategies). This is important as the current evidence suggests that cognitive behavior therapy (CBT), coupled with limiting access and reassurance, provide the best outcomes.

At times, the patient will require some kind of reassurance during the assessment. When offering reassurance, the PA directs the patient on how to properly interpret the symptoms rather than focus on the presence or intensity of symptoms. Moreover, providers should be cautious in their reassurance and recall that the goal is not to remove the patient’s symptoms because the symptoms are real sensations. Furthermore, limited access to the PA may also be beneficial. Once the PA has a good rapport with the patient, the two may collaboratively establish a prescribed time interval between visits. The length of the visit should be limited as well. Experts have suggested that the longest time between visits should be 4 weeks in early treatment. Nevertheless, the precise interval and amount of time allowed for each appointment is best established collaboratively.

During these visits the PA should inquire about the patient’s symptoms while helping the patient to broaden the interpretation of the symptoms (“it sounds as though the abdominal discomfort began after the argument with your wife”). This approach establishes a schedule of reinforcement that has a different structure than what the patient has been accustomed to, and this different structure will hopefully aid in modifying illness perceptions (see “Five suggestions for managing patients with hypochondriasis”).

Pharmacotherapy or CBT? The value of psychotropic medications in the treatment of hypochondriasis has been reported to be inconclusive.¹³ While tricyclics such as clomipramine or imipramine and heterocyclics such as fluoxetine, paroxetine, or fluvoxamine have demonstrated some benefit, the research is confounded by a lack of control for placebo effects. Furthermore, patients who start a medication regimen for the management of hypochondriasis may prefer the personal interest of the provider over the medication, causing symptoms to continue, and they may experience a worsening of their condition as medication side effects start to cause additional symptoms.

If medication is used, consider the following approach. First, explain that the rationale for medication is to reduce hypersensitivity to unpleasant but harmless bodily sensations. Second, inform the patient about the side effects in an effort to prevent catastrophic thinking.

Currently the most widely accepted treatment for hypochondriasis is CBT. The dilemma, or course, is how to connect the patient to a mental health provider who is trained to provide CBT to patients with hypochondriasis. Patients probably know that they are overly concerned about illness, having been told this repeatedly by friends, family, and other providers. It is difficult to predict how many such patients will accept mental health referral. One way to circumvent resistance is to provide CBT in the medical setting. This requires a more direct working relationship among physicians, PAs, and mental health providers.

Walker and colleagues investigated whether persons with hypochondriasis would be receptive to medication management or to CBT.¹⁴ They presented descriptions of the two therapies to 23 persons seeking treatment who had hypochondriasis. They found that 74% of the participants preferred the descriptions of CBT. It may be that patients are more receptive to CBT than previously assumed. Successful treatment depends on adherence because CBT is time-consuming. A typical patient will attend for up to 25 hours.

Complications PAs should be alert to complications that can occur in patients with hypochondriasis. Organic disease may be overlooked, with a delay in diagnosis. Iatrogenic injury may occur during the search for a diagnosis. Patients may become dependent on benzodiazepines, narcotics, or alcohol in an attempt to self-medicate anxiety. They may lose excessive time from work and have domestic conflicts. Family and friends grow tired of listening to their health concerns. Patients may become socially isolated. Their finances might also become unstable as a result of excessive medical bills. All these potential complications will impair well-being.

CONCLUSION

Hypochondriasis is a complicated, multidimensional disorder that causes significant distress and disability. The management of patients with hypochondriasis is often frustrating and challenging for clinicians. A comprehensive psychosocial history and mental status examination should help to clarify the diagnosis of hypochondriasis as well as of disorders that confound or complicate the illness course. Ideally, management involves collaboration between a mental health provider and the PA. The use of CBT can minimize reassurance seeking. With the assistance of a caring professional relationship, persons with hypochondriasis can alter their faulty beliefs and behaviors to become more hopeful, more functional, and less prone to worry about their health.

REFERENCES

	1.	Salkovskis PM, Warwick HMC. Making sense of hypochondriasis: a cognitive model of health anxiety. In: Admundson GJG, Taylor S, Cox BJ, eds. Health Anxiety: Clinical and Research Perspectives on Hypochondriasis and Related Conditions. New York, NY: John Wiley & Sons, Ltd; 2001:46-63.
	2.	American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Washington, DC: American Psychiatric Association, 2000.
	3.	Speckens AEM, Van Hemert AM, Spinhoven P, Bolk JH. The diagnostic and prognostic significance of the Whitely Index, the Illness Attitudes Scales and the Somatosensory Amplification Scale. Psychol Med. 1996;26:1085-1090.
	4.	Speckens AEM, Van Hemert AM, Spinhoven P, et al. Cognitive behavioural therapy for medically unexplained physical symptoms: a randomized controlled trial. BMJ. 1995;311(7016):1328-1332.
	5.	Longley SL, Watson D, Noyes R. Assessment of the hypochondriasis domain; the Multidimensional Inventory of Hypochondriacal Traits. Psychol Assess. 2005;17(1):3-14.
	6.	Barsky AJ, Ahern DK. Cognitive behavior therapy for hypochondriasis: a randomized controlled trial. JAMA. 2004;291(12):1464-1470.
	7.	Warwick HMC, Salkovskis PM. Hypochondriasis. Behav Res Ther. 1990;28(2):105-117.
	8.	Fink P, Ornbol E, Toft T, et al. A new, empirically established hypochondriasis diagnosis. Am J Psychiatry. 2004;161(9):1680-1691.
	9.	Zuckerman M. Vulnerability to Psychopathology: A Biosocial Model. Washington, DC: American Psychological Association; 1999.
1	0.	Barsky AJ, Ahern DK, Bailey ED, et al. Hypochondriacal patients’ appraisal of health and physical risks. Am J Psychiatry. 2001;158(5):783-787.
	11.	Persing JS, Stuart SP, Noyes R Jr, Happel RL. Hypochondriasis: the patient’s perspective. Int J Psychiatr Med. 2000;30(4):329-342.
	12.	Vogt WP. Dictionary of Statistics & Methodology: A Nontechnical Guide for the Social Sciences. 3rd ed. Thousand Oaks, Calif: Sage Publications, Inc; 2005.
	13.	Taylor S, Asmundson GJG, Coons MJ. Current directions in the treatment of hypochondriasis. J Cogn Psychotherapy. 2005;19(3):285-304.
	14.	Walker J, Vincent N, Furer P, et al. Treatment preference in hypochondriasis. J Behav Ther Exp Psychiatry. 1999;30(4):251-258.