Hypochondriasis: A Fresh Outlook on Treatment

This is the fourth in a series of five articles regarding obsessive-compulsive spectrum disorders. The first three articles ran in the March 1997, June 1997 and January 1998 issues of Psychiatric Times. The first article gave an overview of spectrum disorders, the second discussed obsessive-compulsive disorder and the third examined body dysmorphic disorder.

Hypochondriasis is a disorder that has been well-known for centuries but not well studied. In fact, although both clinicians and laypersons immediately have an image of someone who exaggerates the significance of their physical symptoms, many physicians don't know what to do for such a patient. Family members and friends often reassure the person that there is nothing wrong with them, and physicians, armed with medical test results, often do the same. Unfortunately, the patient never seems satisfied and continues to be preoccupied with his or her symptoms.

The DSM-IV describes the core symptom present in hypochondriasis (HC) as the perception of having a serious disease based upon the misinterpretation of one or more bodily signs and symptoms (American Psychiatric Association, 1994). The term "hypochondrium" can be traced back to Hippocrates, who used it in 400 B.C. to describe the superolateral region in the abdomen. In ancient times it was believed that hypochondriasis was due to disturbed function of organs in this region. Over the years the term has taken on a negative connotation and therefore it has at times been replaced by the terms "health anxiety," "illness phobia" and "somatic preoccupation."

The hypochondriacal patient is often believed to be self-absorbed and illogical, a constant whiner who is never satisfied, despite efforts to reassure the patient that there is nothing wrong. For these reasons, the hypochondriacal patient is often sent from one professional to another. However, it seems that little is known about how to treat these individuals, aside from providing reassurance. The onus is on the scientific community to develop new treatment strategies.

Hypochondriasis needs to be differentiated from prodromal schizophrenia, conversion disorder, somatization disorder, major depression, generalized anxiety disorder, panic disorder, obsessive-compulsive disorder (OCD), delusional disorder-somatic type, body dysmorphic disorder (BDD) and somatoform pain disorder. The commonality in these conditions seems to be a preoccupation with somatic symptoms due to a faulty perception or impaired cognition. The intense worry about being ill mimics an obsession, and the constant reassurance-seeking and checking of the body for physical evidence resembles compulsions. Thus, it seems that HC may be a variant of OCD.

It is also believed that HC is actually masked depression, especially in the elderly. In fact, until recently, HC and melancholia were synonymous. Although very similar to panic disorder, HC differs from panic disorder in that the individual with HC believes that the illness will develop in the future rather than immediately.

Most hypochondriacal complaints concern the head and neck, abdomen and chest (Kenyon, 1976). Nearly all complaints center on the experience of pain. Most importantly for clinicians, the hypochondriacal patient seems more concerned with the authenticity, meaning or etiological significance of symptoms rather than with unpleasant physical sensations or pain. In other words, it is the meaning of the physical sensation rather than the sensation itself. For example, the hypochondriac who complains about headaches is more concerned with the "tumor" that is "causing" the headache than the headache pain itself.

Patients with HC have multiple symptoms in many different organ systems that tend to wax and wane over long periods of time. Most of the symptoms they experience are ones that occur transiently in normal, healthy people (Barsky and Klerman, 1983).

Although some findings are contradictory, hypochondriasis usually occurs between the ages of 36 to 57, and it is believed to occur more frequently in females than in males. Estimates of the prevalence of HC range from 4% to 20% of the general population. Due to HC, more than $20 billion a year is spent on unnecessary doctor and emergency room visits as well as on unneeded tests.

Given the enormous resources utilized by these patients, it is amazing that we have had so little treatment to offer them. Part of the problem has been the lack of accessibility to this population within the psychiatric community. In part, this is because HC patients do not see their distress as psychologically based and therefore tend to visit family practitioners or specialists rather than psychiatrists or psychologists.

To date, no specific psychological intervention has been proven to be differentially effective for HC patients. Reassurance or supportive psychotherapy is utilized because efficient treatment modalities have not been available or sought out by HC patients. As stated earlier, these patients often go to emergency rooms or internists, and are known to "shop" for doctors in an attempt to find a diagnosis for their ailment. However, we now have more information on treatment with the HC population than in the past for a number of reasons. There is greater public awareness (thus HC patients are more likely to seek psychiatric assistance after everything else has failed), researchers in the field of OCD have seen similarities between the two disorders and therefore have been seeking out HC patients, and patients who are seeking treatment for depression or anxiety are often evaluated for HC.

Currently, the three most widely utilized forms of treatment are reassurance/supportive therapy, cognitive and behavior therapy, and psychopharmacological treatment. In reassurance therapy, medical testing is viewed as essential for reducing preoccupation with health by pointing to objective evidence that nothing is wrong. Although this temporarily relieves the patient, it has not been found to lead to a long-term positive outcome.

Cognitive and behavior therapy is receiving more empirical research and support. The basis of cognitive and behavior therapy lies in the assumption that patients with HC magnify somatosensory cues, believe them to be dangerous and at the same time perceive themselves as incapable of coping with the perceived threat. They also equate good health with being relatively symptom-free and consider symptoms to be equal to sickness. Thus, an inadequate concept of health may contribute to a perceptual and cognitive style of somatosensory amplification.

Cognitive and behavior therapy is based on two goals: challenging the faulty assumptions and preventing avoidance behaviors (Barsky et al., 1993; Neziroglu and Anderson, 1995; Salkovskis and Warwick, 1986; Visser and Bouman, 1992). In this kind of psychology, the clinician reviews the physical evidence for the complaints, identifies testable alternative explanations for the symptoms and discovers automatic faulty assumptions. Examples of these would be: "I cannot tolerate the pain," "Any physical symptom is a sign of danger" or "If I don't seek immediate help something catastrophic will happen." Once articulated by the patient, the assumptions are then challenged.

In the behavioral component of the treatment, patients are asked to refrain from activities such as seeking reassurance, checking their bodies for evidence of illness, or either reading or avoiding reading about their "illness." The treatment is very similar to that given to patients with OCD, specifically exposure and response prevention with cognitive therapy. Results of various studies on cognitive and behavior therapy suggest that both are effective forms of treatment, especially used in combination (Neziroglu et al., in press[a,b]; Visser and Bouman, 1992).

Finally, psychopharmacological interventions have been used, primarily targeted at the prominent symptoms of HC such as depression, anxiety and obsessive-compulsive symptoms (Yaryura-Tobias and Neziroglu, 1997a,b). The medications most examined for their effect on HC patients are the antidepressants.

Improvement has been reported for imipramine (Tofranil) (Wesner and Noyes, 1991), clomipramine (Anafranil) (Kamlana and Gray, 1988; Stone, 1993), fluoxetine (Prozac) (Fallon et al., 1991; Viswanathan and Paradis, 1991) and amitriptyline (Elavil, Etrafon) (Kellner et al., 1986). In addition to antidepressants, various MAO inhibitors, pimozide (Orap) (for monosymptomatic hypochondriacal obsession) and doxepin (Sinequan) have been used. However, the antidepressants seem to be the treatment of choice. Systematic double-blind studies are still lacking in this area.

In summary, more research in HC is needed. It is one of the biggest areas of health dollar expenditure and yet we have no clear guidelines for treatment and referral. Some evidence exists for the usage of antidepressants and for cognitive and behavior therapy but randomized controlled research has not been conducted.

Dr. Neziroglu is a behavior therapist and clinical director of the Institute for Bio-Behavioral Therapy and Research in Great Neck, N.Y., and is senior consultant of The Obsessive-Compulsive Disorder Inpatient Program at North Shore University Hospital. She has cowritten three books on obsessive-compulsive disorders.

References:

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