HYPOCHONDRIACAL

DISORDER
Dr. Manu Sharma
Chairperson: Dr. Manju Bhaskar

Introduction
Hypochondriasis is a preoccupation with the fear

that one has, or may develop, serious disease

despite evidence to the contrary.
Increase health care utilization
Dissatisfaction with care received
To their physicians, pts with this disorder are an
enigma & a source of frustration
Primary care physicians have had little interest
Psychiatrists see few pts with this condition

History
Hypochondria was used by Hippocrates to refer to a

region below the cartilage of the ribs

Galen, 2nd century, linked it to organs in this area as well
as humors & animal spirits
Associated with melancholia, a temperamental
disturbance caused by an excess of black bile
Burton (1621) described hypochondriacal melancholy in
terms of vague physical Sx, disturbances of mood & fears
Syndenham viewed it in men as counterpart of hysteria in
women. Modern description by Sims in 1799.
By 18th century it became part of a fashionable
disturbance attributed to the English way of life (Cheyene)

History
Falret (1822) first to identify it as a mental disorder,

neuroses.
Freud viewed it as an actual neurosis with physiological
basis, not amenable to psychoanalysis
As reviewed by Murphy(1990), Gillespie(1928)
encapsulated a concept of hypochondriasis consistent
with the current concept
a mental preoccupation with a real or supposititious
physical or mental disorder

Conceptualizations
A personality trait- early onset & long term

stability
A dimension of psychopathology- illness worry
as a continuum with hypochondriasis on the
severe end
A categorical approach- primary or secondary?
High rates of comorbidity- independent status?

Nosology
DSM-I did not include hypochondriasis as a separate

illness.
Hypochondriacal preoccupation was mentioned as one of
the malignant symptoms observed in psychotic but not
reactive depression.
DSM-II included hypochondriacal neurosis.
In DSM-III, DSM-III-R, and DSM-IV-TR, hypochondriasis
is included as one of the somatoform disorders.
DSM excludes pts whose Sx are better accounted for by
anxiety, depressive or other somatoform disorders.
Specific phobia of illness separated from hypochondriasis.

Abbrv. DSM-IV-TR
a) Preoccupations with fears of having, or the idea that

b)
c)
d)
e)
f)

one has, a serious disease based on misinterpretation

of bodily symptoms
The preoccupation persists despite appropriate medical
evaluation & reassurance
Belief not of delusional intensity
Preoccupation causes significant distress or impairment
Duration of atleast 6 months
Not better accounted for by other anxiety, depressive or
somatoform disorders

Nosology
ICD-10- a persistent belief about having one or

more specifically named serious physical

diseases.
Include body dysmorphic disorder.
w.r.t illness behavior, hypochondriacal concerns
cause persons to seek medical invstgns/Rx.
Pts may accept reassurance in the short-term,
but in the long run are unlikely to respond.

Nosology issues
The somatoform disorders category to which

hypochondriasis belongs is controversial.

They see disorders as ill-defined, of questionable validity
A number of studies suggested that of the many patients
with hypochondriacal complaints few meet criteria for the
full diagnosis (Barsky et al. 1993 )
Based more on illness behavior than on distinctive features
View them as creations of western biomedicine that serve
to devalue pts who challenge the theoretical model upon
which it is based (Rief,2004)
Proposals to move hypochondriasis to anxiety disorders
(health anxiety) or to OC spectrum disorders

Epidemiology
Prevalence in gen population: 1-5%.Affects btw 2-7%

of pts attending general medical clinics.(DSM IV TR)

Most prevalence research related to hypochondriasis
has been conducted in some type of medical or
psychiatric setting and results have been
inconclusive (cf. Iezzi & Adams,1993).
Research has been impeded by the use of different
definitions of hypochondriasis.
Kenyon (1976) used a strict definition and
determined that 314% of patients in a medical
setting were hypochondriacal.

Epidemiology
As reviewed by Kellner ( 1991 ), 1020% of

normal and 45% of neurotic persons have

intermittent unfounded worries about illness, with
9% of patients doubting reassurances given by
physicians.
In another review, Kellner ( 1985 ) estimated that
50% of all patients attending physicians offices
suffer either primary hypochondriacal symptoms
or have minor somatic disorders with
hypochondriacal overlay.

Epidemiology
49% of patients in general medical settings

suffer from hypochondriasis (Fallon et al. 1993).

Risk factors for unexplained somatic Sx- female,
older age, non-white race, less education, lower
income
It does appear that hypochondriasis is equally
common in males and females.
Data concerning socioeconomic class are
conflicting.

Epidemiology
Psychiatric comorbidity in 62%. Anxiety &

Depressive disorders most common.

Family study (Noyes et al. 1997)- hostility, low
aggreableness, dissatisfaction with care.
Twin study (Taylor et al. 2006)- genetic factors
accounted for 37% of the variance in fear of
disease, 10% in disease conviction. Such anxiety
is largely a learned phenomenon.
Impairment in functioning, low QOL & high
service utilization.

Clinical Features
Essential features
Fear of disease, the consequences of which
may include pain, suffering, disability & death.
May take form of alarming thoughts & images of
specific diseases.
Disease conviction- this belief is overvalued
meaning that is strongly held despite lack of
evidence; not delusional.
Bodily preoccupation-interest in, attention to
somatic Sx which tend to be multiple & diffuse.
Attention directed to bodily sensations, functions,
minor abnormalities.

Clinical Features
Related concerns- medical, diet, exercise,
environmental exposure.
Activities & conversations of pts dominated by
medical concerns. As a consequence of their selfabsorption, interest in people & other pursuits is
withdrawn.
Reassurance seeking- main behavioral feature.
self examinations, search medical sources for the
meaning of their Sx, ask friends, family & med
professionals for reassurance

Clinical Features
Associated features
Fears of aging & death
Overvaluation of health & appearance
Low self-esteem
Sense of vulnerability to illness
Subtypes/dimensions
Disease phobia
Disease conviction
Resemblance to OCD or personality disorder

Course
the most common age at onset is in early

adulthood.
approximately 25% of patients do poorly,
65% show a chronic but fluctuating course, and
10% recover.
This pertains to the full syndrome.
A much more variable course is seen in patients
with just some hypochondriacal concerns.

Course
Good prognostic indicators:
Acute onset
Brief duration
Mild hypochondriacal symptoms
Presence of GMC
Absence of comorbid mental disorder
Absence of secondary gain

Body Dysmorphic Disorder

Cognitions: Preoccupation with distorted body

image and appearance, dissatisfaction and

feeling unattractive
Behaviors: Compulsive mirror checking, body
measuring, diet and exercise
Comorbidity: 12% BDD have Eating Disorder
40% Anorexia Nervosa have BDD

CONCEPTUALIZATION
Hypothesis 1: A symptom of OCD,

hypochondriasis (ICD), social phobia, depression

or schizophrenia Hence treated by addressing
the primary disorder
Hypothesis 2: A separate, independent entity

(DSM) Hence treated separately

Similarities: BDD vs.

Hypochondriasis
Cognitions: Bodily fears & preoccupations
Behaviors: Frequent medical help seeking,

repeated checking, reassurance seeking

Gender: Similar rates
Course: Both have early age at onset, chronic
waxing and waning course

Differences: BDD vs. Hypochondriasis

BDD
Body parts

Hypochondriasis
Body illness

Distress

Due to
perceived
deformity

Due to levels of
health concerns

Treatment

SSRIs or CBT

SSRIs/SNRIs,
CBT and NonCBT
psychotherapies

Cognitions

Differential Diagnosis
Physical Disorders
Neurological conditions- Multiple sclerosis,
myasthenia gravis
Endocrine conditions- thyroid or parathyroid
disorders
Multisystem diseases- SLE
Occult malignancies
Because of such possibilities, a physical cause
warrants continuing consideration even after
initial work up has been completed

Differential Diagnosis
Panic disorder

Hypochondriacal
Disorder

Fear immediate
Fear long term
consequences of illness consequences of illness
(eg. heart attack)
(eg. Cancer)
Fear dying
Fear death
Misinterpret the
Misinterpret a range of
symptoms of autonomic bodily symptoms
arousal
Frequent unexpected
panic attacks

--

Differential Diagnosis
Specific phobia, illness subtype
Pts with hypochondriacal disorder are
preoccupied with a disease they believe is
already present
Illness phobics fear developing a disease they do
not yet have.
Illness phobic symptoms may be triggered by
external as well as internal cues

Differential Diagnosis
Obsessive-Compulsive Disorder
Cognitions: Somatic preoccupations
Behaviors: Reassurance seeking, checking for
signs of illness
Familial aggregation: More with somatization
disorders but, OCD variant of hypochondriasis
has high familial aggregation with OCD/BDD

OCD

Hypochondriasis

Cognitions

Intrusive
thoughts of
contamination
or disease.
Irrational
Resistance

Fear of illness
Rational
No resistance

Sensations

None

Somatic and
visceral sensations

Other classic
+++
OCD obsessions

---

Behaviors

Doctor shopping

Compulsions

Differential Diagnosis
Generalized Anxiety Disorder
Characterized by excessive worry about a
number of areas.
If worry is confined to illness, then a diagnosis of
GAD shouldnt be made.
Pts with GAD have health worries that are
general.
Hypochondriasis involve specific diseases.

Depressive disorder
Hypochondriacal concerns are common during
depression.
They usually remit with the treatment of mood
disturbance.
pt is likely to focus concern upon the vegetative
Sx of depression & interpret these as irreversible
loss of health.
A diagnosis of HD is apt when hypochondriacal
concerns are:
1. Not confined to the depressive episode
2. Not focused on the Sx of the mood disorder

SOMATIZATION

HYPOCHONDRIASIS

Concerned with Sx

Concerned with Disease

process

Multiple frequently
changing Sx

One or two disease

processes

Females/ Family etiology Equal incidence/ No

Family etiology
Asks for relief from Sx

Asks for investigations to

diagnose the disease

Excessive use of drugs

abuse/dependence

Fear drugs- Frequent

visits to various doctors

Delusional belief
Patients with hypochondriasis, although
preoccupied, generally acknowledge the
possibility that their concerns are unfounded.
Delusional patients do not.
Somatic delusions of serious illness are seen in
some cases of schizophrenia and in delusional
disorder, somatic type
Look for other psychotic features

 It is often a thin line between preoccupation and

fear that is a conviction and that which is a

delusion.
Often, the distinction is made on the basis of
whether the patient can consider the
possibility that the conviction is erroneous
Yet, patients with hypochondriasis vary in the
extent to which they can do this. DSM-IV-TR
acknowledges this by its inclusion of the
specifier with poor insight.
In the past, some argued that differentiation could
be made on the basis of response to
neuroleptics.
one case report (Brophy 1994).

Etio-pathogenesis
Personality
Neuroticism or negative emotionality- a tendency
to experience & report negative emotions &
overreact to stress.
Neuroticism may represent a vulnerability factor
for hypochondriasis
Obsessive-compulsive & masochistic personality
traits
Difficult doctor-pt relationship
Pts described as angry, mistrustful.

Etio-pathogenesis
Developmental factors
Traumatic events during childhood
Childhood exposure to illness or death
Parental attitudes- overprotection
These suggest that hypochondriasis is in large
measure learned behavior
Life events- illness, death, cardiac neurosis

Etio-pathogenesis
Cognitive & perceptual factors
Misinterpretations of bodily Sx as signs of serious
disease & on the experience of somatic
sensations as intense, noxious & disturbing.
Faulty attribution of innocuous sensations is the
central defect.
Physiological abnormalities (Gramling et al.
1996):
Cold pressor test- higher mean HR, lower mean
hand temp. Subjects terminated the test more
frequently & rated it more unpleasant than
controls.

Interpersonal factors- hypochondriasis is a form

of care-eliciting behavior that finds expression in
physical complaints.
Need for support of this kind arises from insecure
attachment that originated in early relationships
with caregivers.
Social & cultural factors
Persons who are lacking in social support or
socially isolated-more prone for care-eliciting
behavior
Role of physicians
Cultural differences in threshold for pain, pain
tolerance, responses to pain

Measures
Self-rated questionnaires
Whiteley Index
Illness Attitude scales
Illness worry scale
Health anxiety questionnaire
Health anxiety inventory
Multidimensional inventory of hypochondriacal
traits
Psychiatric diagnostic screening questionnaire

Measures
Structured interviews
Structured diagnostic interview for
hypochondriasis (Barsky et al.)
Structured clinical interview for DSM-IV (SCID)
Composite international diagnostic interview
(CIDI)
Schedules for clinical assessment in psychiatry
(SCAN)

Management
Strategies
1. Legitimize the pts symptoms
2. Establish a regular schedule of visits
3. Base diagnostic evaluation on objective findings
4. Approach Rx of physical symptoms cautiously
5. Provide plausible explanations for symptoms
6. Establish a goal of improved functioning
7. Maintain a therapeutic relationship

Psychological therapies
Explanatory therapy
involves repeated physical examinations,
reassurance concerning Sx, information about
psycho-physiologic process.
In a controlled trial, this therapy yielded significant
improvement in illness behavior & health care
utilization compared to no treatment. Gains were
maintained for 6 months.
Additional controlled trials are clearly needed.

Psychological therapies
Cognitive Behavior therapies
Cognitive procedures include identifying &
challenging dysfunctional thoughts & formulating
more realistic beliefs
Behavioral procedures involve in vivo exposure
with response prevention.
Four RCTs have shown CBT to be superior to no
treatment & gains sustained upto 12 months.
A non-specific intervention, behavioral stress
management, was effective as well

Psychological therapies
Fallon et al (1993) reported in their review:
Dynamic therapies had minimal effectiveness
Supportiveeducative psychotherapy helpful only
in illness <3years
CBT (psychoeducation, cognition restructuring,
and exposure-response prevention): Moderately
effective

Psychological therapies
Some questions
Are psychological therapies acceptable to most
pts in primary care settings?
Are the techniques specific or do the benefits
result from non-specific factors (e.g. therapeutic
attention, t-pt relationship, credible procedures)
Are these treatments cost-effective?
Availability?

Pharmacological therapies
Pharmacotherapy for comorbid psychiatric

disorder.
No RCTs for hypochondriasis have been
completed.
Anecdotal and open-label studies suggest that
serotoninergic agents such as clomipramine
and the SSRI fluoxetine may be effective (Fallon
et al.,1993)
SNRIs, Olanzapine and Pimozide (case reports)

Antidepressants and hypochondriasis

6 uncontrolled open label studies and several case

reports
Use of these medicines derives from the traditional

view that HC exists primarily in the context of

depression
have been found to reduce
Fear of disease
Dysfunctional beliefs
Anxiety
Somatic complaints
Phobic avoidance
Reassurance seeking behavior

Fluoxetine: Fallon et al.

trial lasted 12 weeks
that patients started on 20 mg/day and had dose increases

as needed to 80 mg/day
The mean end dose was 52 mg/day (S.D. 28 mg).
(70%) study completers were responders
28.5% were rated as symptom free
patients without other Axis I comorbidity were as likely or

more likely to benefit than patients with Axis I comorbidity

although disease conviction and disease fear improved

significantly, bodily preoccupation did not improve.

Fluvoxamine: Fallon et al.

trial consisted of 2 weeks of placebo followed by 10

weeks of fluvoxamine
started at 50 mg/day and increased weekly by 50 mg to

the target dose of 300 mg/day.

The responder rate was 72.7% among the study

completers of min. 6 weeks

was comparable to the rate reported in the fluoxetine

study.
Unlike the fluoxetine study, there was significant

improvement in bodily preoccupation, as well as

disease phobia and conviction

Paroxetine: Oosterbaan et al.

A 12-week trial, entered 11 patients.
used a flexible dosing schedule to a target

maximum of 60 mg/day.
Of the 9 patients who completed the trial, 8 were

rated as improved (88.88%).

5 were considered virtually symptom free (55.55%).
The mean completer dose was 31 mg/day (S.D.

17.9 mg).

Other trials: Nefazodone-Kjernsted et al.

open-label trial
11 patients entered and 9 completed the 8 weeks of

treatment.
(mean dose: 432 mg/day).
5 of whom were rated at least much improved

(55.55%).
significant improvement was noted in a variety of

areas including illness worry, concern about pain,

hypochondriacal beliefs, and body preoccupation.

Other trials: Imipramine- Wesner et al.

Trial lasted 8 weeks
Had a dose schedule that increased to

150mg/day.
8 of 10 patients completed at least 4

weeks, each of whom was at least

moderately improved (100%).

In reviewing the above open-label

trials, it appears that the percentage
of patients considered virtually
symptom free was greater
among patients given serotoninreuptake inhibitors (range: 28.6
55.6%) than among patients given
the tricylic imipramine (12.5%).

Body Dysmorphic Disorder

There is little to no research on treatments for

BDD
Distinguish BDD from normal concerns about
appearance or overvaluing of appearance
(resistant to reality testing and reassurance;
cause significant distress or impairment;
delusional)
Pharmacotherapy: SSRIs at higher doses & for
longer duration
CBT strategies: exposure and response
prevention, self-esteem building, modifying
distorted thinking, and coping strategies

Are drugs really helpful?

YES and NO
Shortcomings of studies
Inherent limitations of drugs
Adverse effects
Increased relapse rates following

discontinuation
Do not address the cognitive component

Future directions
More trials are needed
Longer term
Larger sample sizes
Head to head comparison between

pharmacological and other methods esp.

CBT.
Participation from developing countries
To determine:
Optimum dose, duration of treatment
Long term outcome

Future directions
Controlled studies
Parallel design studies
To be located in community based settings
Consideration to be given to duration and

severity of disease
To include measures of comorbid conditions
A thorough medical evaluation before study

entry

Conclusion
HC is now known to occur quite often as a

primary diagnosis.
A frequent drain on medical resources
Patients who have HC can be viewed as suffering
essentially from an anxiety disorder in which
intense fear is focused on the possibility that they
might be seriously physically ill or that such
illness is imminent.

Conclusion
The processes that contribute to the development

and maintenance of such health anxiety consist

largely of beliefs, assumptions, and behavioral
responses that, although internally consistent with
the perception of health-related threat, are
erroneous and highly maladaptive in that they
prevent the correction of erroneous perceptions
of threat.
There is growing evidence that this
conceptualization leads to effective reduction in
HC symptoms through cognitive-behavioral and
pharmacologic treatments.

Conclusion
Prevalence of 2%-7% in general medical settings.
Rule out physical disorders.
Many pts with HD have comorbid anxiety &

depressive disorders.
Treatment of the comorbidity yields significant
improvement.
Specific Rx to be acceptable, must be available in
primary care settings
Treating professionals must let pts know that their
concerns are legitimate & their suffering
understood.

Conclusion
main obstacle to successful treatment of HC is the

patients reluctance to view the problem as

anything other than physical.
These pts are prone to drug side effects & often
discontinue medication.
Treating professionals must acknowledge the pts
sensitivity & deal with empathy.
Until recently, the Rx of HD was regarded with
pessimism. It now appears that effective
psychological & pharmacolgical interventions are
being developed.

THANK YOU