Hypochondriasis

Definition

Description

Causes and symptoms

Demographics

Diagnosis

Treatments

Prognosis

Prevention

Resources

Definition

Hypochondriasis is a mental disorder in which the individual is preoccupied with the thought of having a serious physical disease based on the incorrect or exaggerated interpretation of physical symptoms. This preoccupation continues for at least six months and interferes with the individual’s social and occupational functioning even in the face of medical evidence to the contrary. Hypochondriasis is considered a somato-form disorder.

Description

The primary feature of hypochondriasis is excessive fear of having a serious disease. This fear is not relieved when a medical examination finds no evidence of disease. People with hypochondriasis are often able to acknowledge that their fears are unrealistic, but this intellectual realization is not enough to reduce their anxiety. In order to qualify for a diagnosis of hypochondriasis, preoccupation with fear of disease must cause a great deal of distress or interfere with a person’s ability to perform important activities, such as work, school activities, or family and social responsibilities. Hypochondriasis is included in the category of somatoform disorders in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), which is the reference handbook that clinicians use to guide the diagnosis of mental disorders. Some experts, however, have argued that hypochondriasis shares many features with obsessive-compulsive disorder or panic disorder and would be more appropriately classified with the anxiety disorders.

The fears of a person with hypochondriasis may be focused on the possibility of a single illness, but more often they include a number of possible conditions. The focus of the fears may shift over time as a person notices a new symptom or learns about an unfamiliar disease. The fears appear to develop in response to minor physical abnormalities, like fatigue , aching muscles, a mild cough, or a small sore. People with hypochondriasis may also interpret normal sensations as signs of disease. For instance, an occasional change in heart rate or a feeling of dizziness upon standing up will lead a person with hypochondriasis to fears of heart disease or stroke. Sometimes hypochondriacal fears develop after the death of a friend or family member, or in response to reading an article or seeing a television program about a disease. Fear of illness can also increase in response to stress. Individuals with hypochondriasis visit physicians frequently; and when told there is nothing physically wrong, they are likely to seek a second opinion since their fears are not soothed. Their apparent distrust of their physicians’ opinions can cause tensions in doctor-patient relationships, leading to the patient’s further dissatisfaction with health-care providers. Physicians who regularly see a patient with hypochondriasis may become skeptical about any reported symptom, increasing the danger that a real illness may be overlooked. People with hypochondriasis also run the risk of undergoing unnecessary medical tests or receiving unneeded medications. Although they are usually not physically disabled, they may take frequent sick days from work, or annoy friends and family with constant conversation or complaints about illness, reducing their ability to function effectively in some aspects of life.

Causes and symptoms

Causes

AMPLIFICATION OF SENSORY EXPERIENCE

One theory suggests that people with hypochondriasis are highly sensitive to physical sensations. They are more likely than most people to pay close attention to sensations within their bodies (heart rate, minor noises in the digestive tract, the amount or taste of saliva in the mouth, etc.), which magnifies their experience of these feelings. While many people fail to notice minor discomfort as they go about their regular activities, the individual with hypochondriasis pays constant attention to inner sensations and becomes alarmed when these sensations vary in any way. This heightened scrutiny may actually increase the intensity of the sensations, and the intensity of the experience fuels fears that the sensations signal an underlying illness. Once the fears are aroused, preoccupation with the symptom increases, further enhancing the intensity of sensations. The tendency to amplify may be either temporary or chronic; it may also be influenced by situational factors, which helps to explain why hypochondriacal fears are made worse by stress or by events that appear to justify concerns about illness. Some researchers have observed that heightened sensitivity to internal sensations is also a feature of panic disorder, and have suggested that there may be an overlap between the two disorders.

DISTORTED INTERPRETATION OF SYMPTOMS

Another theory points to the centrality of dysfunctional thinking in hypochondriasis. According to this theory, the internal physical sensations of the person with hypochondriasis are not necessarily more intense than those of most people. Instead, people with hypochondriasis are prone to make catastrophic misinterpretations of their physical symptoms. They are pessimistic about the state of their physical health and overestimate their chances of falling ill. Hypochondriasis thus represents a cognitive bias; whereas most people assume they are healthy unless there is clear evidence of disease, the person with hypochondriasis assumes he or she is sick unless given a clean bill of health. Interestingly, research suggests that people with hypochondriasis make more realistic estimations of their risk of disease than most people, and in fact underestimate their risk of illness. Most people simply underestimate their risk even more. Some studies indicate that people with hypochondriasis are more likely to have had frequent or serious illnesses as children, which may explain the development of a negative cognitive bias in interpreting physical sensations or symptoms.

Symptoms

The primary symptom of hypochondriasis is preoccupation with fears of serious physical illness or injury. The fears of persons with hypochondriasis have an obsessive quality; they find thoughts about illness intrusive and difficult to dismiss, even when they recognize that their fears are unrealistic. In order to relieve the anxiety that arises from their thoughts, people with hypochondriasis may act on their fears by talking about their symptoms, by seeking information about feared diseases in books or on the Internet, or by “doctor-shopping,” going from one specialist to another for consultations. Others may deal with their fears through avoidance, staying away from anything that might remind them of illness or death. Persons with hypochondriasis vary in their insight into their disorder. Some recognize themselves as “hypochondriacs,” but have anxiety in spite of their recognition. Others are unable to see that their concerns are unreasonable or exaggerated.

Demographics

According to the DSM-IV-TR, hypochondriasis affects 1-5% of the general population in the United States. The rates of the disorder are higher among clinical outpatients, between 2% and 7%. One recent study suggests that full-blown hypochondriasis is fairly rare, although lesser degrees of worry about illness are more common, affecting as many as 6% of people in a community sample.

Hypochondriasis can appear at any age, although it frequently begins in early adulthood. Men and women appear to equally develop the disorder. The DSM-IV-TR notes that people from some cultures may appear to have fears of illness that resemble hypochondriasis, but are in fact influenced by beliefs that are traditional in their culture.

Diagnosis

Hypochondriasis is most likely to be diagnosed when one of the doctors consulted by the patient considers the patient’s preoccupation with physical symptoms and concerns excessive or problematic. After giving the patient a thorough physical examination to rule out a general medical condition, the doctor will usually give him or her a psychological test that screens for anxiety or depression as well as hypochondriasis. If the results suggest a diagnosis of hypochondriasis, the patient should be referred for psychotherapy. It is important to note, however, that patients with hypochondriasis usually resist the notion that their core problem is psychological. A successful referral to psychotherapy is much more likely if the patient’s medical practitioner has been able to relate well to the patient and work gradually toward the notion that psychological problems might be related to fears of physical illness.

Specific approaches that have been found useful by primary care doctors in bringing psychological issues to the patient’s attention in nonthreatening ways include the following:

• drawing connections between the patient’s current physical symptoms and recent setbacks or upsetting incidents in the patient’s life. For example, the patient may come in with health worries within a few days of having a problem in other areas of life, such as their car needing repairs, a quarrel with a family member, an overdue bill, etc.
• asking the patient to keep a careful diary of his or her symptoms and other occurrences. This diary may be useful in guiding the patient to see patterns in his or her worries about health.
• scheduling the patient for regular but short appointments. It is also better to see the patient briefly than to prescribe medications in place of an appointment, because many patients with hypochondriasis abuse medications.
• conduct routine screening tests during a yearly physical for patients with hypochondriasis, while discouraging them from scheduling extra appointments each time they notice a minor physical problem.
• maintain a realistic but optimistic tone in his or her conversation with the patient. He or she may wish to talk to the patient about health-related fears and clarify the differences between normal internal body sensations and serious symptoms.

In order to receive a DSM-IV-TR diagnosis of hypochondriasis, a person must meet all six of the following criteria:

• the person must be preoccupied with the notion or fear of having a serious disease. This preoccupation is based on misinterpretation of physical symptoms or sensations.
• appropriate medical evaluation and reassurance that there is no illness present do not eliminate the preoccupation.
• the belief or fear of illness must not be of delusional intensity. Delusional health fears are more likely to be bizarre in nature—for instance, the belief that one’s skin emits a foul odor or that food is rotting in one’s intestines. The preoccupations must not be limited to a concern about appearance; excessive concerns that focus solely on defects in appearance would receive a diagnosis of body dysmorphic disorder.
• the preoccupation must have lasted for at least six months.
• the person’s preoccupation with illness must not simply be part of the presentation of another disorder, including generalized anxiety disorder, obsessive-compulsive disorder, panic disorder, separation anxiety, major depressive episode, or another somatoform disorder.

The DSM-IV-TR also differentiates between hypochondriasis with and without poor insight. Poor insight is specified when the patient does not recognize that his or her concerns are excessive or unreasonable.

Treatments

Traditionally hypochondriasis has been considered difficult to treat. In the last few years, however, cognitive and behavioral treatments have demonstrated effectiveness in reducing the symptoms of the disorder.

Cognitive therapy

The goal of cognitive therapy for hypochondriasis is to guide patients to the recognition that their chief problem is fear of illness, rather than vulnerability to illness. Patients are asked to monitor worries and to evaluate how realistic and reasonable they are. Therapists encourage patients to consider alternative explanations for the physical signs they normally interpret as disease symptoms. Behavioral experiments are also employed in an effort to change the patient’s habitual thoughts. For instance, a patient may be told to focus intently on a specific physical sensation and monitor increases in anxiety. Another behavioral assignment might ask the patient to suppress urges to talk about health-related worries with family members, then observe their anxiety level. Most people with hypochondriasis believe that their anxiety will escalate until they release it by seeking reassurance from others. In fact, anxiety usually crests and subsides in a matter of minutes. Cognitive therapy effectively reduces many symptoms of the disorder, and many improvements persist up to a year after treatment ends.

BEHAVIORAL STRESS MANAGEMENT

One study compared cognitive therapy to behavioral stress management. This second form of therapy focuses on the notion that stress contributes to excessive worry about health. Patients were asked to identify stressors in their lives and taught stress management techniques to help them cope with these stressors. The researchers taught the patients relaxation techniques and problem-solving skills, and the patients practiced these techniques in and out of sessions. Although this treatment did not focus directly on hypochondriacal worries, it was helpful in reducing symptoms. At the end of the study, behavioral stress management appeared to be less effective than cognitive therapy in treating hypochondriasis, but a follow-up a year later found that the results of two therapies were comparable.

KEY TERMS

Comorbid psychopathology — The presence of other mental disorders in a patient together with the disorder that is the immediate focus of therapy.

Somatoform disorders — A group of psychiatric disorders in the DSM-IV-TR classification that are characterized by the patient’s concern with external physical symptoms or complaints. Hypochondriasis is classified as a somatoform disorder.

EXPOSURE AND RESPONSE PREVENTION

This therapy begins by asking patients to make a list of their hypochondriacal behaviors, such as checking body sensations, seeking reassurance from physicians or friends, and avoiding reminders of illness. Behavioral assignments are then developed. Patients who frequently monitor their physical sensations or seek reassurance are asked not to do so, and to allow themselves to experience the anxiety that accompanies suppression of these behaviors. Patients practice exposing themselves to anxiety until it becomes manageable, gradually reducing hypochondriacal behaviors in the process. In a study comparing exposure and response prevention to cognitive therapy, both therapies produced clinically significant results. Although cognitive therapy focuses more on thoughts and exposure therapy more on behaviors, both appear to be effective in reducing both dysfunctional thoughts and behaviors.

Prognosis

Untreated hypochondriasis tends to be a chronic disorder, although the intensity of the patient’s symptoms may vary over time. The DSM-IV-TR notes that the following factors are associated with a better prognosis: the symptoms develop quickly; are relatively mild; are associated with an actual medical condition; and are not associated with comorbid psychopathology or benefits derived from being ill.

Prevention

Hypochondriasis may be difficult to prevent in a health-conscious society, in which people are constantly exposed to messages reminding them to seek regular medical screenings for a variety of illnesses, and telling them in detail about the illnesses of celebrities and high-ranking political figures. Trendy new diagnostic techniques like full-body MRIs may encourage people with hypochondriasis to seek unnecessary and expensive medical consultations. Referring patients with suspected hypochondriasis to psychotherapy may also help to reduce their overuse of medical services.

See alsoExposure treatment.

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed., Text rev. Washington D.C.: American Psychiatric Association, 2000.

Asmundson, Gordon J. G., Steven Taylor, and Brian J. Cox, eds. Health Anxiety: Hypochondriasis and Related Disorders. New York: John Wiley and Sons, 2002.

Maj, Mario, Hagop S. Akiskal, Juan E. Mezzich, and Ahmed Okasha, eds. Somatoform Disorders, WPA Series. Evidence and Experience in Psychiatry, Volume 9. New York: John Wiley and Sons, 2005.

Walker, John R., and Patricia Furer. “Treatment of Hypochondriasis and Psychogenic Movement Disorders: Focus on Cognitive-Behavior Therapy.” Psychogenic Movement Disorders: Neurology and Neuropsychiatry. Mark Hallett, Stanley Fahn, Joseph Jankovic, Anthony E. Lang, and C. Robert Cloninger, eds. Philadelphia: Lippincott Williams and Wilkins Publishers, 2006: 163–79.

VandenBos, Gary R., ed. APA Dictionary of Psychology. Washington D.C.: American Psychological Association, 2006.

PERIODICALS

Abramowitz, Jonathan S. “Hypochondriasis: Conceptualization, Treatment, and Relationship to Obsessive Compulsive Disorder.” Annals of Clinical Psychiatry 17.4 (Oct.-Dec. 2005): 211–17.

Abramowitz, Jonathan S., and Autumn E. Braddock. “Hypochondriasis: Conceptualization, Treatment, and Relationship to Obsessive-Compulsive Disorder.” Psychiatric Clinics of North America 29.2 (June 2006): 503–19.

Asmundson, Gordon J. G., and Michael J. Coons. “Current Directions in the Treatment of Hypochondriasis.” Journal of Cognitive Psychotherapy 19.3 (Fall 2005): 285–304.

Avia, M. D., and M. A. Ruiz. “Recommendations for the Treatment of Hypochondriac Patients.” Journal of Contemporary Psychotherapy 35.3 (Fall 2005): 301–13.

Bleichhardt, Gaby, Barbara Timmer, and Winfried Rief. “Hypochondriasis Among Patients with Multiple Somatoform Symptoms—Psychopathology and Outcome of a Cognitive-Behavioral Therapy.” Journal of Contemporary Psychotherapy 35.3 (Fall 2005): 239–49.

Furer, Patricia, and John R. Walker. “Treatment of Hypochondriasis with Exposure.” Journal of Contemporary Psychotherapy 35.3 (Fall 2005): 251–67.

Martínez, M. Pilar, and Cristina Botella. “An Exploratory Study of the Efficacy of a Cognitive-Behavioral Treatment for Hypochondriasis Using Different Measures of Change.” Psychotherapy Research 15.4 (Oct. 2005): 392–408.

Monopoli, John. “Managing Hypochondriasis in Elderly Clients.” Journal of Contemporary Psychotherapy 35.3 (Fall 2005): 285–300.

Noyes, Russell, Jr., Scott Stuart, David B. Watson, and Douglas R. Langbehn. “Distinguishing Between Hypochondriasis and Somatization Disorder: A Review of the Existing Literature.” Psychotherapy and Psychosomatics 75.5 (Aug. 2006): 270–81.

Starcevic, Vladan. “Fear of Death in Hypochondriasis: Bodily Threat and Its Treatment Implications.” Journal of Contemporary Psychotherapy 35.3 (Fall 2005): 227–37.

Stuart, Scott, and Russell Noyes, Jr. “Treating Hypochondriasis with Interpersonal Psychotherapy.” Journal of Contemporary Psychotherapy 35.3 (Fall 2005): 269–83.

Danielle Barry, MS
Ruth A. Wienclaw, PhD

Hypochondriasis

Definition

The primary feature of hypochondriasis is excessive fear of having a serious disease. These fears are not relieved when a medical examination finds no evidence of disease. People with hypochondriasis are often able to acknowledge that their fears are unrealistic, but this intellectual realization is not enough to reduce their anxiety. In order to qualify for a diagnosis of hypochondriasis, preoccupation with fear of disease must cause a great deal of distress or interfere with a person's ability to perform important activities, such as work, school activities, or family and social responsibilities. Hypochondriasis is included in the category of somatoform disorders in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR ), which is the reference handbook that clinicians use to guide the diagnosis of mental disorders. Some experts, however, have argued that hypochondriasis shares many features with obsessive-compulsive disorder or panic disorder and would be more appropriately classified with the anxiety disorders.

Description

The fears of a person with hypochondriasis may be focused on the possibility of a single illness, but more often they include a number of possible conditions. The focus of the fears may shift over time as a person notices a new symptom or learns about an unfamiliar disease. The fears appear to develop in response to minor physical abnormalities, like fatigue , aching muscles, a mild cough or a small sore. People with hypochondriasis may also interpret normal sensations as signs of disease. For instance, an occasional change in heart rate or a feeling of dizziness upon standing up will lead a person with hypochondriasis to fears of heart disease or stroke . Sometimes hypochondriacal fears develop after the death of a friend or family member, or in response to reading an article or seeing a television program about a disease. Fear of illness can also increase in response to stress . Individuals with hypochondriasis visit physicians frequently; and when told there is nothing physically wrong, they are likely to seek a second opinion since their fears are not soothed. Their apparent distrust of their physicians' opinions can cause tensions in doctor-patient relationships, leading to the patient's further dissatisfaction with health care providers. Physicians who regularly see a patient with hypochondriasis may become skeptical about any reported symptom, increasing the danger that a real illness may be overlooked. People with hypochondriasis also run the risk of undergoing unnecessary medical tests or receiving unneeded medications. Although they are usually not physically disabled, they may take frequent sick days from work, or annoy friends and family with constant conversation or complaints about illness, reducing their ability to function effectively in some aspects of life.

Causes and symptoms

Causes

AMPLIFICATION OF SENSORY EXPERIENCE. One theory suggests that people with hypochondriasis are highly sensitive to physical sensations. They are more likely than most people to pay close attention to sensations within their bodies (heart rate, minor noises in the digestive tract, the amount or taste of saliva in the mouth, etc.), which magnifies their experience of these feelings. While many people fail to notice minor discomfort as they go about their regular activities, the individual with hypochondriasis pays constant attention to inner sensations and becomes alarmed when these sensations vary in any way. This heightened scrutiny may actually increase the intensity of the sensations, and the intensity of the experience fuels fears that the sensations signal an underlying illness. Once the fears are aroused, preoccupation with the symptom increases, further enhancing the intensity of sensations. The tendency to amplify may be either temporary or chronic; it may also be influenced by situational factors, which helps to explain why hypochondriacal fears are made worse by stress or by events that appear to justify concerns about illness. Some researchers have observed that heightened sensitivity to internal sensations is also a feature of panic disorder, and have suggested that there may be an overlap between the two disorders.

DISTORTED INTERPRETATION OF SYMPTOMS. Another theory points to the centrality of dysfunctional thinking in hypochondriasis. According to this theory, the internal physical sensations of the person with hypochondriasis are not necessarily more intense than those of most people. Instead, people with hypochondriasis are prone to make catastrophic misinterpretations of their physical symptoms. They are pessimistic about the state of their physical health, and overestimate their chances of falling ill. Hypochondriasis thus represents a cognitive bias; whereas most people assume they are healthy unless there is clear evidence of disease, the person with hypochondriasis assumes he or she is sick unless given a clean bill of health. Interestingly, research suggests that people with hypochondriasis make more realistic estimations of their risk of disease than most people, and in fact underestimate their risk of illness. Most people simply underestimate their risk even more. Some studies indicate that people with hypochondriasis are more likely to have suffered frequent or serious illnesses as children, which may explain the development of a negative cognitive bias in interpreting physical sensations or symptoms.

Symptoms

The primary symptom of hypochondriasis is preoccupation with fears of serious physical illness or injury. The fears of persons with hypochondriasis have an obsessive quality; they find thoughts about illness intrusive and difficult to dismiss, even when they recognize that their fears are unrealistic. In order to relieve the anxiety that arises from their thoughts, people with hypochondriasis may act on their fears by talking about their symptoms; by seeking information about feared diseases in books or on the Internet; or by "doctor-shopping," going from one specialist to another for a consultation. Others may deal with their fears through avoidance, staying away from anything that might remind them of illness or death. Persons with hypochondriasis vary in their insight into their disorder. Some recognize themselves as "hypochondriacs," but suffer anxiety in spite of their recognition. Others are unable to see that their concerns are unreasonable or exaggerated.

Demographics

According to DSM-IV-TR, hypochondriasis affects 1%–5% of the general population in the United States. The rates of the disorder are higher among clinical outpatients, between 2% and 7%. One recent study suggests that full-blown hypochondriasis is fairly rare, although lesser degrees of worry about illness are more common, affecting as many as 6% of people in a community sample.

Hypochondriasis can appear at any age, although it frequently begins in early adulthood. Men and women appear to suffer equally from the disorder. DSM-IV-TR notes that people from some cultures may appear to have fears of illness that resemble hypochondriasis, but are in fact influenced by beliefs that are traditional in their culture.

Diagnosis

Hypochondriasis is most likely to be diagnosed when one of the doctors consulted by the patient considers the patient's preoccupation with physical symptoms and concerns excessive or problematic. After giving the patient a thorough physical examination to rule out a general medical condition, the doctor will usually give him or her a psychological test that screens for anxiety or depression as well as hypochondriasis. If the results suggest a diagnosis of hypochondriasis, the patient should be referred for psychotherapy . It is important to note, however, that patients with hypochondriasis usually resist the notion that their core problem is psychological. A successful referral to psychotherapy is much more likely if the patient's medical practitioner has been able to relate well to the patient and work gradually toward the notion that psychological problems might be related to fears of physical illness.

Specific approaches that have been found useful by primary care doctors in bringing psychological issues to the patient's attention in nonthreatening ways include the following:

• Whenever possible, the doctor should draw connections between the patient's current physical symptoms and recent setbacks or upsetting incidents in the patient's life. For example, the patient may come in with health worries within a few days of having a problem in other areas of life, such as their car needing repairs, a quarrel with a family member, an overdue bill, etc.
• The doctor may consider asking the patient to keep a careful diary of his or her symptoms and other occurrences. This diary may be useful in guiding the patient to see patterns in his or her worries about health.
• The doctor may want to schedule the patient for regular but short appointments. It is also better to see the patient briefly than to prescribe medications in place of an appointment, because many patients with hypochondriasis abuse medications.
• Another approach is to conduct routine screening tests during a yearly physical for patients with hypochondriasis, while discouraging them from scheduling extra appointments each time they notice a minor physical problem.
• The doctor should maintain a realistic but optimistic tone in his or her conversation with the patient. He or she may wish to talk to the patient about health-related fears and clarify the differences between normal internal body sensations and serious symptoms.

In order to receive a DSM-IV-TR diagnosis of hypochondriasis, a person must meet all six of the following criteria:

• The person must be preoccupied with the notion or fear of having a serious disease. This preoccupation is based on misinterpretation of physical symptoms or sensations.
• Appropriate medical evaluation and reassurance that there is no illness present do not eliminate the preoccupation.
• The belief or fear of illness must not be of delusional intensity. Delusional health fears are more likely to be bizarre in nature— for instance, the belief that one's skin emits a foul odor or that food is rotting in one's intestines. The preoccupations must not be limited to a concern about appearance; excessive concerns that focus solely on defects in appearance would receive a diagnosis of body dysmorphic disorder.
• The preoccupation must have lasted for at least six months.
• The person's preoccupation with illness must not simply be part of the presentation of another disorder, including generalized anxiety disorder , obsessive-compulsive disorder, panic disorder, separation anxiety, major depressive episode, or another somatoform disorder.

DSM-IV-TR also differentiates between hypochondriasis with and without poor insight. Poor insight is specified when the patient does not recognize that his or her concerns are excessive or unreasonable.

Treatments

Traditionally, hypochondriasis has been considered difficult to treat. In the last few years, however, cognitive and behavioral treatments have demonstrated effectiveness in reducing the symptoms of the disorder.

Cognitive therapy

The goal of cognitive therapy for hypochondriasis is to guide patients to the recognition that their chief problem is fear of illness, rather than vulnerability to illness. Patients are asked to monitor worries and to evaluate how realistic and reasonable they are. Therapists encourage patients to consider alternative explanations for the physical signs they normally interpret as disease symptoms. Behavioral experiments are also employed in an effort to change the patient's habitual thoughts. For instance, a patient may be told to focus intently on a specific physical sensation and monitor increases in anxiety. Another behavioral assignment might ask the patient to suppress urges to talk about health-related worries with family members, then observe their anxiety level. Most people with hypochondriasis believe that their anxiety will escalate until they release it by seeking reassurance from others. In fact, anxiety usually crests and subsides in a matter of minutes. Cognitive therapy effectively reduces many symptoms of the disorder, and many improvements persist up to a year after treatment ends.

BEHAVIORAL STRESS MANAGEMENT. One study by Clark and colleagues compared cognitive therapy to behavioral stress management. This second form of therapy focuses on the notion that stress contributes to excessive worry about health. Patients were asked to identify stressors in their lives and taught stress management techniques to help them cope with these stressors. The researchers taught the patients relaxation techniques and problem-solving skills, and the patients practiced these techniques in and out of sessions. Although this treatment did not focus directly on hypochondriacal worries, it was helpful in reducing symptoms. At the end of the study, behavioral stress management appeared to be less effective than cognitive therapy in treating hypochondriasis, but a follow-up a year later found that the results of two therapies were comparable.

EXPOSURE AND RESPONSE PREVENTION. This therapy begins by asking patients to make a list of their hypochondriacal behaviors, such as checking body sensations, seeking reassurance from physicians or friends, and avoiding reminders of illness. Behavioral assignments are then developed. Patients who frequently monitor their physical sensations or seek reassurance are asked not to do so, and to allow themselves to experience the anxiety that accompanies suppression of these behaviors. Patients practice exposing themselves to anxiety until it becomes manageable, gradually reducing hypochondriacal behaviors in the process. In a study comparing exposure and response prevention to cognitive therapy, both therapies produced clinically significant results. Although cognitive therapy focuses more on thoughts and exposure therapy more on behaviors, both appear to be effective in reducing both dysfunctional thoughts and behaviors.

Prognosis

Untreated hypochondriasis tends to be a chronic disorder, although the intensity of the patient's symptoms may vary over time. DSM-IV-TR notes that the following factors are associated with a better prognosis: the symptoms develop quickly; are relatively mild; are associated with an actual medical condition; and are not associated with comorbid psychopathology or benefits derived from being ill.

Prevention

Hypochondriasis may be difficult to prevent in a health-conscious society, in which people are constantly exposed to messages reminding them to seek regular medical screenings for a variety of illnesses, and telling them in detail about the illnesses of celebrities and high-ranking political figures. Trendy new diagnostic techniques like full-body MRIs may encourage people with hypochondriasis to seek unnecessary and expensive medical consultations. Referring patients with suspected hypochondriasis to psychotherapy may also help to reduce their overuse of medical services.

See also Exposure treatment; Cognitive-behavioral therapy

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th edition, text revised. Washington, DC: American Psychiatric Association, 2000.

Botella, Cristina, and Pilar Martinez Narvaez. "Cognitive behavioural treatment for hypochondriasis." In International Handbook of Cognitive and Behavioural Treatments for Psychological Disorders, edited by V. E. Caballo. Oxford, UK: Pergamon, 1998.

Pilowsky, Issy. Abnormal Illness Behavior. Chichester, UK: John Wiley and Sons, 1997.

PERIODICALS

Barsky, Arthur J., David K. Ahern, E. Duff Bailey, Ralph Saintfort, Elizabeth B. Liu, and Heli M. Peekna. "Hypochondriacal patients' appraisal of health and physical risks." American Journal of Psychiatry 158, no. 5 (2001): 783-787.

Clark, D. M., P. M. Salkovskis, A. Hackman, A. Wells, M. Fennell, J. Ludgate, S. Ahmad, H. C. Richards, and M. Gelder. "Two psychological treatments for hypochondriasis: A randomized controlled trial." British Journal of Psychiatry 173 (1998): 218-225.

Looper, Karl J. and Laurence J. Kirmayer. "Hypochondriacal concerns in a community population." Psychological Medicine 31 (2001): 577-584.

Neziroglu, Fugen, Dean McKay, and Jose A. Yaryura-Tobias. "Overlapping and distinctive features of hypochondriasis and obsessive-compulsive disorder." Journal of Anxiety Disorders 14, no. 6 (2000): 603-614.

Visser, Sako and Theo K. Bouman. "The treatment of hypochondriasis: Exposure plus response prevention vs cognitive therapy." Behaviour Research and Therapy 39 (2001): 423-442.

Danielle Barry, M.S.

HYPOCHONDRIA

Hypochondria is a psychopathological formation whose locus of suffering, anxiety, or even (fantasized) erasure is the body or one of its parts or functions, even though the symptoms in most cases appear to have no material cause. Symptoms can range from minor, transient forms to massive, debilitating forms. Despite some strong lines of evidence pointing toward a link with various specific structural organizations of the psyche, hypochondria is currently seen as transnosographic, as present as an element in a neuropsychosis or preceding certain psychoses.

For centuries, hypochondria has challenged medicine, philosophy, and even religion. Some ancient lines of inquiry are echoed by modern investigations, notably on the enigmatic link between psyche and soma and on similarities between hypochondria and melancholia. The absence of any material organic cause has elicited a variety of hypotheses from psychoanalysts, including accounts of pathogenicity that extend to delusions in the subject.

Has the enigma of hypochondria been fully deciphered by contemporary psychoanalysis? Freud acknowledged this poorly understood disorder as an awkward gap in his theories. Later it was deemed surprising that hypochondriacs had been the object of so little psychoanalytic research, but in the 1990s there were a number of studies on the topic. One reason that psychoanalysis has paid little attention to hypochondria is that the autocratic attitude of hypochondriacs has made analysts unreceptive to types of transference unconducive to analytic listening. However, a broadening of treatment indications seems to have made psychoanalysis more receptive to hypochondriacs, and this has allowed psychoanalysis to draw conclusions from them that go beyond Freud's hypotheses. It is also true that hypochondriacal behavior can emerge in the course of any treatment, as a displacement or means of discharge when the patient's psyche is placed under stress.

Freud encountered hypochondria early on in his work. On the basis of the semantics and nosology of his era as well as his own theories, he placed hypochondria among the pure forms of "actual neurosis," alongside neurasthenia and anxiety neurosis, and thus outside of the realm of the defensive neuropsychoses. His description of the actual neuroses contains the same elements as hypochondria: the patient's representational contents have a basis in current reality and not in what has been repressed into the unconscious; the patient's meaningful contents or unconscious overdeterminations capable of being symbolized do not indicate an internal conflict with current reality.

In "On Narcissism: An Introduction" (1914c), Freud revised his account of hypochondria in light of his theory that the libido is divided into the object-libido and the (narcissistic) ego-libido. He placed (bodily) ego-libido, the realm of hypochondriacal anxiety, in opposition to object libido, the realm of neurotic anxiety. As a function of this opposition, the more one realm absorbs, the more the other is impoverished. Therefore, the idea of excessive, dammed-up narcissistic libido is essential to understanding hypochondria. The chosen organ of hypochondria, which has strong erotogenic potential, is nevertheless a source of unpleasure, suffering, and anxiety owing to this increase in tension, this damming up of libido. Many authors have viewed this account, a schematic model of dynamic energies, as problematic and fraught with questions.

During the same period, Freud tried to understand the possible relationship between hypochondria and paraphrenia. In "On Narcissism: An Introduction" (1914c) he wrote, "We may suspect that the relation of hypochondria to paraphrenia is similar to that of the other 'actual' neuroses to hysteria and obsessional neurosis: we may suspect, that is, that it is dependent on ego-libido just as the others are on object-libido, and that hypochondriacal anxiety is the counterpart, as coming from ego-libido, to neurotic anxiety" (p. 84). In this perspective he viewed hypochondria as the first stage in delusion and linked it to narcissistic pathologies affecting the body. Three years earlier he wondered about the connections between hypochondria and paranoia. For example, in "Psycho-Analytic Notes on an Autobiographical Account of a Case of Paranoia (Dementia Paranoides )" (1911c [1910]), his text on Daniel Paul Schreber, he wrote, "I shall not consider any theory of paranoia trustworthy unless it also covers the hypochondriacal symptoms by which that disorder is almost invariable accompanied" (pp. 56-57, n. 3). Freud thus viewed hypochondria as a precursor to psychosis and sometimes as an independent condition.

Some authors have interpreted hypochondria in terms of true projections that are no longer directed outward but instead are directed at the body, like an internal paranoia. In his subsequent writings Freud did not return to the comparison with melancholia, nor did he reexamine his hypotheses in light of his second theory of the instincts or in terms of the concept of primary masochism, as later authors did, thereby somewhat undermining Freud's classification of hypochondria as an actual neurosis.

Many others, notably followers of Melanie Klein, have emphasized the close relationship between hypochondria and melancholic depression. Others have inferred a masochistic dimension or a "locked-up" autoerotism. In the view of still others, the "hypochondriacal solution," despite its fragile and largely unstructured nature and despite being pregnant with the death instinct, is the subject's last bastion against madness.

Alain Fine

See also: Actual neurosis/defense neurosis; Body image; Eroticism, anal; Erotogenic zone; Erotogenicity; "On Narcissism: An Introduction"; "Neurasthenia and Anxiety Neurosis"; Organ pleasure; Persecution; Psychoanalytical nosography.

Bibliography

Aisenstein, Marilia; Fine, Alain; & Pragier, Georges (Eds.). (1995). L'hypocondrie. Paris: Presses universitaires de France.

Freud, Sigmund. (1898a). Sexuality in the aetiology of the neuroses. SE, 3: 259-285.

——. (1911c [1910]). Psycho-analytic notes on an autobiographical account of a case of paranoia (dementia paranoides ). SE, 12: 1-82.

——. (1914c). On narcissism: An introduction. SE, 14: 67-102.

Jeanneau, Augustin. (1990). L'hypocondrie, ou La mentalisation de l'impossible. Cahiers du Centre pour la psychanalyse et la psychothérapie, 21, 83-99.

Perrier, François. (1994). Psychanalyse de l'hypocondriaque. In Jacques Sédat (Ed.), La Chaussée d'Antin (rev. ed.). Paris: Albin Michel. (Originally published 1959)

Further Reading

Rosenfeld, Herbert. (1958). Observations on the psycho-pathology of hypochondriacal states. International Journal of Psychoanalysis, 39, 121-124.

Stolorow, Robert D. (1977). Notes on the signal function of hypochondriacal anxiety. International Journal of Psychoanalysis, 58, 245-246.

Hypochondria

More Than a Temporary Worry

When Medical Reassurance Does Not Help

What Causes Hypochondria?

How Is Hypochondria Diagnosed and Treated?

Hypochondria (hy-po-KON-dree-a) is a mental disorder in which people believe or fear that they have a serious disease even though medical examination or tests show no sign of illness.

Keywords

for searching the Internet and other reference sources

Anxiety

Factitious disorder

Hypochondriosis

Mental disorders

Psychosomatic

More Than a Temporary Worry

Everyone has probably worried about their health from time to time. For example, a symptom such as chest pain can have many causes and is usually not serious. But if anyone experiencing this symptom has just read a newspaper article about someone who has had a heart attack*, they might worry that they are about to have one too. This temporary concern is not an example of hypochondria. With true hypochondria the worry is more lasting, and it interferes with one’s daily life.

* heart attack

is an injury to the heart muscle that occurs when blood flow is interrupted, cutting off the supply of oxygen to the heart.

The prevalence of hypochondria among the general public is unknown, but studies have indicated that it accounts for between 4 and 9 percent of visits to doctors. Hypochondria occurs in all age groups and cultures and is about equally prevalent among males and females.

When Medical Reassurance Does Not Help

People with hypochondria may be overly concerned with a variety of symptoms and even with their normal bodily functions. Minor aches and pains, occasional coughing, dizziness, nausea, or small sores can convince people with hypochondria that they are seriously ill. They may also closely monitor normal bodily functions, such as heartbeat, breathing, sweating, and intestinal function, for signs of disease. The health worries of someone with hypochondria may be focused on a particular body organ, such as the heart, or on several parts of the body.

An important characteristic of people with hypochondria is that they are not fully reassured after a medical examination and tests have shown no physical basis for their complaints. Although their fears may be temporarily relieved, the belief that they are ill may still be so strong that they go from one physician to another seeking new tests and treatments.

What Causes Hypochondria?

Why is it that some people are constantly worried about being sick? The cause or causes of hypochondria are not clearly understood, and experts have varying views.

One theory is that people who have hypochondria are excessively sensitive to their bodily sensations and may misinterpret their meaning. In some cases, hypochondria appears to be triggered by the death of a loved one. Researchers have also noted that hypochondria seems to be more common in people who were seriously ill as a child or who have spent a lot of time around sick relatives. Such past experiences may contribute to health worries.

Hypochondria may be one symptom of another mental disorder, such as depression* or anxiety*. For example, in some cases of obsessive-compulsive disorder*, a person may have extreme unfounded health worries and feel compelled to keep seeking reassurance from health professionals.

* depression

(de-PRESH-un) is a mental state characterized by feelings of sadness, despair, and discouragement.

* anxiety

can be experienced as a troubled feeling, a sense of dread, fear of the future, or distress over a possible threat to a person’s physical or mental well-being.

* obsessive-compulsive disorder

causes people to feel trapped by distressing thoughts or to feel as if they have to repeat actions, such as washing hands.

How Is Hypochondria Diagnosed and Treated?

The first step in diagnosing hypochondria is a thorough physical examination to make sure there is no medical disease or condition causing the patient’s complaints. When the patient has been reassured that he or she is not ill, yet the intense health worries continue, the diagnosis of hypochondria may be made. The physician will need to take care not to confuse hypochondria with malingering*, or with such closely related mental conditions as conversion disorder* and Munchausen syndrome*.

* malingering

(ma-LING-er-ing) means intentionally pretending to be sick or injured to avoid work or responsibility.

* conversion disorder

is a mental disorder in which psychological symptoms are converted to physical symptoms, such as blindness, paralysis, or seizures. A person with conversion disorder does not intentionally produce symptoms.

* Munchausen syndrome

(MOON-chow-zen SIN-drome) is a mental disorder in which a person pretends to have symptoms or causes symptoms of a disease in order to be hospitalized or receive tests, medication, or surgery.

Hypochondria can be difficult to treat because the beliefs about illness are usually very strong. Although reassurance that the person is in good health is necessary, it is likely to be helpful only for a short time. Psychotherapy can help a person to make gradual changes in the way they think about their bodily sensations and to cope with health anxiety. When hypochondria is a symptom of depression, anxiety, or obsessive-compulsive disorder, treatment focuses on the underlying disorder.

See also

Anxiety and Anxiety Disorders

Conversion Disorder

Depression

Malingering

Munchausen Syndrome

Obsessive-Compulsive Disorder

Somatoform Disorders

Hypochondriasis

Definition

Hypochondriasis is a mental disorder characterized by excessive fear of or preoccupation with a serious illness, despite medical testing and reassurance to the contrary. It was formerly called hypochondriacal neurosis.

Description

Although hypochondriasis is often considered a disorder that primarily affects adults, it is now increasingly recognized in children and adolescents. In addition, hypochondriasis may develop in elderly people without previous histories of health-related fears. The disorder accounts for about 5% of psychiatric patients and is equally common in men and women.

Causes and symptoms

The causes of hypochondriasis are not precisely known. Children may have physical symptoms that resemble or mimic those of other family members. In adults, hypochondriasis may sometimes reflect a self-centered character structure or a wish to be taken care of by others; it may also have been copied from a parent's behavior. In elderly people, hypochondriasis may be associated with depression or grief. It may also involve biologically based hypersensitivity to internal stimuli.

Most hypochondriacs are worried about being physically sick, although some express fear of insanity. The symptoms reported can range from general descriptions of a specific illness to unusual complaints. In many instances the symptoms reflect intensified awareness of ordinary body functions, such as heartbeat, breathing, or stomach noises. It is important to understand that a hypochondriac's symptoms are not "in the head" in the sense of being delusional. The symptoms are real, but the patient misinterprets bodily functions and attributes them to a serious or even lethal cause.

Diagnosis

The diagnosis is often complicated by the patient's detailed understanding of symptoms and medical terminology from previous contacts with doctors. If a new doctor suspects hypochondriasis, he or she will usually order a complete medical workup in order to rule out physical disease.

Psychological evaluation is also necessary to rule out other disorders that involve feelings of anxiety or complaints of physical illness. These disorders include depression, panic disorder, and schizophrenia with somatic (physical) delusions. The following features are characteristic of hypochondriasis:

• The patient is not psychotic (out of touch with reality or hallucinating).
• The patient gets upset or blames the doctor when told there is "nothing wrong," or that there is a psychological basis for the problem.
• There is a correlation between episodes of hypochondriacal behavior and stressful periods in the patient's life.
• The behavior has lasted at least six months.

Evaluation of children and adolescents with hypochondriasis should include the possibility of abuse by family members.

Treatment

The goal of therapy is to help the patient (and family) live with the symptoms and to modify thinking and behavior that reinforces hypochondriacal symptoms. This treatment orientation is called supportive, as distinct from insight-oriented, because hypochondriacs usually resist psychological interpretations of their symptoms. Supportive treatment may include medications to relieve anxiety. Some clinicians look carefully for "masked" depression and treat with antidepressants.

Follow-up care includes regular physical check-ups, because about 30% of patients with hypochondriasis will eventually develop a serious physical illness. The physician also tries to prevent unnecessary medical testing and "doctor shopping" on the patient's part.

Prognosis

From 33-50% of patients with hypochondriasis can expect significant improvement from the current methods of treatment.

Resources

BOOKS

Eisendrath, Stuart J. "Psychiatric Disorders." In Current Medical Diagnosis and Treatment, 1998, edited by Stephen McPhee, et al., 37th ed. Stamford: Appleton & Lange, 1997.

KEY TERMS

Somatoform disorder— A category of psychiatric disorder characterized by conversion of emotional distress into physical symptoms or by symptoms of physical illness that have no discernible organic cause. Hypochondriasis is classified as a somatoform disorder.

Supportive therapy— Any form of treatment intended to relieve symptoms or help the patient live with them rather than attempt changes in character structure.