HYPOCHONDRIACAL DISORDER

HYPOCHONDRIACAL DISORDERDr. Manu SharmaChairperson: Dr. Manju BhaskarIntroductionHypochondriasis is a preoccupation with the fear that one has, or may develop, serious disease despite evidence to the contrary.Increase health care utilizationDissatisfaction with care receivedTo their physicians, pts with this disorder are an enigma & a source of frustrationPrimary care physicians have had little interestPsychiatrists see few pts with this condition

HistoryHypochondria was used by Hippocrates to refer to a region below the cartilage of the ribsGalen, 2nd century, linked it to organs in this area as well as humors & animal spiritsAssociated with melancholia, a temperamental disturbance caused by an excess of black bileBurton (1621) described hypochondriacal melancholy in terms of vague physical Sx, disturbances of mood & fearsSyndenham viewed it in men as counterpart of hysteria in women. Modern description by Sims in 1799.By 18th century it became part of a fashionable disturbance attributed to the English way of life (Cheyene)History Falret (1822) first to identify it as a mental disorder, neuroses.Freud viewed it as an actual neurosis with physiological basis, not amenable to psychoanalysisAs reviewed by Murphy(1990), Gillespie(1928) encapsulated a concept of hypochondriasis consistent with the current concepta mental preoccupation with a real or supposititious physical or mental disorderConceptualizationsA personality trait- early onset & long term stabilityA dimension of psychopathology- illness worry as a continuum with hypochondriasis on the severe endA categorical approach- primary or secondary?High rates of comorbidity- independent status?

NosologyDSM-I did not include hypochondriasis as a separate illness.Hypochondriacal preoccupation was mentioned as one of the malignant symptoms observed in psychotic but not reactive depression. DSM-II included hypochondriacal neurosis.In DSM-III, DSM-III-R, and DSM-IV-TR, hypochondriasis is included as one of the somatoform disorders.DSM excludes pts whose Sx are better accounted for by anxiety, depressive or other somatoform disorders.Specific phobia of illness separated from hypochondriasis.Abbrv. DSM-IV-TRPreoccupations with fears of having, or the idea that one has, a serious disease based on misinterpretation of bodily symptomsThe preoccupation persists despite appropriate medical evaluation & reassuranceBelief not of delusional intensityPreoccupation causes significant distress or impairmentDuration of atleast 6 monthsNot better accounted for by other anxiety, depressive or somatoform disordersNosologyICD-10- a persistent belief about having one or more specifically named serious physical diseases.Include body dysmorphic disorder.w.r.t illness behavior, hypochondriacal concerns cause persons to seek medical invstgns/Rx.Pts may accept reassurance in the short-term, but in the long run are unlikely to respond.Nosology issuesThe somatoform disorders category to which hypochondriasis belongs is controversial.They see disorders as ill-defined, of questionable validityA number of studies suggested that of the many patients with hypochondriacal complaints few meet criteria for the full diagnosis (Barsky et al. 1993 )Based more on illness behavior than on distinctive featuresView them as creations of western biomedicine that serve to devalue pts who challenge the theoretical model upon which it is based (Rief,2004)Proposals to move hypochondriasis to anxiety disorders (health anxiety) or to OC spectrum disordersEpidemiologyPrevalence in gen population: 1-5%.Affects btw 2-7% of pts attending general medical clinics.(DSM IV TR)Most prevalence research related to hypochondriasis has been conducted in some type of medical or psychiatric setting and results have been inconclusive (cf. Iezzi & Adams,1993). Research has been impeded by the use of different definitions of hypochondriasis.Kenyon (1976) used a strict definition and determined that 314% of patients in a medical setting were hypochondriacal. many patients manifest some hypochondriacal symptomsas part of other psychiatric disorders, and others have transienthypochondriacal symptoms in response to stressessuch as serious physical illness yet never fulfill the inclusioncriteria for DSM-IV-TR hypochondriasis.10EpidemiologyAs reviewed by Kellner ( 1991 ), 1020% of normal and 45% of neurotic persons have intermittent unfounded worries about illness, with 9% of patients doubting reassurances given by physicians. In another review, Kellner ( 1985 ) estimated that 50% of all patients attending physicians offices suffer either primary hypochondriacal symptoms or have minor somatic disorders with hypochondriacal overlay.

How these relate to hypochondriasis as a disorder is difficult to assess because these estimates do not appear to distinguish between a focus on the symptoms themselves (as in somatization disorder) and preoccupation with the implications of the symptoms (as in hypochondriasis).

11Epidemiology49% of patients in general medical settings suffer from hypochondriasis (Fallon et al. 1993).Risk factors for unexplained somatic Sx- female, older age, non-white race, less education, lower incomeIt does appear that hypochondriasis is equally common in males and females. Data concerning socioeconomic class are conflicting.Assessment ofthe incidence and prevalence of hypochondriasis undoubtedlyrequires study of general or primary care rather thanpsychiatric populations, because patients with hypochondriasisare convinced that they suffer from some physicalillness.12EpidemiologyPsychiatric comorbidity in 62%. Anxiety & Depressive disorders most common.Family study (Noyes et al. 1997)- hostility, low aggreableness, dissatisfaction with care.Twin study (Taylor et al. 2006)- genetic factors accounted for 37% of the variance in fear of disease, 10% in disease conviction. Such anxiety is largely a learned phenomenon.Impairment in functioning, low QOL & high service utilization.Clinical FeaturesEssential featuresFear of disease, the consequences of which may include pain, suffering, disability & death.May take form of alarming thoughts & images of specific diseases.Disease conviction- this belief is overvalued meaning that is strongly held despite lack of evidence; not delusional.Bodily preoccupation-interest in, attention to somatic Sx which tend to be multiple & diffuse. Attention directed to bodily sensations, functions, minor abnormalities.Clinical FeaturesRelated concerns- medical, diet, exercise, environmental exposure.Activities & conversations of pts dominated by medical concerns. As a consequence of their self-absorption, interest in people & other pursuits is withdrawn.Reassurance seeking- main behavioral feature. self examinations, search medical sources for the meaning of their Sx, ask friends, family & med professionals for reassuranceClinical FeaturesAssociated featuresFears of aging & deathOvervaluation of health & appearanceLow self-esteemSense of vulnerability to illnessSubtypes/dimensionsDisease phobiaDisease convictionResemblance to OCD or personality disorderCoursethe most common age at onset is in early adulthood.approximately 25% of patients do poorly, 65% show a chronic but fluctuating course, and 10% recover. This pertains to the full syndrome. A much more variable course is seen in patients with just some hypochondriacal concerns.

CourseGood prognostic indicators:Acute onsetBrief durationMild hypochondriacal symptomsPresence of GMCAbsence of comorbid mental disorderAbsence of secondary gainBody Dysmorphic DisorderCognitions: Preoccupation with distorted body image and appearance, dissatisfaction and feeling unattractiveBehaviors: Compulsive mirror checking, body measuring, diet and exerciseComorbidity: 12% BDD have Eating Disorder 40% Anorexia Nervosa have BDD

CONCEPTUALIZATIONHypothesis 1: A symptom of OCD, hypochondriasis (ICD), social phobia, depression or schizophrenia Hence treated by addressing the primary disorder

Hypothesis 2: A separate, independent entity (DSM) Hence treated separately

20Similarities: BDD vs. HypochondriasisCognitions: Bodily fears & preoccupations Behaviors: Frequent medical help seeking, repeated checking, reassurance seekingGender: Similar ratesCourse: Both have early age at onset, chronic waxing and waning course

Differences: BDD vs. HypochondriasisBDDHypochondriasisCognitionsBody partsBody illnessDistressDue to perceived deformityDue to levels of health concerns Treatment SSRIs or CBTSSRIs/SNRIs, CBT and Non-CBT psychotherapies22Differential DiagnosisPhysical DisordersNeurological conditions- Multiple sclerosis, myasthenia gravisEndocrine conditions- thyroid or parathyroid disordersMultisystem diseases- SLEOccult malignanciesBecause of such possibilities, a physical cause warrants continuing consideration even after initial work up has been completed

Differential DiagnosisPanic disorderHypochondriacal DisorderFear immediate consequences of illness (eg. heart attack)Fear long term consequences of illness (eg. Cancer)Fear dyingFear deathMisinterpret the symptoms of autonomic arousalMisinterpret a range of bodily symptomsFrequent unexpected panic attacks- -Differential DiagnosisSpecific phobia, illness subtypePts with hypochondriacal disorder are preoccupied with a disease they believe is already presentIllness phobics fear developing a disease they do not yet have. Illness phobic symptoms may be triggered by external as well as internal cues

Differential DiagnosisObsessive-Compulsive Disorder Cognitions: Somatic preoccupationsBehaviors: Reassurance seeking, checking for signs of illnessFamilial aggregation: More with somatization disorders but, OCD variant of hypochondriasis has high familial aggregation with OCD/BDD

OCDHypochondriasisCognitionsIntrusive thoughts of contamination or disease.IrrationalResistance

Fear of illnessRationalNo resistanceSensationsNoneSomatic and visceral sensationsOther classic OCD obsessions+++---BehaviorsCompulsionsDoctor shopping27Differential DiagnosisGeneralized Anxiety DisorderCharacterized by excessive worry about a number of areas.If worry is confined to illness, then a diagnosis of GAD shouldnt be made.Pts with GAD have health worries that are general.Hypochondriasis involve specific diseases.

Depressive disorderHypochondriacal concerns are common during depression.They usually remit with the treatment of mood disturbance. pt is likely to focus concern upon the vegetative Sx of depression & interpret these as irreversible loss of health.A diagnosis of HD is apt when hypochondriacal concerns are:Not confined to the depressive episodeNot focused on the Sx of the mood disorder SOMATIZATION HYPOCHONDRIASISConcerned with SxConcerned with Disease processMultiple frequently changing SxOne or two disease processesFemales/ Family etiologyEqual incidence/ No Family etiologyAsks for relief from SxAsks for investigations to diagnose the diseaseExcessive use of drugs abuse/dependenceFear drugs- Frequent visits to various doctors30Delusional beliefPatients with hypochondriasis, although preoccupied, generally acknowledge the possibility that their concerns are unfounded. Delusional patients do not.Somatic delusions of serious illness are seen in some cases of schizophrenia and in delusional disorder, somatic typeLook for other psychotic features

It is often a thin line between preoccupation and fear that is a conviction and that which is a delusion. Often, the distinction is made on the basis of whether the patient can consider the possibility that the conviction is erroneousYet, patients with hypochondriasis vary in the extent to which they can do this. DSM-IV-TR acknowledges this by its inclusion of the specifier with poor insight. In the past, some argued that differentiation could be made on the basis of response to neuroleptics. one case report (Brophy 1994).Etio-pathogenesisPersonalityNeuroticism or negative emotionality- a tendency to experience & report negative emotions & overreact to stress.Neuroticism may represent a vulnerability factor for hypochondriasisObsessive-compulsive & masochistic personality traitsDifficult doctor-pt relationshipPts described as angry, mistrustful.

Etio-pathogenesisDevelopmental factorsTraumatic events during childhoodChildhood exposure to illness or deathParental attitudes- overprotectionThese suggest that hypochondriasis is in large measure learned behaviorLife events- illness, death, cardiac neurosisEtio-pathogenesisCognitive & perceptual factorsMisinterpretations of bodily Sx as signs of serious disease & on the experience of somatic sensations as intense, noxious & disturbing.Faulty attribution of innocuous sensations is the central defect.Physiological abnormalities (Gramling et al. 1996): Cold pressor test- higher mean HR, lower mean hand temp. Subjects terminated the test more frequently & rated it more unpleasant than controls.

Interpersonal factors- hypochondriasis is a form of care-eliciting behavior that finds expression in physical complaints.Need for support of this kind arises from insecure attachment that originated in early relationships with caregivers.Social & cultural factorsPersons who are lacking in social support or socially isolated-more prone for care-eliciting behaviorRole of physiciansCultural differences in threshold for pain, pain tolerance, responses to pain

MeasuresSelf-rated questionnairesWhiteley IndexIllness Attitude scalesIllness worry scaleHealth anxiety questionnaireHealth anxiety inventoryMultidimensional inventory of hypochondriacal traitsPsychiatric diagnostic screening questionnaire

MeasuresStructured interviewsStructured diagnostic interview for hypochondriasis (Barsky et al.)Structured clinical interview for DSM-IV (SCID)Composite international diagnostic interview (CIDI)Schedules for clinical assessment in psychiatry (SCAN)39ManagementStrategiesLegitimize the pts symptomsEstablish a regular schedule of visitsBase diagnostic evaluation on objective findingsApproach Rx of physical symptoms cautiouslyProvide plausible explanations for symptomsEstablish a goal of improved functioningMaintain a therapeutic relationshipPsychological therapiesExplanatory therapy involves repeated physical examinations, reassurance concerning Sx, information about psycho-physiologic process.In a controlled trial, this therapy yielded significant improvement in illness behavior & health care utilization compared to no treatment. Gains were maintained for 6 months.Additional controlled trials are clearly needed.Psychological therapiesCognitive Behavior therapiesCognitive procedures include identifying & challenging dysfunctional thoughts & formulating more realistic beliefsBehavioral procedures involve in vivo exposure with response prevention.Four RCTs have shown CBT to be superior to no treatment & gains sustained upto 12 months.A non-specific intervention, behavioral stress management, was effective as wellPsychological therapiesFallon et al (1993) reported in their review:Dynamic therapies had minimal effectivenessSupportiveeducative psychotherapy helpful only in illness