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Don’t be fooled by hypochondria

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

hypochondria “checklist” can help you A 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 par- tial or full remission and change their distressing behaviors. We offer a checklist that is useful in our prac- tice and suggest behavioral and medica- tions that can help calm these patients’ excessive, unwarranted fears.

WORKING AS A TEAM Ideal approach. Because has fea- tures of medical and mental illness, working with Suzanne B. Feinstein, PhD the patient’s is ideal. Instructor in clinical Physicians often consider these patients difficult because they demand a lot of time, support, and Brian A. Fallon, MD, MPH reassurance. Together, you can: Associate professor of clinical • offer the patient a healthy level of com- Department of psychiatry passion and to establish a positive Columbia University, New York therapeutic alliance • set appropriate time limits and guidelines for the patient’s care continued

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Box and bodily sensations, often misinterpret- Hypochondriasis: ing them as life-threatening or serious Persistent, unwarranted distress enough to require immediate medical attention. This excessive focus on benign ypochondriasis is an excessive and persistent fear symptoms (such as an accelerated heart Hor belief that one has a serious illness, despite medical reassurance and lack of diagnostic findings that would rate, sweating, or a bump on the skin) and warrant the health concern. If a medical disorder is the of their signifi- present, the distress and preoccupation exceed what cance result in increased , bodily the patient’s physician considers reasonable. Illness checking, and doctor visits (Box).1-4 preoccupation is intense enough to cause great distress Presentations. Hypochondriasis has three or to interfere with daily functioning and may cause the common presentations: convic- person to miss work or cancel social engagements.1 tion, disease fear, and bodily preoccupa- DSM-IV criteria. A patient’s fear or conviction that he or tion (Table 1).5 are most like- she has a serious health threat must persist at least 6 months and may be accompanied by specific somatic ly to see disease fear, as patients with this symptoms, vague symptoms,1 or no symptoms.2 predominant symptom tend to realize Hypochondriacal preoccupation may be stable over time, that fear plays too prominent a role in where one illness concern dominates, or it may shift— their lives. Physicians in medical practice from fear of AIDS to fear of a heart attack. are more likely to encounter patients A common disorder. Hypochondriasis occurs in 4 to 6% of with high levels of disease conviction or the general medical population. In psychiatric or medical somatic preoccupation. clinics, women are identified as having hypochondriasis Psychiatric comorbidity. Hypochondriasis three to four times more often than men. Average age of is highly comorbid with Axis I and Axis II onset is in the early 20s.3 disorders, which complicate treatment. Nearly one-half of patients with hypochondriasis also have • dissuade patients from “doctor shopping” (45%) or major (43%). Other comor- • set limits on how often patients may visit bidities include (38%), dis- their doctors and request reassurance. order (21%), (17%), and obsessive- For example, you may indicate to the patient, compulsive disorder (8%).6 Patients with hypo- “I will reassure you only at office visits (not by chondriasis are three times more likely than the phone), the office visits will be limited to once a general population to have personality disorders;6,7 month, and during each visit I will reassure you the is believed to be more promising for no more than once.” patients without personality disorders. A doctor-patient relationship based on mutu- Distinguishing between primary and sec- al trust and respect is vital when you treat a ondary hypochondriasis is important. Treating a patient with hypochondriasis. You can help pri- primary psychiatric disorder often alleviates the mary care physicians provide more empathic symptoms of secondary hypochondriasis, particu- treatment by explaining that patients do not feign larly when hypochondriasis masks depression. or desire this distressing condition. HYPOCHONDRIASIS CHECKLIST DIAGNOSTIC FEATURES ■ Underlying medical disorder? Before diagnosing Patients with hypochondriasis tend to be hyper- hypochondriasis, review the medical workup for vigilant about normal physiologic fluctuations underlying disease or illness. Medical conditions

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Table 1 Three common presentations of hypochondriasis

Predominant symptom Characterization Disease conviction Patient 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 fear Patient may avoid doctors because of fear associated with confirmation of a dreaded disease Bodily preoccupation Patient may complain of multiple somatic symptoms, which mask underlying fear or belief of having a serious disease sometimes go undetected when physicians the fear or conviction helps establish the assume that complaints are an expression of long- diagnosis. standing hypochondriasis. ■ Somatoform disorder? Distinguish hypochondri- Sometimes a patient may become anxious asis from other somatoform disorders (Table 2). In when mild or vague do not practice, the terms “hypochondriac” and “soma- yet meet established diagnostic criteria for a med- tizer” are commonly used interchangeably, but ical disorder. An effective approach is to provide the distinction needs to be clear. Hypochondriasis ongoing support, avoid excessive diagnostic tests, Patients with generalized may worry about and help the patient make the best use of his or her illness, but they also worry about other life issues functional capacities while living with uncertainty. is primarily a disorder of abnormal cognition, in ■ Functional somatic ? Fibromyalgia and which symptom meaning is of greatest concern. chronic syndrome do not represent Somatization is primarily a disorder of abnormal hypochondriasis,8 although they may be exacer- sensation, in which the symptoms themselves are bated by comorbid psychiatric disorders. Both the overwhelming focus of attention. disorders have diagnostic criteria and specified ■ Anxiety disorder? Patients with generalized anx- courses and have been studied to identify psychi- iety disorder may worry about illness, but they atric comorbidity. also worry about other life issues. Patients with ■ Transient or sustained? After it is clear that the panic disorder may have intense hypochondriacal patient is not suffering from a medical problem, concerns (such as having a heart attack), but these determine whether hypochondriasis is transient worries tend to be related to panic symptoms and or fully diagnostic: resolve when the panic disorder is treated. • If transient, the patient may only need to ■ Obsessive compulsive disorder? Like obsessive- be educated about how overattention may compulsive disorder (OCD), hypochondriasis is amplify symptoms; reassure him or her that characterized by recurrent intrusive thoughts that a full medical workup has been negative. create heightened anxiety and distress. To relieve • If fully diagnostic, reassurance may work their anxiety, patients with hypochondriasis for only a few days or weeks; the return of engage in compulsions, such as: continued on page 33

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continued from page 29

Table 2 How to distinguish somatoform disorders

Disorder Patient focuses on... Hypochondriasis physical symptoms’ meaning (abnormal cognition) multiple unexplained physical symptoms (abnormal sensation) perceived abnormal bodily appearance motor or sensory function abnormalities that develop soon after life stressors or conflict disorder intense pain, in which psychological factors contribute to pain onset, severity, or maintenance

• undergoing extensive medical tests Although hypochondriasis and OCD have • seeking habitual reassurance from doctors similarities, certain clinical distinctions exist. and family Patients with hypochondriasis worry about hav- • consulting medical literature ing an illness, whereas OCD patients with somat- • performing repeated body checks for per- ic obsessions fear developing or transmitting an ceived lumps or bumps illness. A hypochondriacal patient might fear • avoiding activities that trigger their having AIDS or despite reassurance from health-related .9 doctors, while an OCD patient more typically OCD and hypochon- driasis also may share the Hypochondriasis is worry about having an illness; somatic diagnostic feature of OCD is worry about developing or transmitting illness pathologic doubt; patients’ uncertainty in appraising a situation leads to additional checking and reas- would fear contracting or transmitting the disease surance-seeking behaviors. The immediate relief (a contamination obsession) and would engage gained by these compulsions reinforces the in excessive behaviors to reduce the risk of devel- patient’s urge to engage in more maladaptive oping the disease. behaviors and sends a stronger message to the ■ Depressive disorder? Unlike the anxious-wor- brain that these behaviors are needed to prevent rying version of hypochondriasis, the depressive harm. version is more fatalistic. Patients may be con- Ironically, the emergence of a real medical vinced they are dying of a dreaded disease, often ailment—despite hypochondriacal worry—may believing it to be for an indiscretion, force the patient to re-evaluate the usefulness of such as marital infidelity. Or they may suddenly behaviors motivated by trying to avoid harm. A become hypochondriacal with mild depressive hypochondriacal patient who was diagnosed with features, unaware that the actual problem is optic neuritis and possible unresolved bereavement (hypochondriasis with recently said to these authors, “I had always secondary depression). The appropriate diagno- thought that by being vigilant I could keep ill- sis is primary depressive disorder with secondary nesses away. Now I know that’s not true.” hypochondriacal features when depression

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Table 3 TREATING PRIMARY Recommended dosages for treating primary hypochondriasis SYMPTOMS . When Drug Starting dosage Maximum dosage hypochondriasis is sec- 10 mg/d if panic symptoms 80 mg/d ondary—such as to are present; 20 mg/d otherwise depression or panic dis- 50 mg at bedtime 150 mg bid order—treat the prima- 100 mg bid 300 mg bid ry condition first.11,12 For 20 mg once daily 50 mg once daily primary hypochondria- sis, selective serotonin reuptake inhibitors dominates the presentation and preceded the (SSRIs) such as fluoxetine, paroxetine, or flu- illness fears. voxamine have shown benefit, mostly in open- ■ ? To distinguish hypochon- label studies. An uncontrolled case series sug- driasis from delusional disorder (somatic type), gests that nefazodone—with mixed serotonin consider the patient’s pattern of : reuptake inhibition and agonist properties— • Hypochondriacal patients often vacillate also may help patients with hypochondriasis.13 between poor and excellent insight, depend- In the only published controlled study, fluoxe- ing on their distress level.10 They may tine was more effective than placebo for treating acknowledge the irrationality of their fears, hypochondriasis.10 then later be convinced they have a disease. Continue drug therapy, when used, for at • Patients with delusional disorder are con- least 8 weeks, with each dosage maintained for at vinced they have a serious health threat, least 4 weeks. If patients do not respond to lower despite the absence of medical confirmation. SSRI dosages, increase to the higher dosages These patients are considered to have a pri- reported to be more effective for OCD (Table 3).14 mary psychotic disorder that requires Except for primary illness , hypochon- treatment. driasis has not been shown to respond to tri- cyclics, benzodiazepines, or dopaminergic block- ers. In our experience, electroconvulsive thera- py—although inadequately studied—may help treat patients with severe, treatment-refractory Hypochondriasis’ cognitive hypochondriasis with marked somatization. dysfunction is treatable, once an . Cognitive-behavioral therapy accurate diagnosis is made. Using (CBT)—challenging patients’ irrational fears a checklist can help you differentiate about illness and teaching them problem-solving hypochondriasis from other medical tools—is effective in treating hypochondriasis.15 and psychiatric disorders. A trusting CBT can help patients understand that distorted doctor-patient relationship enhances thoughts lead to their sad or anxious moods. outcome. Instructing patients to keep thought diaries can help them identify irrational fears and use to correct their faulty schemas. Tailor your tech- Bottom Line continued on page 39

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continued from page 34 niques to target the patient’s level of insight at the References 1. Diagnostic and statistical manual of mental disorders (4th ed-text revi- time of therapy. sion). Washington, DC: American Psychiatric Association, 2000. Effective behavioral techniques may include 2. Task Force on DSM-IV. DSM-IV options book. Washington DC: setting limits on doctor visits, checking behaviors, American Psychiatric Association, 1991. 3. Barsky AJ, Wyshak G, Klerman GL, Lathan KS. The prevalence of reassurance seeking, etc. Repeated exposure to hypochondriasis in medical outpatients. Soc Psychiatry Psychiatr feared stimuli such as needles, white lab coats, Epidemiol 1990;25(2):89-94. blood pressure cuffs, medical dialogue, or hospi- 4. Salkovskis PM, Clark DM. Panic and hypochondriasis. Adv Behav Res Ther 1993;15:23-48. tal wards can help the patient habituate to the 5. Pilowsky I. Dimensions of hypochondriasis. Br J Psychiatry anxiety. 1967;113(494):89-93. Relaxation techniques, a healthy diet, and 6. Barsky AJ, Wyshak G, Klerman GL. Psychiatric comorbidity in DSM-III-R hypochondriasis. Arch Gen Psychiatry 1992;49(2):101-8. exercise are also useful. Relaxation exercises— 7. Kellner R. The prognosis of treated hypochondriasis: a clinical such as diaphragmatic breathing, progressive study. Acta Psychiatr Scand 1983;67(2):69-79. muscle relaxation, and visual imagery—may 8. Noyes R, Jr., Kathol RG, Fisher M, Phillips BM, et al. The validity of DSM-III-R hypochondriasis. Arch Gen Psychiatry 1993;50(12): help patients manage anxiety by reducing CNS 961-70. and autonomic nervous system arousal. 9. Fallon BA, Qureshi AI, Laje G, Klein B. Hypochondriasis and its relationship to obsessive-compulsive disorder. Psychiatr Clin North Am 2000;23(3):605-16. Related resources 10. Fallon BA, Schneier FR, Marshall R, Campeas R, et al. The phar- macotherapy of hypochondriasis. Psychopharmacol Bull 1996; Fallon BA., Feinstein SB. Hypochondriasis: clinical, theoretical, 32:607-11. and therapeutic aspects. In: Oldham J (ed). Review of psychiatry 11. Kellner R, Fava GA, Lisansky J, et al. Hypochondriacal fears and (vol. 20). Washington, DC: American Psychiatric Press, 2001:27-60. beliefs in DSM-III : changes with amitriptyline. J Affect Cantor C, Fallon BA. Phantom illness: shattering the myth of Disord 1986;10(1):21-6. hypochondria. Boston: Houghton Mifflin Company, 1996. 12. Noyes R, Jr., Reich J, Clancy J, O’Gorman TW. Reduction in hypochondriasis with treatment of panic disorder. Br J Psychiatry Starcevic V, Lipsitt DR (eds). Hypochondriasis: modern perspectives 1986;149:631-5 (erratum in Br J Psychiatry 1987;150:273). on an ancient malady. New York: Oxford University Press, 2001. 13. Kjernisted KD, Ennis MW, Lander M. An open-label clinical trial of nefazodone in hypochondriasis. Psychosomatics 2002;43:290-4. DRUG BRAND NAMES 14. Fallon BA. Pharmacologic strategies for hypochondriasis. In: Fluoxetine • Prozac Nefazodone • Serzone Starcevic V, Lipsitt DR (eds). Hypochondriasis: modern perspectives Fluvoxamine • Luvox Paroxetine • Paxil on an ancient malady. New York: Oxford University Press, 2001:329- 51. DISCLOSURE Dr. Feinstein and Dr. Fallon report no financial relationship with any com- 15. Warwick HMC, Salkovskis PM. Hypochondriasis. In: Scott J, pany whose products are mentioned in this article or with manufacturers of Williams JMG, Beck AT (eds). Cognitive therapy in clinical practice: competing products. an illustrative casebook. London; Routledge, 1989:78-102.

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