Background Hypochondriasis, which is now known as illness anxiety disorder, and the other somatic symptom disorders (e.g., factitious disorder, conversion disorder) 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, the DMS 5 has revised diagnostic criteria to facilitate clinical care and research. While illness axiety disorder is included in the category of "somatic symptom and related disorders" it continues to have much overlap with obsessive-compulsive disorder and related illness. As with all psychiatric disorders, illness anxiety disorder demands creative, rich biopsychosocial treatment planning by a team that includes primary care physicians, subspecialists, and mental health professionals. This article describes illness anxiety disorder, its diagnosis, and an overview of treatment approaches, with references for details beyond the scope of the article. Finally, the article reviews new developments in psychopharmacologic and psychotherapeutic treatments. Case study A 45-year-old white male engineer presents to a primary care clinic armed with multiple internet searches on the topic of cancer. He states that he “just knows” he has a GI cancer, "probably the colon or maybe the pancreas." When asked how long this concern has bothered him he says "for years I have been concerned that I have cancer." You ask about relevant symptoms and he is a bit vague, saying "I get some pain or pressure right here (he points to the left upper quadrant) but it is not there all the time." Upon asking about prior workups he says “I have had ultrasounds and colonoscopies but they couldn't find anything. I was initially relieved but a couple of weeks later started to think that they must have just missed something.” When you ask about the patient's goals for today’s visit he is emphatic. "I think what I really need is another colonoscopy and abdominal CT scan." His examination is unrevealing. When you suggest a less invasive approach, he brings up error rates of the other evaluations and shows literature endorsing how abdominal CT is the criterion standard. He is anxious at baseline and increasingly irritable when you propose less invasive evaluation. He ends the encounter by stating that he will “find another doctor who sees my point and will get me what I need.” Pathophysiology Neurochemical deficits associated with illness anxiety disorder appear similar to those of mood and anxiety disorders. For example, Hollander et al posited an "obsessive-compulsive spectrum" to include hypochondriasis, obsessive-compulsive disorder (OCD), body dysmorphic disorder (BDD), anorexia nervosa, and Tourette syndrome, all of which were believed to have similarities in responsiveness to serotonin reuptake inhibitors and to demonstrate "hyperactivity" in areas of the frontal lobes.[4] . A more recent article highlights the effectiveness of fluoxetine (a serotonin reuptake inhibitor and a mainstay in the treatment of OCD), as effective in the treatment of hypochondriasis.[2, 3] While the formulation of obsessive-compulsive (OC) spectrum disorders has been adopted by the DSM 5, this new clustering does not include illness anxiety disorder. It does include: OCD, BDD, hoarding disorder, trichotillomania, excoriation disorder, OCD and other related disorders that are substance induced or due to another medical condition. In addition, encountering a patient with more than one of the anxiety spectrum disorders comorbid with illness anxiety disorder is not unusual. Findings of neurochemical deficits in patients with illness anxiety disorder are only preliminary, but such deficits may explain why symptoms overlap, why the disorders are commonly comorbid, and why effective treatments for OC spectrum disorders are also effective for illness anxiety disorder (eg, selective serotonin reuptake inhibitors [SSRIs]). In a study of biological markers, subjects who met DSM-IV-TR diagnostic criteria for hypochondriasis had decreased plasma neurotrophin 3 (NT-3) levels 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] Epidemiology Frequency United States Based on the previously defined "hypochondriasis," the DSM estimates that the community 1-2 year prevalence is 1.3-10%, while the 6-month to 1-year prevalence in medical outpatients is 3-8%. 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.[7, 8] International/cultural effects Efforts have been made to quantify international rates of illness anxiety disorder and other somatic symptom disorders. Those rates are heavily influenced by the diagnostic criteria involved (ie, somatization disorder versus abridged somatization disorder) and how studies are conducted.[9] Within the US, researchers have also worked to define how culture and ethinicity interact to determine "idioms" of distress and also how these factors influence the physician-patient relationship. This research has included the formulation of patterns of presentations that can be classified as "culture bound syndromes." A selective literature review recommends that culture be considered in idiopathic somatic symptom presentations, but also that caution be taken to not be overly generalizing about ethnicity.[9] Mortality/Morbidity Illness anxiety disorder is usually episodic, with 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 illness anxiety disorder 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 few, but patients with illness anxiety disorder appear to have no differences in age or gender than patients without this disorder. There have been several studies that have found patients with illness anxiety disorder to have decreased educational and income levels and higher rates of childhood illness and abuse.[7] 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, vocations, 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 illness anxiety[12] and may well be a presentation of associated abnormal illness behavior.[13] Patients with illness anxiety disorder 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. Sex Illness and anxiety disorder 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. History Hypochondriasis is no longer a diagnosis according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Instead, approximately 75% of individuals previously diagnosed with hypochondriasis are subsumed under the diagnosis of somatic symptom disorder. The remaining 25% have high health anxiety in the absence of somatic symptoms and are classified as having illness anxiety disorder. Both somatic symptom disorder and illness anxiety disorder are classified in the DSM-5 under Somatic Symptom and Related Disorders.[73] The disorders in this class include somatic symptom disorder, illness anxiety disorder, conversion disorder, and factitious disorder. The health preoccupation diagnostic interview has been determined to have sufficient inter-rater reliability for somatic symptoms disorder and illness anxiety disorder (kappa of 0.85; n=104).[79] According to the DSM-5, somatic symptom disorders all share a common feature: the prominence of somatic symptoms associated with significant distress and impairment.[73] The core feature of somatic symptom disorder is the presence of one or more somatic symptoms that are distressing or result in significant disruption of daily life. The core feature of illness anxiety disorder is a preoccupation with having or acquiring a serious, undiagnosed medical illness. Diagnostic criteria (DSM-5) The DSM-5 criteria for illness anxiety disorder are as follows:[73] The individual is preoccupied with having or acquiring a serious illness. Somatic symptoms are not present or, if present, are only mild in intensity. If another medical condition is present or there is a high risk for developing a medical condition (eg, strong family history is present), the preoccupation is clearly excessive or disproportionate. The individual has a high level of anxiety about health, and is easily alarmed about personal health status. The individual performs excessive health-related behaviors or exhibits maladaptive avoidance. The individual has been preoccupied with illness for at least 6 months. The individual's preoccupation is not better explained by another mental disorder. Physical The absence of physical findings, particularly after serial examinations, supports the diagnosis of illness anxiety disorder. 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 See the list below: Modestly or well groomed, not grossly disheveled Cooperative with the examiner, yet ill at ease and not easily reassured Possible signs of anxiety, including moist hands, perspiring forehead, strained/tremulous voice, and wide eyes and intense eye contact Psychomotor status See the list below: Restlessness Frequent shifts in posture Mild-to-moderate agitation Slowed (if sleeping poorly) Mood and affect Mood is the pervasive and sustained emotion that colors the patient's perception of the world and affect is what the examiner observes. Anxious or worried, depressed mood Restricted, shallow, fearful, or anxious affect, with restricted fluctuations and limited depth Thought process See the list below: Spontaneous speaking with occasional abrupt changes in topic Circumstantial, scattered at times Responds to questions but may divert to next worry or revert to an already expressed concern despite reassurance to the contrary No latency unless also depressed No thought blocking or looseness of associations Concrete focus of thought, but with capacity to abstract in a number of areas when encouraged or tested May appear distractible and yet can concentrate independently and with encouragement Thought content See the list below: Preoccupation with being ill Anxious themes concerning what in the body is wrong, how it is wrong, and how it is experienced May have feelings of despair and/or hopelessness, although these are not usually of significant depth unless little relief has come from seeing multiple providers and/or the patient concurrently depressed Catastrophizing tendencies (focused on dire consequences of various symptoms and obtaining more diagnostic testing) Uninterested in revealing other aspects of daily functioning or general lifestyle topics at length Inflexibility regarding bodily concerns, but only rarely to the point of a delusion (ie, fixed, false belief), and if so, limited to somatic complaints rather than grandiose or persecutory complaints No perceptual disturbances (eg, hallucinations) No suicidal ideation, unless concurrently depressed No homicidal ideation Cognitive function See the list below: 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 See the list below: Able to recognize bodily sensations Lacking full understanding of underlying psychological concerns and how they underpin development and maintenance of bodily complaints; tends to see the "trees" rather than the "forest" Some awareness of own feelings about people and events, but not always with the ability to translate that into action, sustained change in mood, or lessening of preoccupations Judgment See the list below: Capable of social greetings and other behaviors Persistence in discussing and evaluating continuing preoccupations (due to limited insight) May be impaired if concurrently depressed Causes Developmental and other predisposing factors 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 illness anxiety disorder and the general population. There are some findings that risk factors for illness anxiety disorder include a lower educational level, lower income, and a history of childhood illness or abuse.[7] A cognitive model of hypochondriasis suggests that patients misinterpret bodily symptoms by augmenting and amplifying their somatic sensations. Patients also appear to have lower-than-usual thresholds for, and tolerance of, physical discomfort. For example, what most people normally perceive as abdominal pressure, patients with illness anxiety 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 illness anxiety to exaggerate their assessment of vulnerability to disease and their appraisal of the risk of serious illness.[11] The social learning theory frames illness anxiety disorder 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 somatic symptoms serve to "undo" guilt felt about the anger and serve as a punishment for being "bad." Neurochemical deficits with illness anxiety disorder and some other somatoform disorders (eg, BDD) appear similar to those of depressive and anxiety disorders. For example, in 1992, Hollander et al posited an obsessive-compulsive spectrum that includes OCD, BDD, anorexia nervosa, Tourette syndrome, and impulse control disorders (eg, trichotillomania, pathological gambling).[4] Although only preliminary data have been reported on these neurochemical deficits, such deficits may explain why symptoms overlap, why the disorders are commonly comorbid, and why treatments may parallel one another (eg, SSRIs). Additionally, P-wave dispersion (the difference between the maximum and minimum P-wave duration on the electrocardiograph) has been found to be significantly higher in patients with panic disorder and in patients with illness anxiety, compared with healthy control subjects. The elevated P-wave dispersion may be an indicator of cardiac autonomic dysfunction in anxiety disorders.[17]
Diagnostic Considerations Physical disease must be excluded, which involves evaluation for an extensive number of neurological (eg, myasthenia gravis, multiple sclerosis), endocrinological, and other systemic diseases. Illness anxiety disorder may be diagnosed in someone with a medical illness if the anxiety is out of proportion to the gravity of the illness. The psychiatric differential diagnosis for illness anxiety disorder includes the following disorders: somatic symptom, adjustment, conversion, body dysmorphic, mood, anxiety, and psychotic, and personality. Some of these are discussed in more detail below. Somatic symptom disorder This disorder is less restricted than the DSM IV somatization disorder, and as such, the prevalence is expected to be higher than somatization disorder. The diagnostic criteria are as follows: A. Patients present with one or more somatic symptoms that are distressing or result in significant disruption of daily life. B. Excessive thoughts, feelings, or behaviors related to the somatic symptoms or associated health concerns as manifested by at least one of the following: Disproportionate and persistent thoughts about the seriousness of one's symptoms Persistently high levels of anxiety about health or symptoms Excessive time and energy devoted to these symptoms or health concerns C. Although any one of somatic symptoms may not be continuously present, the state of being symptomatic is persistent (typically more than 6 months). What differentiates somatic symptom disorder from illness anxiety disorder is the patient's focus on symptoms rather than a preoccupation with illness and the accompanying worry. Somatic symptom disorder may be comorbid with medical illness. Conversion disorder (functional neurolgoical symptom disorder) Diagnostic Criteria: A. One or more symptoms of altered voluntary motor or sensory function. B. Clinical findings provide evidence of incompatiblity between the symptoms and recognized neurological or medical conditions. C. The symptom or deficit is not better explained by another medical or mental disorder. D. The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation. In contrast with illness anxiety disorder, patients with conversion disorder do not generally present with a concern that they have a serious disease and may (though not necessarily) have a noticeable lack of worry even about their presenting symptom. Common symptom presentations include impaired coordination, paralysis or weakness, tremor, difficulty swallowing, loss of pain or touch sensation, double vision, seizure, or blindness. Conversion disorder is also more common in females, with female-to-male ratios varying from 2:1 to 10:1.[19, 20] Body dysmorphic disorder Diagnostic Criteria: A. Preoccupation with one ore more perceived defects or flaws in physical appearance that are not observable or appear slight to others. B. At some point during the course of the disorder, the individual has performed repetitive behaviors (checking, grooming, reassurance seeking) in response to their concerns. C. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The appearance preoccupation is not better explained by concerns with body fat or weight in an individual whose symptoms meet diagnostic criteria for an eating disorder. Complaints include preoccupations with the face, head, hair, skin, genitals, breasts, buttocks, extremities, shoulders, and overall body size or weight. The nose, ears, face, or sexual organs are involved most often.[21] Concerns of patients with BDD, unlike those of patients with illness anxiety disorder, are limited only to bodily appearance, not underlying illness. Mood disorders Depression may be considered in these patients because they often present with somatic symptoms, somatic ruminations, and illness anxiety preoccupation. However, for a diagnosis of depression, patients must have depressed mood or anhedonia (loss of interest or pleasure in activities) and must have 4 associated symptoms, including any of the following: poor appetite or overeating, insomnia or hypersomnia, low energy or fatigue, psychomotor agitation or retardation, poor concentration or indecision, feelings of worthlessness or excessive guilt, or thoughts of death and/or suicide. The patient's appearance is usually consistent with these problems. When depression is treated, the somatic complaints also resolve. Anxiety disorders These disorders are part of the differential diagnosis for hypochondriasis because patients often present with, or have a number of, somatic symptoms. Typically though, the somatic symptoms are alleviated when these disorders are treated. Patients with generalized anxiety disorder have excessive, pervasive, and uncontrollable worries concerning relationships, work, and leisure. However, such worries are generalized and are not limited to worries of being ill. Patients with OCD have obsessions that mimic illness anxiety in that they are recurrent and persistent and experienced as intrusive, but these worries extend beyond concerns about illness (eg, to fear about a door being unlocked) and are often accompanied by thematically related compulsive compensatory behavior (eg, lock checking). On the other hand, OCD may be comorbid with illness anxiety disorder. Based on family data in studies of OCD, Bienvenu et al found a relationship between OCD and hypochondriasis and body dysmorphic disorder, suggesting comorbidity between OCD and these disorders.[22] Van den Heuvel et al found similar frontal-striatal alterations during a planning task among OCD, panic disorder, and hypochondriasis, suggesting a common limbic activation pathway among these disorders.[23] Psychotic disorders A patient with a psychotic disorder (eg, schizophrenia, delusional disorder) may present primarily with a somatic symptom, but the belief has a fixed quality (ie, a delusion) in contrast to the patient with illness anxiety disorder, who is convinced of his or her concerns but is able to consider the possibility that the specific feared disease is not present. Monosymptomatic hypochondriacal psychosis is a term that was commonly used to indicate concerns about delusional parasitosis, or the delusions of infestation by parasitic organisms. Now these patients are generally thought to have delusions (ie, diagnosed formally as DSM-5 delusional disorder, somatic type). Personality disorders Some personality disorders/styles overlap with illness anxiety disorder.[14]Characteristics of patients with illness anxiety include anxiousness, conscientiousness, dependence, narcissism, and avoidance.[24] In a study that compared personality disorder of patients with hypochondriasis with obsessive-compulsive disorder (OCD) and social anxiety disorder (SAD), the amount of personality disorder comorbidity was not significantly different. The most common personality disorders comorbid with hypochondriasis were paranoid (19.4%), avoidant (17.7%), and obsessive-compulsive (14.5%).[25] Primary care As detailed above, the patient's report of his or her physical symptoms may not be specific, and the physical examination may not support a clear medical diagnosis. A history of “doctor shopping” is common. Because multiple evaluations and workups have been unfruitful, frustration may ensue, as the patient feels the physicians do not care. The task of the primary care physician here involves the development of a caring and professional relationship with the patient and setting realistic expectations. The physician must be firm but supportive to avoid the patient fleeing to another physician.[26] Some of the "tests" patients present are predictable. Often, the patient requests a specific blood test, radiological study, or invasive procedure, or a combination thereof. The patient may question the expertise of the primary physician and request referrals to different specialists and an ongoing workup. Any possible yield of an investigation must be balanced by the potential medical risks as well as the psychological risk of reinforcing the cyclical illness anxiety/reassurance seeking pattern. The physician should engage the patient in the decision-making process whenever possible. Premature reflexive reassurance may be interpreted as a physician deflecting responsibility or may serve to feed into the patient’s reassurance-seeking behavior.[27] Meanwhile, the physician must not lose sight of more important health care maintenance examinations, annual screening studies, and lifestyle modifications.[26] Pediatric Illness anxiety, per se, is infrequent in the pediatric population because of children’s lack of knowledge of specific disorders that may engender concerns or fears. Children generally respond to reassurance from parents and health care professionals.[26] On the other hand, somatic disorders as a result of psychological distress do occur (eg, headaches, stomachaches). In childhood, recurrent abdominal pain (RAP) is a common reason for medical consultation, in at least 1 out of 10 school-aged children. The outcomes of RAP among 28 young adults showed higher ratings on the Hypochondriacal Beliefs subscale of the Illness Attitude Scales (IAS).[28] As adults, these patients also perceived themselves as more susceptible to illness and expressed more fear of death. A history of childhood somatic symptoms and psychosocial distress appear to increase the risk of hypochondriasis in adulthood.[29] Several factors may increase the risk for illness anxiety presentations. Somatic disorders seem to occur more in children who are conscientious, sensitive, insecure, and anxious. Childhood adversity, especially overt neglect and sexual abuse, are associated with frequent medical consultations.[30] Interestingly, childhood memory about health may contribute to the development of illness anxiety, though these children may not distinguish between memories about their own health and the health of a friend or stranger.[31] As children develop a better ability to communicate and more awareness of their emotions, the expression of emotion through somatic symptoms lessens. Geriatric The diagnosis of illness anxiety can be particularly challenging in this patient population, since elderly patients may experience both medical and psychiatric disorders as part of aging. Most elderly patients are reluctant to admit to sadness or depressed mood. Instead, the depressive symptoms are expressed somatically. Additionally, an elderly patient is uniquely faced with loss of loved ones, social isolation, reduced financial resources, restricted freedom, and existential crisis. The illness anxiety reaction is often an adaptive response to such unfamiliar psychosocial distress (Ref 33) . Illness anxiety may also be difficult to distinguish from reality-based organic diseases, psychiatric disorders, or adjustment to psychosocial changes.[32] Providers should empathize with the functional value of illness anxiety in the elderly patient in helping the patient face mounting medical problems and inevitable aging. Chronic pain Illness anxiety is associated with chronic pain. This has been studied in an evidence-based structured review of 57 studies that examined the relationship between hypochondriasis or somatization and chronic pain. In some patients, illness anxiety may develop after development of the disorder causing the pain. The more severe the pain, the higher the likelihood that illness anxiety may develop. In some studies, treatment of pain may improve the severity of hypochondriasis.[34] Other specialties Illness anxiety is now being directly or indirectly evaluated in numerous specialties, including cardiology, dermatology, otorhinolaryngology, gastroenterology, infectious disease, obstetrics and gynecology, ophthalmology, and oncology.[26] Differential Diagnoses · Anxiety Disorders · Body Dysmorphic Disorder · Conversion Disorders · Delusional Disorder · Depression · Personality Disorders · Schizophrenia · Somatic Symptom Disorders Laboratory Studies In patients with hypochondriasis, the abnormal laboratory findings characteristic of the suggested physical disorder are absent. Other Tests Screening tools See the list below: 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] Medical Care Basic management principles See the list below: Establish a firm therapeutic alliance with the patient. Educate the patient regarding the manifestations of hypochondriasis. Offer consistent reassurance. Optimize the patient's ability to cope with the symptoms, rather than trying to eliminate the symptoms. Avoid performing high-risk, low-yield invasive procedures. Close collaboration among all treating providers to prevent investigative duplication Physician concerns and influence The most powerful therapeutic tool is the physician and his or her team's attention, concern, interest, careful listening, and nonjudgmental stance, which can potentially break a pathological cycle of maladaptive interactions between the patient and movement from physician to physician (see the image below).[38] Pathological cycle of bodily concern and anxiety in hypochondriasis. One difficulty with which physicians struggle is related to countertransference (ie, physicians' own emotional reactions to the patient). Typically, physicians feel angry, hopeless, and/or helpless because their assessments and interventions are not effective and efforts at reassuring the patient are usually met with resistance and even escalation of physical symptoms. These feelings may lead physicians to reject or withdraw from patients with hypochondriasis. Psychiatric inpatient care As with the other somatoform disorders, inpatient psychiatric hospitalization for the somatoform disorder itself is rarely necessary. As these patients are at risk for concurrent mood, anxiety, and personality disorders, a psychiatric admission may be necessary to manage episodic decompensation of the comorbid psychiatric conditions or suicidal ideation. If the patient experiences suicidal ideation or makes a suicide act based on comorbid depression or personality disorder or develops uncontrollable anxiety, then an inpatient psychiatric hospitalization may be indicated. In such a case, a hypochondriasis diagnosis may be established in the context of an inpatient admission. Formal psychometric testing may be of help. The hypochondriacal patterns of behavior can be addressed in ward therapy interventions. When patients are discharged following recovery of behavioral stability, the hypochondriasis treatment model described below may be implemented. General medical inpatient care Patients with hypochondriasis should be admitted to general medicine and surgery services based on the medical and surgical acuity, not solely to facilitate work-up. Due to the enigmatic nature of various physical symptoms, occasionally patients with hypochondriasis are admitted to the general medical-surgical hospital for an extensive work-up. 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. Factors that maintain anxiety in patients with hypochondriasis. Establish one primary care physician as the patient's main physician. Review the patient's medical history to build an alliance and rule out medical disorders. Premature reassurance, prescription of psychotropic medications, and referral for mental health services may suggest to the patient that he or she is not being taken seriously. Therefore, while such treatments may be indicated at some time (in the future), prematurely offering a diagnosis or psychiatric treatment may, in fact, impair the establishment of a trusting patient-physician relationship. Acknowledge the patient's pain and suffering. Couple reassurance statements of normal findings with statements that that the patient will not be abandoned. For example, “Mr. Smith, it appears that you are still having concern about having a “several medical disorder” despite all the workup, which, so far, has not showed any abnormal finding. I will continue to work with you to maximize you overall well-being and health.” Reassure the patient that evaluation will be ongoing. Understand the “the fear” of having an unknown medical disorder as a form of emotional communication. Search for underlying medical and psychiatric disorders potentially amenable to treatment. Seek consultation or refer the patient to a colleague if establishing an alliance proves difficult. Allow for time-limited structured discussions about somatic concerns. Spend sufficient time on health care maintenance issues such as diet, experience, smoking cessation, and cancer detection. Treat comorbid psychiatric disorders concurrently. Be aware of emotional reactions toward the patient (ie, anger, hopelessness, helplessness) and seek frequent informal consultation when possible. Focus on care of the patient with hypochondriasis, not exclusively on “a cure” for the disorder. Psychotherapy Several authors have suggested a cognitive-educational approach to understand the development of the severe anxiety associated with hypochondriasis (see thefirst image below) and the factors that maintain the long-term anxiety (see the second image below).[39] Randomized controlled trials now suggest that cognitive-behavioral therapy (CBT) is efficacious in the treatment of hypochondriasis[40, 41, 42, 43, 44] and may be the recommended treatment for patients with hypochondriasis. Bibliotherapy, using CBT principles, may also be useful. In a meta-analysis of outcomes using CBT for hypochondriasis, higher pre-treatment severity and great number of CBT sessions is associated with higher effect size.[75] Cognitive and exposure therapy also seems promising for hypochondriasis.[76, 77] Mindfulness-based cognitive therapy also appears to be effective when added to usual care.[78] In clinical settings, both the availability of CBT and treatment adherence of patients with hypochondriasis to psychotherapy in general are major barriers to successful outcomes. It is possible that case management and integrated primary care and psychiatry programs may be especially suitable for patients with hypochondriais, somatic symptom disorder, and illness anxiety disorder. However, prospective treatment studies are urgently needed in this area. Surgical Care Psychosurgery is only recommended for patients with severe and intractable hypochondriasis. Consultations Primary care physicians generally treat hypochondriasis, with psychiatrists providing consultation. 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). 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.
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] There are no medications approved specifically for the treatment of hypochondriasis, somatic symptom disorder, or illness anxiety disorder. Medications are usually started to treat the comorbid depression or anxiety disorder. Antidepressants 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. Beta-adrenergic receptor-blocking agents 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. Benzodiazepines 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. Antipsychotic medications 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. Inpatient & Outpatient Medications Continue successful long-term trials of medications for patients with hypochondriasis. For patients with comorbid disorders, consider maintenance of those trials because these disorders can initiate and/or exacerbate hypochondriacal symptoms. Transfer Physician-to-physician dialogue on the nature of the patient's problems and successful management strategies is useful. Complications Patients who are hypochondriacal may be significant consumers of medical care, undergoing repetitive doctor visits, physical examinations, laboratory testing, and other costly, invasive, and potentially dangerous procedures. Physician concerns regarding workups for somatic complaints also may preclude diagnosis of common comorbid disorders (eg, depression) that are quite treatable. Prognosis Hypochondriasis is a common disorder in primary care settings. The differential diagnosis includes other somatoform, depressive, anxiety (eg, generalized anxiety disorder, OCD), and psychotic disorders. Biopsychosocial treatment is required to manage this complex disorder, and further research is required to better understand its pathophysiology and interface with other psychiatric conditions. Recognizing the biological similarities between these seemingly disparate disorders may be a useful starting point to begin a more systematic study of novel treatments for hypochondriasis.[46] A systematic review of six studies on hypochondriasis indicated that 30-50% of patients achieve recovery.[47] 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 recover by adolescence or early adulthood. There is a dearth of long-term follow-up studies examining outcomes of patients with hypochondriasis. In a prospective study that examined 58 patients with hypochondriasis who had participated in selective serotonin reuptake inhibitor (SSRI) treatment for 4-16 years (mean 8.6±4.5 y), 40% continued to meet the diagnosis of hypochondriasis. Predictors of continued diagnosis of hypochondriasis include longer duration of hypochondriasis prior to treatment, history of childhood physical punishment, and lower use of SSRI during the treatment period. A large portion of patients with hypochondriasis who received SSRI treatment were able to achieve remission.[48] Patient Education Educational approaches provide accurate information, allowing the patient to realize somatic symptoms are exceedingly common, with only a small proportion caused by disease and most compatible with physical health. Accurate information about the relationship of a threatening stimulus and its somatic consequences can influence the severity of autonomic responses, subjective distress, and behavior. Maladaptive iatrogenic beliefs must be countered. Providing a small amount of information at a time and repeating it is best. For excellent patient education resources, visit eMedicineHealth's Mental Health Center and Depression Center. Also, see eMedicineHealth's patient education article Chronic Fatigue Syndrome. For mild and short-lived symptoms, the primary medical provider could provide detailed education (symptoms, course, monitoring, diagnosis, and treatment) about the medical condition about which the patient is concerned. Education should additionally focus on the role of anxiety and how anxiety could increase autonomic activity or arousal and, thereby, cause the body to misattribute certain physical sensations and symptoms. For more persistent and chronic hypochondriasis, especially in situations where the patient has already failed treatment with multiple providers, education needs be delivered in small “doses,” when the time is right, and after the establishment of a firm patient-provider relationship. The tailoring of education delivery as applied to mild versus severe symptoms has not been systematically studied. Since hypochondriasis may be precipitated by psychosocial stress, family support is likely to be additionally helpful. However, the role of family education requires further investigation. Even in the absence of formal research into family education for hypochondriasis, several practical pointers are recommended: The patient needs to give permission to involve family members in diagnosis and treatment planning decisions. Family members need to be told that the physician will not keep secrets from the patient; ie, anything family members tell the physician about the patient will be shared, with direct attribution, to the patient. Family members need to understand that the distress the patient feels is real even if the conviction about illness is false or cannot be substantiated. Family members should not enable overuse of medical services by reinforcing patients’ requests for excessive interventions. Family members should be encouraged to support the outpatient chronic disease model for hypochondriasis as described above. Family members should be educated on the common psychiatric comorbidity of hypochondriasis and help the patient self-monitor for mood and anxiety symptoms and seek help for these separately. Family or couple’s therapy should be considered in patients where family and marital discord is a major source of conflict that is contributing to psychological distress. Alternatively, family therapy should be considered in patients whose symptoms have cause major distress to family dynamics that either seem to perpetuate current symptoms. Source References Barsky AJ, Klerman GL. Overview: hypochondriasis, bodily complaints, and somatic styles. Am J Psychiatry. 1983 Mar. 140(3):273-83. [Medline]. Fallon BA, Petkova E, Skritskaya N, et al. A double-masked, placebo-controlled study of fluoxetine for hypochondiasis. J Clin Psychopharmcol. December 2008. 6:638-45. 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