AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

INTRODUCTION

Section 2 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Background

Hypochondriasis and the other somatoform disorders 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, diagnostic criteria have been revised to facilitate clinical care and research. Long-awaited randomized, placebo-controlled treatment approaches have finally emerged.

As with all psychiatric disorders, the somatoform disorders demand creative, rich biopsychosocial treatment planning by a team that includes primary care physicians, subspecialists, and mental health professionals.

This article describes hypochondriasis, 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.

Pathophysiology

Neurochemical deficits associated with hypochondriasis and some other somatoform disorders (eg, somatization, conversion, and body dysmorphic disorders) appear similar to those of mood and anxiety disorders. For example, Hollander et al posited an "obsessive-compulsive spectrum" to include obsessive-compulsive disorder (OCD), body dysmorphic disorder (BDD), anorexia nervosa, Tourette syndrome, and impulse control disorders (eg, trichotillomania, pathological gambling).¹

This formulation of obsessive-compulsive (OC) spectrum disorders, while not a part of the consensus psychiatric diagnostic and classification literature, crosses boundaries of several diagnostic categories in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition-Text Revision (DSM-IV-TR). In addition, encountering a patient with more than one of the anxiety spectrum disorders during his or her life is not unusual. Although findings of studies of these neurochemical deficits are only preliminary, such deficits may explain why symptoms overlap, why the disorders are commonly comorbid, and why effective treatments parallel one another (eg, selective serotonin reuptake inhibitors [SSRIs]).

Frequency

United States

The prevalence rates for primary hypochondriasis in the primary care setting are 0.8-4.5%.² 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.³

International

International rates are similar to those in the United States.⁴

Mortality/Morbidity

Hypochondriasis is usually episodic, with hypochondriacal 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 hypochondriasis 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 lacking, but patients with hypochondriasis appear similar to those with somatization disorder. 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.⁵

Cognitive, social learning, and psychodynamic theories imply that patients have significant psychosocial disturbances in terms of relationship, vocational, 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.⁶ The medically unexplained complaint is often a symptom of hypochondriasis⁷ and may well be a presentation of associated abnormal illness behavior⁸.

Patients with hypochondriasis have a high rate of psychiatric comorbidity.⁹ 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.⁹ 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.

Race

This disorder has not been well studied with respect to race and ethnicity. More information is needed, too, with regard to its relationship to other medical disorders needing better definition (eg, neurasthenia, chronic fatigue syndrome, fibromyalgia, and multiple chemical sensitivity syndrome).

Sex

Hypochondriasis 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.

CLINICAL

Section 3 of 11  

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• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

History

Hypochondriasis is classified as one of the somatoform disorders, a class that was formulated to accommodate the differential diagnosis of disorders characterized primarily by physical symptoms for which no demonstrable organic findings exist. The DSM-IV-TR stipulates that the symptoms are not under voluntary control (thus excluding malingering and factitious disorders) and are not fully explained by known physiological causes (excluding psychological factors affecting the medical condition). The disorders in the somatoform class include somatization disorder, conversion disorder, pain disorder, hypochondriasis, BDD, and undifferentiated somatoform disorder.

• The core feature of hypochondriasis is not preoccupation with symptoms themselves, but rather the fear or idea of having a serious disease (see Image 1). The fear or idea is based on the misinterpretation of bodily signs and sensations as evidence of disease. The illness persists despite appropriate medical evaluations and reassurance.
• The diagnosis should be considered strongly if the patient has a history of hypochondriasis (or other somatization disorder) or has had multiple nonproductive clinical workups, and if the patient's complaints are markedly inconsistent with objective findings or the examination yields no abnormal findings. Further psychiatric history should be obtained with regard to a history of hypochondriasis (or corresponding behaviors) in family members or a sudden, unexplained loss of function that spontaneously resolved.
• Diagnostic criteria for hypochondriasis include the following (DSM-IV-TR):
• • The patient has a preoccupying fear of having a serious disease.
  • The preoccupation persists despite appropriate medical evaluation and reassurance.
  • The belief is not of delusional intensity (as in delusional disorder, somatic type) and is not restricted to a concern about appearance (as in persons with BDD).
  • The preoccupation causes clinically significant distress or impairment.
  • The preoccupation lasts for at least 6 months.
  • The preoccupation is not explained better by another mood, anxiety, or somatoform disorder.

Physical

The absence of physical findings, particularly after serial examinations, supports the diagnosis of hypochondriasis. 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
• • 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
• • Restlessness
  • Frequent shifts in posture
  • Agitation
  • Slowed, if sleeping poorly
• Mood (the pervasive and sustained emotion that colors the patient's perception of the world) and affect (what the examiner observes)
• • Anxious or worried, depressed, or futile mood
  • Restricted, shallow, fearful, or anxious affect, with fluctuations and limited depth
• Thought process
• • Spontaneous speaking with occasional abrupt changes in topic within an underlying theme
  • 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
• • Preoccupation with being ill
  • Anxious themes concerning what in the body is wrong, how it is wrong, and how it is experienced
  • May have guilt, which is not usually linked to the preoccupations
  • 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 suicidal ideation, unless concurrently depressed
  • No homicidal ideation
• Cognitive function
• • 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
• • 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
• • 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 (see Image 2) 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.¹⁰ Overall however, few demographic and clinical differences have been found between patients with hypochondriasis and the general population. Social position, education level, and marital status do not appear to be factors in this condition.

• 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 hypochondriasis 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 hypochondriasis to exaggerate their assessment of vulnerability to disease and their appraisal of the risk of serious illness.⁶
• The social learning theory frames hypochondriasis 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.¹¹
• The psychodynamic theory implies that aggressive and hostile wishes toward others are transferred via repression and displacement into physical complaints. The hypochondriacal symptoms serve to "undo" guilt felt about the anger and serve as a punishment for being "bad."
• Neurochemical deficits with hypochondriasis 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). 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).

DIFFERENTIALS

Section 4 of 11  

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• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Other Problems to be Considered

Physical disease must be excluded, which involves evaluation for an extensive number of neurological (eg, myasthenia gravis, multiple sclerosis), endocrinological, and other systemic diseases. The psychiatric differential diagnosis for hypochondriasis includes other somatoform, mood, anxiety, and psychotic disorders.

Somatization disorder

This disorder is characterized by early onset (<30 y) and recurrent, multiple, physical complaints that result in medical attention or significant impairment. Somatization disorder is best thought of as preoccupation with numerous and/or sequential symptoms, not an underlying explanatory illness.

The symptoms must meet a specific pattern to be classified as a somatization disorder, including 4 different sites of pain, 2 different gastrointestinal symptoms, 1 sexual or reproductive symptom other than pain, and 1 neurologic symptom. Somatization disorder is distinguished from physical illness by the involvement of multiple organ systems and a prolonged course without the development of findings consistent with somatic illness.

Onset of somatization disorder may be earlier than that of hypochondriasis (eg, <15 y in >50% of cases). Females have a higher lifetime risk of developing somatization disorder, at 2-3%, and the female-to-male ratio is 10:1.¹² What differentiates somatization disorder is the patient's focus on symptoms rather than a preoccupation with illness and the accompanying worry.

Somatoform pain disorder

Patients with pain disorder focus on pain rather than illness more broadly. The 2 types of pain disorders are with (1) psychological factors alone and (2) psychological factors that exacerbate an associated general medical condition. However, pain disorders may have more in common with hypochondriasis than is apparent at first glance because activity induced in the nociceptor and nociceptive pathways may be activated by a psychological state, physical state, or both in combination. Diagnostic criteria include pain in one or more anatomical sites. The pain causes clinically significant distress or impairment. Psychological factors have an important role in the onset, severity, exacerbation, or maintenance of the pain.

Conversion disorder

This disorder is characterized by a symptom that indicates a deficit of voluntary motor or sensory function (other than pain) and is not explained by a neurological or other general medical condition, the effects of a substance, or a culturally sanctioned experience. These patients do not have a general sense of being ill or concerns about serious disease indicated by pseudoneurological symptoms and, indeed, may 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.^{13, 14}

Body dysmorphic disorder

The essential feature of BDD is a preoccupation with some imagined defect in appearance or a markedly excessive concern with a minor physical anomaly. 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.¹⁵ Concerns of patients with BDD, unlike those of patients with hypochondriasis, 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 hypochondriacal 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 hypochondriasis 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).

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 hypochondriasis, who is convinced of his or her concerns but is able to consider the possibility that the specific feared disease is not present. Monosymptomatic hypochondriasis is a term that was previously used to indicate concerns about parasitosis, or the delusions of infestation by parasitic organisms. Now these patients are generally thought to have delusions (ie, diagnosed formally as DSM-IV-TR delusional disorder, somatic type).

Personality disorders

Some personality disorders/styles overlap with hypochondriasis.⁹ Characteristics of patients with hypochondriasis include anxiousness, conscientiousness, dependence, narcissism, and avoidance.¹⁶

Secondary hypochondriasis

Hypochondriasis in the context of another Axis I disorder, a major life stress, or a medical disorder has been described,⁹ but this description is not recognized in the DSM-IV-TR.

Undifferentiated somatoform disorder

This is characterized by the presence of one or more clinically significant, medically unexplained somatic symptom or symptoms lasting for 6 months or longer. Proposed alternative terms for this disorder include subsyndromal, forme fruste, or abridged somatization disorder. Some patients meet the criteria for somatization disorder on follow-up evaluation.

As discussed earlier, depressive, anxiety, or personality disorders are highly comorbid as secondary consequences of hypochondriasis. Therefore, rather than excluding hypochondriasis when the comorbid disorder is discovered, both disorders should likely be treated concurrently. Evidence to recommend sequential versus concurrent treatment is insufficient. Clinically, the most prominent and disturbing symptoms should be addressed first.

Special Populations

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.¹⁷ 

Hypochondriasis, 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.¹⁷ 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).¹⁹ As adult, 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.²⁰ 

Several factors may increase the risk for hypochondriacal 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.²¹ Interestingly, childhood memory about health may contribute to the development of hypochondriasis, though these children may not distinguish between memories about their own health and the health of a friend or stranger.²² As children develop a better ability to communicate and more awareness of their emotions, the expression of emotion through somatic symptoms lessens. 

WORKUP

Section 5 of 11  

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• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Lab Studies

• In patients with hypochondriasis, the abnormal laboratory findings characteristic of the suggested physical disorder are absent.

Other Tests

Screening tools

• 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.¹⁸
• The Illness Attitude Scale (29 items, 15 min, English only) is used for detection and to assess severity.²⁵
• The Whitely Index of Hypochondriasis (14 items, 5 min, >14 languages) is used for detection, for rating severity, and for measuring change per interventions.²⁶
• The Somatoform Disorders Symptom Checklist (65 yes-or-no items, 20 min, >5 languages) screens for hypochondriasis, somatization disorder, BDD, and others.²⁷

TREATMENT

Section 6 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Medical Care

• Basic management principles
• • 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 Image 1).
  • 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.
• Numerous other strategies appear to benefit patients with hypochondriasis (see Image 3). These strategies may prevent potentially serious complications, including the effects of unnecessary diagnostic and therapeutic procedures.
• • 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, 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 pain 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.”
  • Explain to the patient that he or she is not crazy and that symptoms are not just "in his or her head."
  • Understand the symptoms as a form of emotional communication.
  • Reassure the patient that evaluation will be ongoing.
  • Search for underlying medical and psychiatric disorders potentially amenable to treatment.
  • Use good judgment when deciding whether to perform elaborate diagnostic evaluations.
  • Seek consultation or refer the patient to a colleague if establishing an alliance proves difficult.
  • Set up regularly scheduled visits approximately every 4-8 weeks and gradually taper visits when the patient is less symptomatic.
  • 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 and disorder, not on a cure for the disorder.
  • Frequent regularly scheduled visits, attentive but “focal” physical examinations, and benign remedies (eg, bandages, lotions, vitamins, heating pads, massage, slings, and vitamins) help to provide tangible evidence of the physician’s interest and acknowledge the patient's suffering.
• Psychotherapy
• • Several authors have suggested a cognitive-educational approach to understand the development of the severe anxiety associated with hypochondriasis (see Image 3) and the factors that maintain the long-term anxiety (see Image 4). Randomized controlled trials now suggest that cognitive-behavioral therapy (CBT) is efficacious in the treatment of hypochondriasis^{28, 29, 30}  and may be the recommended treatment for patients with hypochondriasis.
  • Treatments target selective attention³¹, compatibility between distressing physical symptoms and physical health and longevity³², the cycle involving fear and autonomic overactivity³¹, and explanations for symptoms and fears³².
  • In a corollary vein, controlled studies of patients with noncardiac chest pain show that patients who accept psychological factors as the major cause of their symptoms report a significant decrease in pain.^{33, 34}
  • In one study, 74% of patients being treated for hypochondriasis indicated psychological therapy would be their first choice for treatment, versus 4% who indicated that medication would be their first choice.³⁵
  • Exposure and response prevention and cognitive therapy have been shown to be equally valuable in the treatment of patients with hypochondriasis.²⁹
  • In general, patients with hypochondriasis who show little response to cognitive-behavioral therapy interventions have a higher level of preexisting hypochondriasis, more somatic symptoms, more general psychopathology, and greater psychosocial impairment.³⁶
  • Group therapy interventions have gained prominence in recent years, including a cognitive-educational approach.³⁷ Positive results have also been shown for community and group therapy interventions.^{38, 39}
  • Psychoeducational approaches provide accurate information (ie, somatic symptoms are exceedingly common, with only a small proportion caused by disease and most compatible with physical health). They also explain that selective attention to one part of the body makes a person more aware of sensation in that part than in other parts (eg, paying attention to vague chest pain while ignoring a badly sprained ankle). Accurate information about the relationship of a threatening stimulus and its somatic consequences can influence the severity of autonomic responses, subjective distress, and behavior. Group psychoeducation has demonstrated short- and long-term (follow-up at 6 mo) improvement.³⁸
  • Psychotherapy can counter maladaptive iatrogenic beliefs. Evidence indicates that patients frequently either forget information or distort it. Giving a small amount of information at one time and repeating it appears best.
  • Complex developmental, environmental (eg, medical care, family, social network supports, work/disability, sociopolitical, institutional), and cultural factors also influence hypochondriasis (see Image 2). Individual, group, and family psychotherapeutic modalities are uniquely qualified to address these factors.
  • Individual CBT has been compared to paroxetine and placebo in a recent randomized trial of 112 patients.⁴⁰
  • A number of other psychotherapy methods have been used to treat hypochondriasis. In one study, psychoanalytic psychotherapy achieved satisfactory results for only 4 of 23 patients. Psychodynamically oriented therapies may be less desirable in the treatment of hypochondriasis.
  • Behavioral treatments emphasizing exposure, based on the belief that hypochondriasis is a disease phobia, have been examined. Uncontrolled trials suggest that these strategies help a substantial portion of patients. Persuasion techniques, similar to psychoeducation, have been used to convince patients that symptoms are not due to medical illness.
  • For patients who do not respond to psychotherapy, some authors have advocated more intensive treatments in specialized inpatient units, including those aimed at changing the patient's habits, motives, and goals.
  • In a survey of patients with hypochondriasis, psychological treatment (ie, cognitive-behavioral treatment) was preferred as the first choice by 74% of respondents, medication was preferred by 4%, and an equal preference for both was indicated by 22%. Of respondents, 48% said they would only accept psychological treatment.³⁵
• Pharmacotherapy
• • Off-label usage is being studied for primary hypochondriasis. Initial case reports reported positive effects from fluoxetine, clomipramine, fluvoxamine, and imipramine. More recently, additional reports have cited positive effects for fluvoxamine (originally approved for OCD), nefazodone (now off the market), and paroxetine.
  • A recent 16-week, randomized, placebo-controlled trial compared CBT, paroxetine, and placebo in 112 patients. In the completer analysis, paroxetine (average dose 40 mg/d) performed better than placebo and was not statistically significant compared to CBT, based on the Whiteley Index scores. The responders in the completer group were paroxetine, 38%; CBT, 54%; and placebo, 12%. The responders in the intention-to-treat analysis (ITT) were paroxetine, 30%; CBT, 50%; and placebo, 14%. Overall, both CBT and paroxetine performed better than placebo. About 75% of this cohort of patients had a comorbid depressive, anxiety, or another somatoform disorder. ⁴⁰
• In a 12-week double-blind, placebo-controlled trial of fluoxetine in 20 patients, of the 12 patients treated with fluoxetine, 8 responded, compared with 4 of 8 patients on placebo.⁴¹
• Consistent with findings from studies in subjects with OCD or BDD, studies in subjects with hypochondriasis indicate that an adequate trial of medication is 3 months before concluding that it is ineffective; moreover, combination pharmacotherapy may be more effective than monotherapy.⁴²
• Pharmacotherapy has also been directed at anxiety or depression coexisting with hypochondriasis. In controlled trials, benzodiazepines, imipramine, phenelzine, propranolol, and alprazolam were found to decrease somatic symptoms in anxious patients. However, some of these medications are associated with significantly more adverse effects, and benzodiazepine could potentially be addictive for those with comorbid substance use disorder.
• Treatment of delusional disorder, somatic type (monosymptomatic hypochondriacal psychosis or parasitosis) has been largely successful via pharmacotherapy. If the hypochondriacal fear is of delusional intensity, treatment with haloperidol, pimozide, thioridazine, risperidone, olanzapine, and other antipsychotics may lead to improvement. For parasitosis, 2 double-blinded, placebo-controlled studies revealed that pimozide is superior to placebo.⁴³
• Open trials have suggested the efficacy of monoamine oxidase inhibitors, tricyclic antidepressants, antipsychotics, and electroconvulsive therapy (ECT).

A survey showed that most patients do not prefer medication treatment. Prematurely prescribing a psychotropic medication to a patient with hypochondriasis could potentially damage the therapeutic relationship. While medication could definitely be helpful, especially in the setting of a comorbid psychiatric disorder, establishing a therapeutic alliance and providing a caring nonjudgmental treatment structure is the foundation to treatment.

• Other interventions
• • Other treatments for hypochondriasis include exercise, ECT, and psychosurgery. 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. Studies show conflicting results about the efficacy of ECT, which appears to be effective only if a comorbid mood disorder exists. Psychosurgery is only recommended for patients with severe and intractable hypochondriasis.
  • A number of psychiatric consultation interventions that have been successful for somatization disorder have yet to be evaluated for hypochondriasis. Efforts have been made to educate primary care physicians on the essentials of psychosocial assessment, interviewing, developing approaches to dealing with patients with a somatoform disorder, or improving referral skills.
  • One randomized controlled trial revealed that referral to a psychiatrist was associated with a 12% reduction in health care costs and no deterioration in physical, mental, or general health. Two controlled studies have shown that consultation with a psychiatrist and an instructive letter to the physician about diagnostic and therapeutic measures resulted in a sharp reduction in health care charges and no change in patient satisfaction.

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

Section 7 of 11  

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• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

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.⁴⁴

Drug Category: Antidepressants

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.

Drug Category: Beta-adrenergic receptor-blocking agents

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.

Drug Category: Benzodiazepines

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.

Drug Category: Antipsychotic medications

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.

Drug Category: Calcium channel blockers

Indicated for angina and hypertension. May have role in reducing mood disturbance (based on use in bipolar disorder) and/or hypochondriacal symptoms (based on pathophysiology)

FOLLOW-UP

Section 8 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

In/Out Patient Meds

• 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