Evidence-Based Reviews

Don’t be fooled by hypochondria

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Diagnostic checklist helps rule out psychiatric and medical disorders and avoid treatment errors


 

References

A hypochondria “checklist” can help you sort through many overlapping medical and psychiatric disorders and increase your chances of making an accurate diagnosis. Then—by addressing hypochondria’s cognitive dysfunction—you can help patients achieve partial or full remission and change their distressing behaviors.

We offer a checklist that is useful in our practice and suggest behavioral therapies and medications that can help calm these patients’ excessive, unwarranted fears.

WORKING AS A TEAM

Ideal approach. Because hypochondriasis has features of medical and mental illness, working with the patient’s primary care physician is ideal. Physicians often consider these patients difficult because they demand a lot of time, support, and reassurance. Together, you can:

  • offer the patient a healthy level of compassion and empathy to establish a positive therapeutic alliance
  • set appropriate time limits and guidelines for the patient’s care
  • dissuade patients from “doctor shopping”
  • set limits on how often patients may visit their doctors and request reassurance.

Box

Hypochondriasis: Persistent, unwarranted distress

Hypochondriasis is an excessive and persistent fear or belief that one has a serious illness, despite medical reassurance and lack of diagnostic findings that would warrant the health concern. If a medical disorder is present, the distress and preoccupation exceed what the patient’s physician considers reasonable. Illness preoccupation is intense enough to cause great distress or to interfere with daily functioning and may cause the person to miss work or cancel social engagements.1

DSM-IV criteria. A patient’s fear or conviction that he or she has a serious health threat must persist at least 6 months and may be accompanied by specific somatic symptoms, vague symptoms,1 or no symptoms.2 Hypochondriacal preoccupation may be stable over time, where one illness concern dominates, or it may shift—from fear of AIDS to fear of a heart attack.

A common disorder. Hypochondriasis occurs in 4 to 6% of the general medical population. In psychiatric or medical clinics, women are identified as having hypochondriasis three to four times more often than men. Average age of onset is in the early 20s.3

For example, you may indicate to the patient, “I will reassure you only at office visits (not by phone), the office visits will be limited to once a month, and during each visit I will reassure you no more than once.”

A doctor-patient relationship based on mutual trust and respect is vital when you treat a patient with hypochondriasis. You can help primary care physicians provide more empathic treatment by explaining that patients do not feign or desire this distressing condition.

DIAGNOSTIC FEATURES

Patients with hypochondriasis tend to be hyper-vigilant about normal physiologic fluctuations and bodily sensations, often misinterpreting them as life-threatening or serious enough to require immediate medical attention. This excessive focus on benign symptoms (such as an accelerated heart rate, sweating, or a bump on the skin) and the cognitive distortion of their significance result in increased anxiety, bodily checking, and doctor visits (Box).1-4

Presentations. Hypochondriasis has three common presentations: disease conviction, disease fear, and bodily preoccupation (Table 1).5 Psychiatrists are most likely to see disease fear, as patients with this predominant symptom tend to realize that fear plays too prominent a role in their lives. Physicians in medical practice are more likely to encounter patients with high levels of disease conviction or somatic preoccupation.

Psychiatric comorbidity. Hypochondriasis is highly comorbid with Axis I and Axis II disorders, which complicate treatment. Nearly one-half of patients with hypochondriasis also have dysthymia (45%) or major depression (43%). Other comorbidities include phobias (38%), somatization disorder (21%), panic disorder (17%), and obsessive-compulsive disorder (8%).6 Patients with hypochondriasis are three times more likely than the general population to have personality disorders;6,7 the prognosis is believed to be more promising for patients without personality disorders.

Distinguishing between primary and secondary hypochondriasis is important. Treating a primary psychiatric disorder often alleviates the symptoms of secondary hypochondriasis, particularly when hypochondriasis masks depression.

HYPOCHONDRIASIS CHECKLIST

Underlying medical disorder? Before diagnosing hypochondriasis, review the medical workup for underlying disease or illness. Medical conditions sometimes go undetected when physicians assume that complaints are an expression of longstanding hypochondriasis.

Table 1

Three common presentations of hypochondriasis

Predominant symptomCharacterization
Disease convictionPatient may appear delusional in believing he or she has a disease and in persistent efforts to find a doctor who will make the “accurate” diagnosis
Disease fearPatient may avoid doctors because of fear associated with confirmation of a dreaded disease
Bodily preoccupationPatient may complain of multiple somatic symptoms, which mask underlying fear or belief of having a serious disease

Sometimes a patient may become anxious when mild or vague signs and symptoms do not yet meet established diagnostic criteria for a medical disorder. An effective approach is to provide ongoing support, avoid excessive diagnostic tests, and help the patient make the best use of his or her functional capacities while living with uncertainty.

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