Recognizing hypochondriasis in primary care

Nurse Practitioner, Jun 2001 by Hardy, R Elaine, Warmbrodt, Lynn, Chrisman, Susan Kasal

Abstract

Between 50/6 and 9% of primary care patients exhibit hypochondriacal symptoms. Hypochondriasis may be primary or secondary to panic disorder or depression. Despite negative diagnostic findings and clinician reassurance, hypochondriacal patients manifest disease conviction, disease phobia, or both. Primary care providers, in collaboration with mental health care providers, can provide optimal treatment for patients with hypochondriasis. The use of various intervention phases and selective serotonergic reuptake inhibitors provide the most favorable patient outcomes.

Hypochondriasis is a patient's preoccupation with his or her fear or conviction of having a serious medical problem despite negative clinical findings and reassurance from health care providers.1 The condition is defined as a disorder of perception and cognition in which somatic sensation is experienced as abnormally intense and is incorrectly attributed to serious medical disease.2

Six major criteria are associated with hypochondriasis: 1) preoccupation with having a serious disease based on physical symptom misinterpretation, 2) misinterpretation that persists despite medical reassurance, 3) preoccupation that is not as intense or distorted as delusional disorder or as restricted as body dysmorphic disorder, 4) preoccupation that causes significant distress and impaired social and occupational functioning, 5) disorder duration of at least 6 months; and 6) ruling out other anxiety, somatoform, and major depressive disorders.3,4 Hypochondriacal patients tend to manifest disease conviction, the sincere belief that they have a life-threatening illness; disease phobia, an intense fear that a life-threatening illness may be contracted; or both.5

Between 5% and 9% of primary care patients have hypochondriasis.1,6,7 Some 25% to 75% of primary care office visits involve somatic presentations.8-11

Etiologic Theories

Four etiologic theories have been proposed for hypochondriasis. Although similar theories may continue to be proposed and debated, the definitive etiology probably lies in a combination of these four theories.12

The first theory concerns amplification of normal bodily sensations. Specifically, individuals attribute pathologic meanings to normal somatic sensations and functions. For example, although most individuals attribute an enlarged lymph node to a viral infection, hypochondriacal individuals with enlarged lymph nodes become fearful that they have lymphoma or another malignant disease. The interpretation of normal somatic sensations can have major consequences for the individual's psychological and behavioral health.13

The second theory is related to Sigmund Freud's psychodynamic hypothesis that unconscious conflicts are the result of traumatic or frustrating childhood experiences being reawakened in adult life by similar stress or frustration. When an individual cannot verbally express an evoked emotion because of guilt or fear, the emotion may be expressed physically.

The third theory suggests that hypochondriasis is a learned behavior that is consolidated by social reinforcement and need gratification.

The fourth theory concerns whether hypochondriasis is familial.7 One study showed that relatives of subjects with hypochondriasis did not have an increased rate of hypochondriasis compared with relatives of controls. Twin studies, however, have shown an increase in concordance rates in identical twins. Other data indicate that hypochondriasis occurs in 10% to 20% of female, first-degree relatives. Although research remains inconclusive, individuals with a genetic predisposition to hypochondriasis likely manifest the disorder subsequent to a somatic experience that is socially reinforced.

Primary, Secondary, and Transient Hypochondriasis

Hypochondriasis may manifest with a primary, secondary, transient, or overlapping presentation.5,14,15 Primary hypochondriasis is synonymous with the hypochondriasis diagnostic category listed in the Diagnostic and Statistical Manual-IV (DSM-IV).3 Secondary hypochondriasis occurs during other mental disorders such as depression, panic, anxiety, or somatoform disorders.',' The bodily symptoms of depression and panic disorder appear to induce secondary hypochondriacal fears or beliefs.5

Research suggests that primary hypochondriasis is refractory to treatment, but secondary hypochondriasis tends to improve significantly when the underlying condition is treated effectively.2 The differential diagnosis of primary versus secondary hypochondriasis may be confusing for clinicians because the symptoms are similar to those for other disorders. However, accurately diagnosing the disorder as primary or secondary is crucial because treating the underlying disorder may alleviate secondary hypochondriacal symptoms.

Transient hypochondriasis often occurs during a medical illness, particularly a terminal or acute, life-threatening illness (for example, a cardiac neurosis subsequent to myocardial infarction).14 Transient hypochondriasis has also been associated with life events unrelated to illness such as the death of a close relative.