Hypochondriasis (Health Anxiety)
Russell Noyes Jr.
Introduction
Hypochondriasis is a preoccupation with the fear that one has, or may develop, serious disease despite evidence to the contrary. So defined, the disorder affects between 2 and 7 per cent of patients attending general medical clinics and is a cause of physical dysfunction and disability.(1) It is also a reason for increased health care utilization and dissatisfaction with care received. To their physicians, patients with this disorder are an enigma and a source of frustration.
Unfortunately, relatively little is known about hypochondriasis. Primary care physicians have had little interest and psychiatrists see few patients with the condition. It is a pejorative label that, even if entertained, is rarely communicated. And, even if communicated, the diagnosis would not, until very recently, have led to effective treatment.
History
Hypochondria was used by Hippocrates to refer to a region below the cartilage of the ribs. In the second century, Galen linked it to organs in this area as well as humours and animal spirits. The symptom picture was ill-defined and only gradually took on the characteristics recognized today. From earliest times the disorder was associated with melancholia, a temperamental disturbance caused by an excess of black bile. Burton (1621) described hypochondriacal melancholy in terms of vague physical symptoms, disturbances of mood, and fears. In the seventeenth century, Sydenham viewed hypochondria in men as the counterpart of hysteria in women, but the first modern description was published in 1799 by Sims.
By the eighteenth century, hypochondria became part of a fashionable disturbance that Cheyne attributed to the English way of life and environment. However, as notions of aetiology began to shift under the influence of Cartesian dualism, hypochondria was increasingly seen as a weakness and moral failing. Falret (1822) was
perhaps the first to identify it as a mental disorder, one of the neuroses. Freud viewed hypochondria as an ‘actual neurosis’, having a physiological basis and not amenable to psychoanalysis. However, present-day descriptions began with Gillespie,(2) who in 1928 defined hypochondriasis as ‘a mental preoccupation with a real or supposititious physical or mental disorder’.
perhaps the first to identify it as a mental disorder, one of the neuroses. Freud viewed hypochondria as an ‘actual neurosis’, having a physiological basis and not amenable to psychoanalysis. However, present-day descriptions began with Gillespie,(2) who in 1928 defined hypochondriasis as ‘a mental preoccupation with a real or supposititious physical or mental disorder’.
Table 5.2.5.1 Essential and associated features of hypochondriasis | ||||||||||||||||||||||
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Conceptualizations
Authors disagree about how hypochondriasis should be conceptualized. Some look upon it as a personality trait; its early onset and long-term stability in many patients fit this conception. Others view it as a dimension of psychopathology. They see illness worry as a continuum with hypochondriasis falling on the severe end. For those who take a categorical approach, the issue of whether hypochondriasis is primary or secondary remains unsettled. High rates of comorbidity create doubt about its independent status. Based on existing evidence, some question whether hypochondriasis can be regarded as a discrete psychiatric disorder.(3)
Clinical picture
Essential features
The essential characteristics of hypochondriasis are shown in Table 5.2.5.1. These include fear of serious disease, the consequences of which may include pain, suffering, disability, and death. Such fears take the form of alarming thoughts and images of specific diseases. They also include conviction or belief that the feared disease is already present. This belief is overvalued meaning that it is strongly held despite lack of evidence; it is not delusional.
Bodily preoccupation is perhaps the most important feature.(4) This takes the form of intense interest in, and attention to, what is happening in the body. The focus is upon somatic symptoms which tend to be multiple and diffuse. Attention is also directed to bodily sensations, bodily functions, and minor abnormalities as well as related concerns such as diet, exercise, and environmental exposures. The activities and conversation of patients are dominated by medical concerns. As a consequence of their self-absorption, interest in other people and pursuits is withdrawn.
Reassurance-seeking is the main behavioural feature. Patients repeatedly check their bodies for signs of serious disease. They check their pulse, look for lumps, examine themselves in the mirror, etc. In addition, they search medical sources for the meaning of their symptoms. Such patients also ask friends, family, and medical professionals for reassurance. Their search may lead to excessive utilization of health services.
Associated features
Associated characteristics include fears of aging and death, which appear to be an integral part of hypochondriasis. Overvaluation of health and appearance is another related feature. Hypochondriacal patients may become preoccupied with eating natural foods, achieving physical fitness, and living a healthy lifestyle, activities that reflect their idealized conception of good health.
Patients with hypochondriasis feel unworthy and unlovable.(4) As a consequence of their low self-esteem they have negative expectations of others including medical professionals. In addition, they have a sense of vulnerability to illness.(5) These characteristics have to do with fundamental aspects of the self that the hypochondriacal patient views as deficient.
Subtypes
Hypochondriacal patients are heterogeneous and subtypes may exist. Separate dimensions of disease phobia and disease conviction have consistently been identified; in some patients fears are prominent and in others conviction dominates the picture. Others may resemble patients with obsessive-compulsive disorder or personality disorders of one kind or another.
Classification
Criteria
Hypochondriasis initially appeared in DSM-II as one of the neuroses. In DSM-III, it was moved to the somatoform disorders, and diagnostic criteria were provided. In a revision of the classification (DSM-III-R), a duration of 6 months was added, and patients with delusional beliefs were excluded. The DSM-IV criteria are shown in Table 5.2.5.2. They exclude patients whose symptoms are better explained by other anxiety, depressive, or somatoform disorders.(1) Also, in DSM-IV, specific phobia of illness is separated from hypochondriasis. The illness phobic is said to fear contracting an illness whereas the hypochondriac fears disease already present.
The ICD-10 criteria for hypochondriacal disorder differ from those in DSM-IV. They require a persistent belief about having one or more specifically named serious physical diseases.(6) In addition, they include body dysmorphic disorder. With respect to illness behaviour, the ICD-10 criteria state that hypochondriacal concerns cause persons to seek medical investigation or treatment. They also state that patients may accept reassurance in the short-term, but that in the long run they are not likely to respond.
Table 5.2.5.2 Abbreviated DSM-IV diagnostic criteria for hypochondriasis | ||||||||||||
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The somatoform disorders category to which hypochondriasis belongs is controversial, and many question its inclusion in the classification.(7) They see these disorders as ill-defined, of questionable validity and based more on illness behaviour than on distinctive features. They also view them as creations of Western biomedicine that serve to devalue patients who challenge the theoretical model upon which it is based.(8) According to that model, illness is a response to disease, and the person who is ill without disease, e.g. hypochondriasis, is marginalized.
Were the somatoform disorders to be eliminated, some have proposed moving hypochondriasis to the anxiety disorders (health anxiety) or to a proposed grouping, the obsessive-compulsive spectrum disorders.
Validity
Evidence for the validity and utility of the diagnosis of hypochondriasis remains limited. In studies aimed at demonstrating validity, Barsky et al.(9) showed that distinguishing characteristics of the disorder aggregated in some medical outpatients but were less common in others. The same patients had other features of hypochondriasis indicating external validity. Using a structured interview for hypochondriasis, these investigators and others(10,11) observed a positive correlation between interview and physician ratings (concurrent validity). Hypochondriacal patients also had more ancillary features of hypochondriasis than did control patients (external validity). Also, other clinical characteristics distinguished interview positive from interview negative patients, indicating discriminate validity. Follow-up studies have shown a degree of diagnostic stability suggesting predictive validity.(12,13)
Measures
A variety of measures have been developed to screen for hypochondriasis and assess the severity of hypochondriacal concerns.(14) These are shown in Table 5.2.5.3. The Whiteley Index, a self-report instrument based on the observed characteristics of hypochondriacal psychiatric patients, is one of the most widely used.(15) It consists of 14 yes versus no items, but recent work suggests that a 7-item version is satisfactory for screening. The Illness Attitude Scales is a 27-item measure of psychopathology associated with hypochondriasis.(16) A principal components’ analysis yielded two factors, one measuring health anxiety and the other illness behaviour. The health anxiety subscale has been used to distinguish hypochondriacal from non-hypochondriacal patients.
Table 5.2.5.3 Measures for the assessment of hypochondriasis | ||||||||||||||||||||||||||
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Recently, self-assessment measures have been developed to assess the various dimensions of health anxiety and hypochondriasis. The Health Anxiety Inventory contains 47 items covering a range of hypochondriacal features.(17) An advantage of this scale is that it distinguishes patients with high health anxiety from those with physical illness.
The Structured Clinical Interview for DSM-IV (SCID) and the Composite International Diagnostic Interview (CIDI) are comprehensive diagnostic interviews that contain somatoform disorder modules. The CIDI has been used in epidemiologic surveys. Its stem question for hypochondriasis is, ‘In the past 12 months, have you had a period of 6 months or more when most of the time you worried about having a serious physical illness or deformity?’
Based on the SCID, Barsky et al.(10) developed a structured interview that focuses exclusively on hypochondriasis. It begins with a series of probe questions that, if answered affirmatively, trigger the remaining interview. It is suitable for confirming the diagnosis in a screened population.
Diagnostic assessment remains less than satisfactory because the threshold for caseness has not been established, medical and psychiatric comorbidity make diagnostic decision-making difficult, and independent medical evaluation is rarely part of the process.
Differential diagnosis
Physical disorders
A few hypochondriacal patients suffer from undetected physical disease. Consequently, it is important to exclude medical conditions that, in their early stages, may cause vague symptoms with few signs or laboratory abnormalities. These include neurological conditions, such as multiple sclerosis or myasthenia gravis; endocrine conditions, such as thyroid or parathyroid disorders; multisystem disease such as systemic lupus erythematosus or occult malignancies. Because of such possibilities, a physical cause warrants continuing consideration even after the initial work-up has been completed.
Psychiatric disorders
Patients with panic disorder may be difficult to distinguish from those with hypochondriasis because they commonly have hypochondriacal features. A diagnosis of hypochondriasis should not be made if illness concerns are better accounted for by panic disorder. Patients with hypochondriasis tend to fear the long-term consequences of illness (such as cancer) whereas those with panic fear the immediate consequences of illness events (such as a heart attack); the former fear death, the latter dying. Also, those with hypochondriasis misinterpret a range of bodily sensations, whereas those with panic misinterpret the symptoms of autonomic arousal.
Hypochondriasis must be distinguished from specific phobia, illness subtype.(1) Patients with hypochondriasis are preoccupied with a disease they believe is already present, whereas illness phobics fear developing a disease they do not yet have. Illness phobic symptoms are triggered by external as well as internal cues. For instance, exposure to a person with the feared disease may elicit a fear response.
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