204 Hypochondriasis (300.7)

DSM -IV-TR criteria

A. Preoccupation with fears of having, or the idea that one has, a serious disease based on the person’s misinterpretation of bodily symptoms

B. The preoccupation persists despite appropriate medical evaluation and reassurance.

C. The belief in Criteria A is not a delusional intensity (as in Delusional Disorder, Somatic Type) and is not restricted to a circumscribed concern about appearance (as in Body Dysmorphic Disorder).

D. The preoccupation cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

E. Duration of disturbance at least six months.

F The preoccupation is not better accounted for by Generalized Anxiety Disorder, Obsessive-Compulsive Disorder, Panic Disorder, a Major Depressive episode, Separation Anxiety or other Somatoform Disorder.

Specify if: With Poor Insight: if for most of the time during the current episode, the person does not recognize that the concern about having a serious illness is excessive or unreasonable.

Barlow and Durand (2009) give an example of hypochondriasis:

Gail was married at 21 and looked forward to a new life. As one of many children in a lower-middle-class household, she felt weak and somewhat neglected and suffered from low self-esteem. An older stepbrother berated and belittled her when he was drunk. Her mother and stepfather refused to listen to her or believe her complaints. But she believed that marriage would solve everything; she was finally someone special. Unfortunately, it didn’t work out that way. She soon discovered her husband was continuing an affair with an old girlfriend.

Three years after her wedding, Gail came to our clinic complaining of anxiety and stress. She was working part-time as a waitress and found her job extremely stressful Although to the best of her knowledge her husband had stopped seeing his former girlfriend, she had trouble getting the affair out of her mind.

Although Gail complained initially of anxiety and stress, it soon became clear that her major concerns were about her health. Any time she experienced minor physical symptoms such as breathlessness or a headache, she was afraid she had a serious illness. A headache indicated a brain tumor. Breathlessness was an impending heart attack. Other sensations were quickly elaborated into the possibility of AIDS or cancer. Gail was afraid to go to sleep at night for fear that she would stop breathing. She avoided exercise, drinking, and even laughing because the resulting sensations upset her. Public restrooms and, on occasion, public telephones were feared as sources of infection.

The major trigger of uncontrollable anxiety and fear was in the new in the newspaper and on television. Each time an article or show appeared on the “disease of the month,” Gail found herself irresistibly drawn into it, intentionally noting symptoms that were part of the disease. For days afterwards she was vigilant, looking got the symptoms in herself and others. She even watched her dog closely to see whether he was coming down with the dreaded disease. Only with great effort could she dismiss these thoughts after several days. Real illness in a friend or relative would incapacitate her for days at a time.

Gail’s fears developed during the first year of her marriage, around the time she learned of her husband’s affair. At first, she spent a great deal of time and more money than they could afford going to doctors. Over the years, she heard the same thing during each visit: “There’s nothing wrong with you; you’re perfectly healthy.” Finally, she stopped going, as she became convinced her concerns were excessive, but her fears did not go away and she was chronically miserable.

Associated Features

• Hypochondriasis is characterized by a preoccupation with physical symptoms; however, a key feature is that it combines the fear with the conviction that one has an organic disease (Mai, 2004).
• Fear of aging and death. They place a greater importance on physical health, but do not have better health habits than someone who does not have a disorder. “Doctor shopping”, as well as deterioration with Doctor relationships with frustration and anger towards each other are common. This deterioration could be due to the fact that even when a medical examination proves that there is nothing wrong, the patient continues to believe he or she is sick. The patient may also believe he or she is not getting proper care, and they may resist referral to mental health professionals. Social relationships become strained.
• One interprets physical symptoms and feelings as signs of a serious medical illness in spite of medical assurance that they are not.
• May be especially concerned about a particular organ system (such as the cardiac or digestive system).
• They usually present their medical record in great detail.
• Individuals suffering from Hypochondriasis generally need to be under constant reassurance from family, friends, and doctors. Certain individuals suffering from this disorder rarely speak about their anxieties whereas other individuals constantly talk about their anxieties.
• Anxiety, clinical depression, phobias, somatization disorder and obsessive-compulsive personality traits are frequently observed.

Child vs. Adult Presentation

• This can occur at any age; however it is usually seen in early adulthood.

Gender and Cultural Differences in Presentation

• Males and Females show the same rates through most of the studies.
• Culturally, some may have a fear of illness that resembles Hypochondriasis, but it is not the same and they are influenced by cultural beliefs and practices.

Epidemiology

• The prevalence of Hypochondriasis in the general population is 1%-5% (community), 2-7% (primary care outpatients).
• The disorder can begin at any age, but the most common age at onset is early adulthood. The course is typically chronic, and the symptoms fluctuate, but there are some complete recoveries. Acute onset, mild duration, mild symptoms, general medical comorbidity, and the absence of a comorbid mental disorder, and the absence of secondary gain indicate a favorable prognosis. Some view this disorder as having certain “trait like” characteristics.

Etiology

Serious illnesses, particularly in childhood, and past experience with disease in a family member are associated with the occurrence of Hypochondriasis. Psychosocial stressors, in particular the death of someone close to the individual, are thought to precipitate the disorder in some cases.

The etiology of this disorder has no exact cause; it is unknown. There are some things that can bring about this disorder such as past abuse, problems expressing emotions, or an inherited susceptibility.

One theory as to the cause of this is that people with this are highly sensitive to physical pain. They pay attention more closely to changes in their body. They tend to freak out when something had changed and often make a bigger deal out of it than it really is. Situational factors can play a role in this.

Another theory suggests that people with this disorder misinterpret their symptoms. Most people think they are healthy until they have symptoms of a disease. However, this theory suggest that people with Hypochondriasis think they are ill or something is wrong with them, until they have proof that there is not.

Empirically supported treatments

The physician and his or her team’s attention, concern, interest, careful listening, and nonjudgmental stance, can potentially break a pathological cycle of maladaptive interactions between the patient and movement from physician to physician. Cognitive behavioral therapy (CBT) and selective serotonin re uptake inhibitors (SSRIs such as fluoxetine and paroxetine) are also treatments that have proven to be useful in treating Hypochondriasis. SSRIs generally diminish the anxiety through changing the neurotransmitter levels to a more compatible level.

Comorbidity

Patients with hypochondriasis have high levels of psychiatric distress including anxiety, depressive and somatoform symptoms (Magarnos, Zafar, Nissenson, & Blanco, 2002).

DSM-V recommended revisions www.dsm5.org

Major changes:

#1: Rename Somatoform disorders to Somatic Symptom Disorders and combine with PFAMC and Factitious Disorders.

#2: Combine somatization disorder, hypochondriasis, undifferentiated somatoform disorder, and pain disorder into a new category entitled “Complex Somatic Symptom Disorder” (CSSD).

The work group is recommending that this disorder be subsumed into a new disorder: Complex Somatic Symptom Disorder.

The following optional specifiers may be applied to a diagnosis of CSSD where one of the following dominates the clinical presentation:

High health anxiety (previously, hypochondriasis) {If patients present solely with health-related anxiety in the absence of somatic symptoms, they may be more appropriately diagnosed as having an anxiety disorder.} *

*Note: Both the Somatic Symptom Disorders Work Group and the Anxiety, Obsessive-Compulsive Spectrum, Posttraumatic, and Dissociative Disorders Work Group are considering the possibility that what was described as Hypochondriasis in DSM-IV may represent a heterogeneous disorder in which some individuals may be better considered to have CSSD and some may be better considered to have an anxiety disorder. There will be ongoing discussion of this issue.