We were surprised at first when we were invited to give a presentation at a conference focusing on psychogenic
movement disorders. Our challenge was to consider the connection between psychogenic movement disorders and hypochondriasis or, more broadly, health anxiety. It became clear that there are many common issues, and that research and clinical experience with hypochondriasis may be helpful in understanding psychogenic movement disorders. Some of the common issues are as follows:

Assessment of hypochondriasis and other somatoform disorders usually has not been included in large-scale studies of mental disorders in the community. This may have been because of the limited research focused on somatoform disorders and the broad range of other mental disorders typically assessed in these interviews. As noted above, the number of cases identified is strongly related to the restrictiveness of the diagnostic criteria and the specific definitions applied. Clearly, however, the conditions frequently comorbid with hypochondriasis, particularly anxiety and depressive disorders, are very common in the community (4).

The most comprehensive community study of the epidemiology of somatoform disorders was carried out by Faravelli et al. (11) in Florence, Italy. A random sample of 800 residents of two health districts was identified and 84% agreed to participate in a structured interview (using DSM-III-R criteria) (12). Several unique features of this study make it especially important. The structured interviews were carried out by physicians providing services to these catchment areas. These physicians had access to the participants’ health records and undertook further investigations to rule out organic causes of symptoms. Among the respondents, 31.6% reported physical symptoms that were explainable by medical pathology, and 33.3% reported physical symptoms apparently not due to organic factors. The mean number of physical symptoms reported by respondents with symptoms but no demonstrable somatic illness was 6.24 (S.D. 3.58), and respondents with a physical illness reported an average of 2.99 (S.D. 2.24) symptoms. The study found one-year prevalence rates of 4.5% for hypochondriasis, 0.7% for somatoform disorder, 13.8% for undifferentiated somatoform disorder, 0.6% for somatoform pain disorder, 0.3% for conversion disorder, and 0.7% for body dysmorphic disorder. Symptoms related to movement were frequently reported by the subgroup who met the diagnostic criteria for hypochondriasis: difficulty swallowing, 6.7%; loss of voice, 13.3%; double vision, 3.3%; blurred vision, 13.3%; fainting, 6.7%; trouble walking, 10%; and paralysis, 23.3%. In this sample, a high proportion of those meeting the criteria for somatoform disorders were women. For example, 67.7% of those with hypochondriasis were women, as were 75% of those with undifferentiated somatoform disorder. The rate of mood and anxiety disorders was three to four times higher among those with hypochondriasis compared to the overall population. Considering use of medical services in the year covered by the study, among those with hypochondriasis, 3.3% had sought no medical services, and 66.7% saw a GP, 3.3% a public psychiatrist, 40% a private psychiatrist, and 3.3% a psychologist/psychotherapist.

Noyes et al. (13) describe a community study of illness fears in a random sample of 500 residents in a county in the Midwestern United States. Respondents were asked a
series of 14 questions about illness fears, fear of medical care, fear of blood or needles, and fear of aging or death. The researchers found that 5% of respondents reported much more nervousness than did most people in relation to at least four of six illness/injury items, 4% indicated that such fears interfered with obtaining medical care, and 5% reported some negative effect of these fears on their lives.

In a review of the occurrence of hypochondriasis in general medical settings, Noyes (14) reported a range of 2.2% to 6.9%. Rates were higher in psychiatric populations and specialty medical clinics.

The factor analytic studies of hypochondriacs described above identify three aspects of hypochondriasis, varying across individuals, identified by self-report measures: bodily preoccupation, disease phobia, and disease conviction. Disease phobia was the characteristic that most clearly differentiated individuals with hypochondriasis from those with other common psychiatric disorders (anxiety and depression). On the other hand, a group with hypochondriasis would be higher than individuals in the general population on all these measures. It is likely that many individuals with psychogenic movement disorders are also high on these dimensions, particularly disease conviction and bodily preoccupation. It is not clear to what extent these individuals would report disease phobia—the fear that their symptoms are related to a serious or life-threatening disease—but this may be one of the factors that motivates people to seek assessment and treatment. A variety of anxiety and mood disorders is common in the backgrounds of patients with hypochondriasis and psychogenic movement disorders. This suggests there may be some common factors in the development of these disorders.

Another framework that has been helpful in understanding hypochondriasis has been to consider and assess three systems where anxiety symptoms are seen: bodily sensations, thoughts, and behavior. Just as individuals with hypochondriasis typically have symptoms in each of these areas, many individuals with psychogenic movement disorders also present with symptoms in these areas. The treatment approach applied most consistently in understanding and treating these problems has been cognitive-behavioral therapy (CBT).

Specialists in child development and parents have often noted that somatic symptoms are a major way in which children experience and express problems with stress and distress. Most of us are familiar with the tendency of many children to report stomachaches and headaches, or more broadly, to feel sick and want to avoid difficult situations when they are experiencing stress. Most adults have had some experience with somatic symptoms, and with reducing or avoiding activities when we are feeling unwell, that dates back to childhood years.

The development of the concept of the sick role in sociology (15) has been one of the most thorough considerations of common expectations concerning health and illness in our society. With his description of the sick role, Parsons (16) had a strong impact on the development of a sociological understanding of illness behavior. He described the rights and duties conferred on individuals in the sick role and the impact on their functioning in society. In Parson’s view, the sick role was conferred on the individual by a medical practitioner.

Segall (15) described later criticisms of Parson’s concept of the sick role as being overly medicalized and argued for a broader view of health behavior. He maintained that much of the assessment and management of sickness takes place outside the formal health care system. The most common forms of health care are self-care and care by members of the individual’s support system. He suggested:

A sick role concept would consist of the following rights: the right to make decisions about health-related behavior (Right 1), the right to be exempt from performing usual well roles (Right 2), and the right to become dependent on lay others for care and social support (Right 3).… [The] sick role concept would also consist of the following duties: the duty to maintain health and overcome illness (Duty 1), the duty to engage in routine self-health management (Duty 2), and the duty to make use of a range of health care resources (Duty 3).

These rights and duties will vary with the nature and severity of the illness (exemption from some responsibilities vs. all responsibilities) and duration (temporary vs. permanent). Depending on the nature of the condition, some individuals rely heavily on the health care system in negotiating these rights and duties, and others rely extensively on their own resources and those of their social system. Given that so much happens outside the formal health care system, it is very important to understand the beliefs (and theories) about the health condition that guide decision-making and health (or illness) behavior.

Most people will move into the sick role when dealing with episodic bouts of illness (e.g., influenza or severe back pain), but for some individuals, the sick role becomes a central part of their larger role in their social network for extended periods of time. This is certainly the case for many patients with psychogenic movement disorders, but it is also true of individuals with other forms of severe chronic illness. Patients’ beliefs about their role in coping with their
health problems will be influenced by their experience with, and understanding of, the sick role. For some individuals, the sick role is a way of escaping from very stressful situations or from life problems that seem insoluble.

Our society looks to medical practitioners to provide information and advice concerning the sick person’s rights and responsibilities. As an example, the physician is often required to provide information concerning an individual’s request to be excused from work responsibilities. Many sources of assistance to those who are ill (unemployment or disability income, home care) require the recommendation of a physician. A physician’s recommendation is frequently sought concerning an appropriate course of assessment and treatment. Finally, the opinion of the physician is frequently sought concerning whether the patient is following his or her duty to care for the health problem and striving to return to a state of good health.

As noted above, individuals with high levels of somatic concern and hypochondriasis are frequently seen in primary care. Several clinicians and researchers with a special interest in this area have developed recommendations for primary care providers in helping these patients. Arthur Barsky (17) has been particularly influential in this area with his recommendations for medical management of hypochondriasis and his work on a cognitive-educational treatment (18).

Goldberg and colleagues developed a model of treatment for somatization appropriate for use in primary care during brief medical consultations (15 minutes) that may occur over a series of visits (19). This model has undergone extensive development and been evaluated in a cost-effectiveness analysis in primary care settings (20). The most common physical complaints involved pain or fatigue. After primary care providers received training in the treatment model, costs of referrals outside the primary health care team decreased by 23% with little overall change in primary care costs. Total direct health care costs were reduced by 15% even when the cost of training was considered.

Smith, Monson, and Ray (21) studied a structured psychiatric consultation for individuals with somatization disorder receiving services in primary care. After a thorough assessment, a consultation letter was sent to the primary care physician, describing somatization disorder, including its chronic relapsing course and low morbidity and mortality rates. The letter encouraged the physician to continue to serve as the primary care physician for the patient, to schedule regular visits (possibly every 4 to 6 weeks), and to carry out a physical examination each visit. It was suggested the physician avoid hospitalization, diagnostic procedures, surgery, and the use of laboratory procedures unless they were clearly indicated. Finally, physicians were encouraged not to tell patients “it’s all in your head.” No other psychiatric services were provided. Quarterly health care charges in the consultation group declined by 53%, and there was no change in the average charges for control patients. The number of outpatient visits remained the same in both groups but a decrease in hospital days for the consultation group was the major factor in the reduction in cost. There were no changes in health status or patient satisfaction with health care.

The primary care interventions discussed above are very compatible with the CBT approaches described in the following sections.

CBT has been a very influential approach in the psychosocial treatment of a wide range of health and mental health problems. It has the advantage of a close relationship to an extensive body of research in the behavioral sciences on environmental influences on behavior and cognition, and the development over many years of methodologies for evaluating behavior and cognitive change strategies. Clinical scientists developing CBT approaches have a strong allegiance to the development and evaluation of evidence-based treatments. This approach has been applied to problems of hypochondriasis and other somatoform disorders, and has the largest body of research of any approach to these problems.