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Hypochondriasis
o Author: Glen L Xiong, MD
o Chief Editor: David Bienenfeld, MD
Overview
Clinical Presentation
Differential Diagnoses
Workup
Treatment & Management
Medication
Follow-up
Overview
Background
Pathophysiology
Epidemiology
Clinical Presentation
History
Physical
Causes
Workup
Laboratory Studies
Other Tests
Follow-up
Inpatient & Outpatient Medications
Transfer
Complications
Prognosis
Background
Hypochondriasis and the other somatoform disorders are among the most difficult and most
complex psychiatric disorders to treat in the general medical setting. On the basis of many
new developments in this field, diagnostic criteria have been revised to facilitate clinical care
References
Pathophysiology
Neurochemical deficits associated with hypochondriasis and some other somatoform
disorders (eg, somatization, conversion, and body dysmorphic disorders) appear similar to
those of mood and anxiety disorders. See Medscape Reference articles Somatoform Disorders
and Conversion Disorders.
For example, Hollander et al posited an "obsessive-compulsive spectrum" to include
obsessive-compulsive disorder (OCD)[2, 3] , body dysmorphic disorder (BDD), anorexia
nervosa, Tourette syndrome, and impulse control disorders (eg, trichotillomania, pathological
gambling).[4] Other authors postulate that somatoform disorders including hypochondriasis
may be a learned unconscious behavior that may serve to avoid internal conflicts and external
stressors.[5]
This formulation of obsessive-compulsive (OC) spectrum disorders, while not a part of the
consensus psychiatric diagnostic and classification literature, crosses boundaries of several
diagnostic categories in the Diagnostic and Statistical Manual of Mental Disorders, Fourth
Edition-Text Revision (DSM-IV-TR). In addition, encountering a patient with more than one
of the anxiety spectrum disorders during his or her life is not unusual. Although findings of
studies of these neurochemical deficits are only preliminary, such deficits may explain why
symptoms overlap, why the disorders are commonly comorbid, and why effective treatments
parallel one another (eg, selective serotonin reuptake inhibitors [SSRIs]).
In a recent study of biological markers, subjective who met DSM-IV-TR diagnostic criteria
for hypochondriasis had decreased plasma neurotrophin 3 (NT-3) level and platelet serotonin
(5-HT) levels, compared to healthy control subjects. NT-3 is a marker of neuronal function
and platelet 5-HT is a surrogate marker for serotonergic activity.[6]
References
Epidemiology
Frequency
United States
The prevalence rates for primary hypochondriasis in the primary care setting are 0.84.5%.[7] Some degree of preoccupation with disease is apparently common, because 10-20%
of people who are healthy and 45% of people without a major psychiatric disorder have
intermittent unfounded worries about illness.[8]
International
International rates are similar to those in the United States.[9]
Mortality/Morbidity
Hypochondriasis is usually episodic, with hypochondriacal symptoms that last from months
to years and equally long quiescent periods. Although formal outcome studies have not been
conducted, one third of patients with hypochondriasis are believed to eventually improve
significantly. A good prognosis appears to be associated with high socioeconomic status,
treatment-responsive anxiety or depression, the absence of a personality disorder, and the
absence of a related nonpsychiatric medical condition. Most children are believed to recover
by adolescence or early adulthood, but empiric studies have not been carried out.
Epidemiological studies are lacking, but patients with hypochondriasis appear similar to those
with somatization disorder. These individuals use medical care at high rates, making frequent
visits to the emergency department, the doctor, and other health care providers and
undergoing frequent physical examinations, laboratory testing, and other costly, invasive, and
potentially dangerous procedures.[10]
Cognitive, social learning, and psychodynamic theories imply that patients have significant
psychosocial disturbances in terms of relationships, vocational, and other endeavors.
Exacerbations may occur with psychological stressors and in patients with comorbid
psychiatric conditions.
These high-use patterns differ dramatically from those of nonsomatizing patients and remain
true even when comorbid medical conditions and sociodemographic differences are
accounted for.[11] The medically unexplained complaint is often a symptom of
hypochondriasis[12] and may well be a presentation of associated abnormal illness
behavior.[13]
Patients with hypochondriasis have a high rate of psychiatric comorbidity.[14] In one general
medical outpatient clinic, 88% of patients with hypochondriasis had one or more concurrent
psychiatric disorders, the most common being generalized anxiety disorder (71%), dysthymic
disorder (45.2%), major depression (42.9%), somatization disorder (21.4%), and panic
disorder (16.7%). These patients are 3 times more likely to have a personality disorder than
the general population.[14] Substance abuse or dependence is also a serious comorbid
condition, particularly use of benzodiazepines, though epidemiological studies have not
assessed the exact frequency of this problem. The long-term prognosis of patients with
hypochondriasis is understudied due to the heterogeneity of the disorder. However, higher
severity at baseline is likely associated with worse outcome.
Race
This disorder has not been well studied with respect to race and ethnicity. More information
is needed, too, with regard to its relationship to other medical disorders needing better
definition (eg, neurasthenia, chronic fatigue syndrome, fibromyalgia, and multiple chemical
sensitivity syndrome).
Sex
Hypochondriasis appears to occur equally in men and women.
Age
Hypochondriasis can begin at any age, but the most common age of onset is early adulthood.
References
History
Hypochondriasis is classified as one of the somatoform disorders, a class that was formulated
to accommodate the differential diagnosis of disorders characterized primarily by physical
symptoms for which no demonstrable organic explanations or physical findings exist.
The DSM-IV-TR stipulates that the symptoms are not under voluntary control (thus excluding
malingering and factitious disorders) and are not fully explained by known physiological
causes (excluding psychological factors affecting the medical condition). The disorders in the
somatoform class include somatization disorder, conversion disorder, pain disorder,
hypochondriasis, BDD, and undifferentiated somatoform disorder.
The core feature of hypochondriasis is not preoccupation with symptoms themselves, but
rather the fear or idea of having a serious disease (see the image below). The fear or idea is
based on the misinterpretation of bodily signs and sensations as evidence of disease. The
illness persists despite appropriate medical evaluations and reassurance.
Physical
The absence of physical findings, particularly after serial examinations, supports the
diagnosis of hypochondriasis. 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
Psychomotor status
Restlessness
Frequent shifts in posture
Mild-to-moderate agitation
Slowed (if sleeping poorly)
Mood (the pervasive and sustained emotion that colors the patient's perception of the
world) and affect (what the examiner observes)
Restricted, shallow, fearful, or anxious affect, with restricted fluctuations and limited
depth
Thought process
Thought content
Cognitive function
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
Judgment
References
Causes
Developmental and other predisposing factors (see the image below) 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
hypochondriasis and the general population. Social position, education level, and marital
status do not appear to be factors in this condition.
Mood, cultural, developmental, and environmental factors that influence
View Image hypochondriasis.
A cognitive model of hypochondriasis suggests that patients misinterpret bodily symptoms by
augmenting and amplifying their somatic sensations. Patients also appear to have lower-thanusual thresholds for, and tolerance of, physical discomfort. For example, what most people
normally perceive as abdominal pressure, patients with hypochondriasis 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 hypochondriasis to exaggerate their assessment of
vulnerability to disease and their appraisal of the risk of serious illness.[11]
The social learning theory frames hypochondriasis 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 hypochondriacal
symptoms serve to "undo" guilt felt about the anger and serve as a punishment for being
"bad."
Neurochemical deficits with hypochondriasis and some other somatoform disorders (eg,
BDD) appear similar to those of depressive and anxiety disorders. For example, in 1992,
References
Differential Diagnoses
Anxiety Disorders
Body Dysmorphic Disorder
Conversion Disorders
Delusional Disorder
Depression
Personality Disorders
Schizophrenia
Somatoform Disorders
Laboratory Studies
In patients with hypochondriasis, the abnormal laboratory findings characteristic of the
suggested physical disorder are absent.
References
Other Tests
Screening tools
The Health Anxiety Inventory (HAI) (long version; short version of 14 items, 5 min)
reliably distinguishes patients with hypochondriasis from patients with anxiety
disorders or healthy controls.[27]
The Illness Attitude Scale (29 items, 15 min, English only) is used for detection and
to assess severity.[35]
The Whitely Index of Hypochondriasis (14 items, 5 min, >14 languages) is used for
detection, for rating severity, and for measuring change per interventions.[36]
The Somatoform Disorders Symptom Checklist (65 yes-or-no items, 20 min, >5
languages) screens for hypochondriasis, somatization disorder, BDD, and others.[37]
References
Medical Care
Due to the enigmatic nature of various physical symptoms, occasionally patients with
hypochondriasis are admitted to the general medical-surgical hospital for an extensive workup.
When hypochondriasis is suspected in a medical or surgical inpatient, a psychosomatic
medicine consultation should be performed to elucidate the diagnosis and address psychiatric
comorbidity.
If clinically recommended by the psychosomatic medicine consultant, psychotropic
medication interventions can be started.
As in the outpatient care model, patients should not be exposed to high-risk invasive
procedures.
Numerous other strategies appear to benefit patients with hypochondriasis (see the image
below). These strategies may prevent potentially serious complications, including the effects
of unnecessary diagnostic and therapeutic procedures.
References
Surgical Care
Psychosurgery is only recommended for patients with severe and intractable hypochondriasis.
References
Consultations
Primary care physicians generally treat hypochondriasis, with psychiatrists providing
consultation.
References
Diet
Patients with hypochondriasis should eat 3 meals per day to feel as healthy as possible. They
should avoid substances that adversely affect mood, exacerbate anxiety symptoms, or reduce
the quality of sleep (eg, caffeine, alcohol, nicotine).
References
Activity
Exercise increases psychological well-being. Patients who are hypochondriacal may be
reluctant to follow this advice, but many patients greatly increase their physical activity as
treatment progresses. Exercise helps to improve mood, reduce tension, and improve sleep in
patients with associated depression, anxiety, or both.
References
Medication
Medication Summary
Antidepressants
Beta-adrenergic receptor-blocking agents
Benzodiazepines
Antipsychotic medications
Medication Summary
Pharmacotherapy is used as an adjunct to psychotherapy and educational treatments. The
goals of pharmacotherapy are to reduce comorbid symptoms and disorders (eg, depression),
to prevent complications, and, in a few circumstances, to reduce hypochondriacal symptoms.
Each medication has advantages and disadvantages.[45]
References
Antidepressants
Class Summary
Fluoxetine (Prozac)
Paroxetine (Paxil)
Sertraline (Zoloft)
Venlafaxine (Effexor XR)
Clomipramine (Anafranil)
Fluvoxamine (Luvox)
Imipramine (Tofranil)
Phenelzine (Nardil)
Citalopram (Celexa)
Escitalopram (Lexapro)
Fluoxetine (Prozac)
References
Paroxetine (Paxil)
Clinical Context: Potent selective inhibitor of neuronal serotonin reuptake. Also has weak
effect on norepinephrine and dopamine neuronal reuptake
References
Sertraline (Zoloft)
References
References
Clomipramine (Anafranil)
Clinical Context: Affects serotonin uptake while affecting norepinephrine uptake when
converted into its metabolite desmethylclomipramine.
References
Fluvoxamine (Luvox)
Clinical Context: Potent selective inhibitor of neuronal serotonin reuptake. Does not bind
significantly to alpha-adrenergic, histamine, or cholinergic receptors and, thus, has fewer
adverse effects than TCAs.
References
Imipramine (Tofranil)
References
Phenelzine (Nardil)
Clinical Context: Usually reserved for patients who do not tolerate or respond to traditional
cyclic or second-generation antidepressants.
References
Citalopram (Celexa)
References
Escitalopram (Lexapro)
References
Class Summary
These are typically used for depression or anxiety comorbid with hypochondriasis, although
in some cases they alleviate hypochondriacal symptoms in the absence of another disorder.
They are indicated for use in adults with depression, anxiety (eg, panic disorder, OCD, social
phobia, generalized anxiety, posttraumatic stress disorders), and bulimia nervosa disorders.
Off-label uses include insomnia, attention-deficit/hyperactivity disorder, premenstrual
dysphoric disorder, and other conditions. All SSRIs (eg, fluoxetine [Prozac], sertraline
[Zoloft], paroxetine [Paxil], citalopram [Celexa], escitalopram [Lexapro], fluvoxamine
[Luvox]), one selective norepinephrine and serotonin inhibitor (ie, venlafaxine [Effexor
XR]), 2 TCAs (ie, clomipramine [Anafranil], imipramine [Tofranil]), and one MAOI (ie,
tranylcypromine [Parnate]) have been listed; the latter should be used with care because of
dietary restrictions and drug interactions. Data on bupropion (Wellbutrin) and mirtazapine
(Remeron) are insufficient to warrant listing, but they may also be used.
Initial doses are listed below. The general principle in these patients is to start at a low dose
and progress slowly, unless a psychiatric emergency (eg, suicidal ideation) is present. Once
established, a well-tolerated and efficacious antidepressant should be continued as indicated
for the comorbid condition (eg, 6-12 mo for a single depression or indefinitely for recurrent
depression and an anxiety disorder). If used for hypochondriasis alone, for maintenance
dosing, adjust the dose to maintain the patient on the lowest effective dosage, and reassess the
patient periodically to determine the need for continued treatment.
References
Propranolol (Inderal)
References
Class Summary
Compete with beta-adrenergic agonists for available beta-receptor sites. Propranolol inhibits
beta-1 receptors (located mainly in cardiac muscle) and beta-2 receptors (located mainly in
bronchial and vascular musculature), inhibiting chronotropic, inotropic, and vasodilatory
responses to beta-adrenergic stimulation.
References
Benzodiazepines
Class Summary
Alprazolam (Xanax)
Alprazolam (Xanax)
Clinical Context: For management of panic attacks. Binds receptors at several sites within
CNS, including limbic system and reticular formation. Effects may be mediated through
GABA receptor system.
References
Class Summary
Indicated for treatment of anxiety disorders and panic attacks, with or without agoraphobia,
which are commonly comorbid with hypochondriasis. Use with caution because patients with
hypochondriasis may have increased risk of substance abuse or dependence.
References
Antipsychotic medications
Class Summary
Pimozide (Orap)
Risperidone (Risperdal)
Olanzapine (Zyprexa)
Pimozide (Orap)
Clinical Context: Indicated for Tourette syndrome for suppression of motor and phonic tics.
Off-label use for psychosis, hypochondriacal delusions and parasitosis, and Huntington
chorea.
References
Risperidone (Risperdal)
Clinical Context: Binds to dopamine D2 receptor with 20-times lower affinity than for
serotonin receptor. Improves negative symptoms of psychoses and reduces incidence of EPS.
Indicated for treatment of psychotic disorders, including schizophrenia and bipolar disorder
mania; also used for sleep.
References
Olanzapine (Zyprexa)
References
Class Summary
Have been shown to reduce morbidity associated with this disorder, particularly in presence
of comorbid anxiety or hypochondriacal worries that mimic obsessions or delusions. Because
of potential for serious long-term adverse effects (eg, tardive dyskinesia), consultation with
psychiatrist recommended to evaluate need for antipsychotic medication. Insufficient data to
list other antipsychotics, although they have been used in patients with hypochondriasis.
References
For patients with comorbid disorders, consider maintenance of those trials because
these disorders can initiate and/or exacerbate hypochondriacal symptoms.
References
Transfer
Physician-to-physician dialogue on the nature of the patient's problems and successful
management strategies is useful.
References
Complications
Prognosis
Author
Glen L Xiong, MD, Associate Clinical Professor, Department of Psychiatry and Behavioral
Sciences, Department of Internal Medicine, University of California Davis School of
Medicine; Attending Psychiatrist, Sacramento Mental Health Treatment Center; Attending
Physician, Sacramento County Primary Care Clinic
Disclosure: Lippincott Williams & Wilkins Royalty Book Editor; National Alliance for
Research in Schizophrenia and Depression Grant/research funds Independent contractor
Coauthor(s)
Donald M Hilty, MD, Professor of Clinical Psychiatry, Vice-Chair of Faculty Development,
Department of Psychiatry and Behavioral Sciences, University of California, Davis School of
Medicine
Disclosure: Nothing to disclose.
James A Bourgeois, OD, MD, MPA, Clinical Professor, Department of Psychiatry,
University of California, San Francisco, School of Medicine; Faculty Psychiatrist,
Consultation-Liaison Division, Department of Psychiatry, Langley Porter Psychiatric
Institute, University of California, San Francisco, Medical Center
Disclosure: Nothing to disclose.
Peter M Yellowlees, MD, MBBS, Professor of Psychiatry, Director of Health Informatics
Program, University of California, Davis, School of Medicine
Disclosure: Medscape Consulting fee Independent contractor
Specialty Editors
Sarah C Aronson, MD, Associate Professor, Departments of Psychiatry and Medicine, Case
Western Reserve School of Medicine/University Hospitals of Cleveland
Disclosure: Nothing to disclose.
Francisco Talavera, PharmD, PhD, Adjunct Assistant Professor, University of Nebraska
Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Medscape Salary Employment
Harold H Harsch, MD, Program Director of Geropsychiatry, Department of
Geriatrics/Gerontology, Associate Professor, Department of Psychiatry and Department of
Medicine, Froedtert Hospital, Medical College of Wisconsin
Disclosure: Novartis Honoraria Speaking and teaching; Sunovion Honoraria Speaking and
teaching; Otsuke Grant/research funds reseach; Merck Honoraria Speaking and teaching
Chief Editor
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