Common Presentations and Treatment Strategies in Primary Care and Specialty Settings
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REVIEW Hypochondriasis: common presentations and treatment strategies in primary care and specialty settings Glen L Xiong, Hypochondriasis is a somatoform disorder marked by recurrent preoccupation with fears of James A Bourgeois, having a life-threatening disease despite appropriate work-up and medical reassurance. The Celia H Chang, Dandan Liu & etiological explanations for hypochondriasis have evolved over time from a psychoanalytic Donald M Hilty† stance (as an unconscious manifestation of instinctual drives) to social learning, cognitive–behavioral, and biological models that focus on functional values of †Author for correspondence University of California, hypochondriasis and parallels to anxiety disorders. We review recent therapeutic Davis, 2230 Stockton developments while emphasizing the importance of the therapeutic alliance. Although Boulevard, Sacramento, reassurance, psychotherapy, psychopharmacology and mental health referral are clearly CA 95817, USA Tel.: +1 916 734 8110; indicated, we caution against using them prematurely. Since primary care and nonpsychiatric Fax: +1 916 734 3384; specialty physicians care for the majority of patients with hypochondriasis, we review the E-mail: [email protected] clinical presentations and treatment nuances specific to several different settings. Hypochondriasis is a vexing somatoform disor- and that the preoccupation persists despite med- der associated with marked economic and social ical evaluation and reassurance [3]. There is some costs [1,2]. Defined as an illness that does not overlap of the criteria with other somatoform respond to appropriate medical evaluation and disorders and the patient may respond some- reassurance, hypochondriasis is difficult, frus- what to reassurance [4]. Recent empirically trating and seemingly impossible for most physi- derived criteria for hypochondriasis call for the cians to manage, partly because of its deviation use of ‘obsessive rumination’ of illness to be a from the traditional medical model. Patients vig- major criterion [5]; however, the revised criteria orously seek treatment but paradoxically dismiss await validation. We outline a pragmatic and efforts made by physicians. This may represent a dimensional conceptualization of the hypochon- stance of ‘hostile dependency’. The physician is driacal spectrum from normal health anxiety to often left with a mixed feeling of anger and futil- hypochondriacal psychosis in Figure 1. The two ity. Even more discouraging is the reluctance of clinically important dimensions are the degree patients to seek mental health care when recom- of impairment in reality testing and the severity mended. Nevertheless, despite these challenges, of symptoms. It is important to have this frame- many physicians can provide effective treatments work in mind while attempting to diagnose and, for patients with hypochondriasis. more importantly, to understand and thereby We believe that empathic understanding and provided specifically tailored treatment for each dedicated attention to the therapeutic relation- patient. Somatoform disorders (e.g. body dys- ship are foundations to treatment. We briefly phormic disorder and somatization disorder) review the evolution of etiological models that also fit in this continuum. Other psychiatric explain the origin of hypochondriasis and pro- conditions, such as depressive disorders, general- vide updated pharmacological and psychothera- ized anxiety disorder (GAD), obsessive–compul- peutic treatment modalities. Since both primary sive disorder (OCD), panic disorder (PD) and care and specialty physicians face specific chal- personality disorders, must also be included in lenges with hypochondriasis patients, we specifi- the differential diagnosis and when considering cally focus on the presentation of psychiatric comorbidities. Prior to making a hypochondriasis in the various practice settings. firm diagnosis of hypochondriasis, subtle pre- Keywords: anxiety disorder, sentations of occult systemic disorders must be hypochondriasis, Diagnosis carefully ruled out. psychopharmacology, psychotherapy, somatoform The Diagnostic and Statistical Manual, 4th Edi- Specific diagnostic instruments for hypochon- disorder tion, Text Revision diagnostic criteria for hypo- driasis include the Whitely Index of Hypochon- chondriasis requires that the patient is driasis (WIH) [6] and Illness Attitude Scales part of preoccupied with fears of having a serious illness (IAS) [7]. The sensitivity and specificity of the based on misinterpretations of bodily symptoms WIH and Health Anxiety subscale of the IAS 10.2217/14750708.4.3.323 © 2007 Future Medicine Ltd ISSN 1475-0708 Therapy (2007) 4(3), 323–338 323 REVIEW – Xiong, Bourgeois, Chang, Liu & Hilty Figure 1. Conceptualization and differential diagnosis of hypochondriasis. Hypochondriacal psychosis Poor Body dysmorphic disorder Hypochondriasis Somatization disorder Reality testing Hypochondriacal concerns Good Moderate Health anxiety Low Moderate High Extreme Symptom severity/illness conviction Health anxiety refers to concern or preoccupation regarding health that is appropriate, reality-based and responds to medical evaluation and reassurance. were 87 and 72%, and 79 and 84%, respectively. this is a popular and plausible model among A high score on the WIH was associated with a psychoanalysts, it is often difficult to engage poor recovery rate at 1 year. The Illness Behavior hypochondriacal patients in such introspection. subscale of the IAS was predictive of the number of primary care visits [7]. Both instruments could Social learning model be used for screening and their subscales were According to this model, hypochondriasis is a sensitive to treatment changes. Other screening, social transactional process whereby a patient general diagnostic and symptoms severity tools assumes the ‘sick role’ to obtain a ‘socially accept- include the Health Anxiety Inventory [8] and able excuse’ or relief from social or occupational Somatoform Disorder Symptom Checklist [9]. It obligations. When a person becomes ill through is important to note that these assessment instru- no fault of his/her own, a different set of social ments have been mainly used in research settings rules apply [11]. Having an illness ensures that the and may lack patient specificity for individual individual will be taken care of [12]. Anxious treatment planning. The Minnesota Multiphasic attachment styles have been found to be associated Personality Inventory (MMPI) hypochondriasis with hypochondriacal symptom reporting [13,14]. scale is commonly used to study general hypo- This highlights the inherent paradoxical pinna- chondriacal concerns but is less specific for cle of hypochondriasis. On the one hand, the hypochondriasis as a disorder. patient wants insurmountable help from the physician (perhaps as a parental figure). On the Etiology: explanatory models other hand, professional recommendations are Psychodynamic model eventually rejected. Therefore, treatment of The development of physical symptoms from hypochondriasis mandates a well-balanced thera- unconscious conflicts may be traced to Sigmund peutic relationship that calls for implicit social Freud. Psychodynamic defenses, such as repres- duties of the physician, both as a caring parental sion and displacement, were regarded as the basis figure and an objective professional caretaker. for hypochondriasis. According to this model, in order to remediate unconscious conflicts, such as Cognitive–behavioral model aggression and hostility towards others, physical According to this model, patients misinterpret complaints serve to reconcile such internally bodily symptoms and amplify their somatic sen- unacceptable drives. The hypochondriacal symp- sations into fears of having a real, life-threaten- toms may serve to ‘undo’ guilt felt regarding anger ing malady [15]. They have lower than usual and serve as a punishment of the self [10]. While tolerance for physical discomfort and lower than 324 Therapy (2007) 4(3) futurefuture sciencescience groupgroup Presentation and therapy of hypochondriasis – REVIEW usual threshold for seeking medical care [16]. is in fact suffering from significant distress. A The automatic belief that good health is the trusting, long-term patient–physician relation- complete absence of physical symptoms may ship is the foundation to treatment. In develop- serve to contribute to bodily preoccupations, ing this therapeutic alliance, premature resistance to reassurance and excessive use of reassurance and abrupt, unplanned confronta- medical services [17]. Such cognitive distortions tion should be avoided. Reassurance and gentle and consequent reassurance-seeking behavior confrontation will contradict the bodily experi- may serve to maintain the disorder [18]. There- ence of the patient and should only be invoked fore, targeted therapy focuses on the patient’s after developing an enduring, trusting therapeu- realistic appraisal of health. tic relationship. Several follow-up appointments may be required to strengthen this relationship, Anxiety spectrum disorder as well as for confirming the diagnosis of hypo- Hypochondriasis may be conceptualized as a vari- chondriasis. When hypochondriasis is suspected, ant manifestation of an underlying anxiety disor- a repeat detailed history and physical examina- der (AD). According to this model, the anxiety tion should be attempted; and laboratory testing originates from the preoccupation with fear of and invasive procedures should be ordered only having a disease,