Recognizing hypochondriasis in primary care

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

Hypochondriasis and Other Mental Disorders

Hypochondriasis and panic disorder often occur contemporaneously16 and may share a similar causal mechanism (see Table 1). Each disorder includes cognitive misinterpretation of benign somatic sensations, which results in excessive anxiety. These disorders are frequently confused with each other.

Continuing controversy exists regarding the classification of hypochondriasis in the DSM-IV. Researchers question whether the key features of hypochondriasis are unique to the disorder or are shared by other disorders.16 Researchers also question whether hypochondriasis is best understood as a somatoform disorder or as an anxiety disorder. To render a proper diagnosis, clinicians must determine which features of hypochondriasis are shared with obsessive compulsive disorder (OCD) and other anxiety disorders (see Table 1). A clinician may mistake the intense fear a hypochondriacal patient exhibits with obsessions observed in OCD. Similarly, the patient's frequent office visits can be misinterpreted as the cyclical rituals (anxiety-reducing measures) seen in OCD.

Individuals who present with hypochondriacal signs or symptoms may have a personal or family history of anxiety or depressive disorders. These patients frequently have obsessive-compulsive personality traits and a traumatic episode in their past.1 Usually, the sick role has been socially reinforced with either sympathy or care and attention.12

Many hypochondriacal patients have had multiple health care providers and become unsatisfied when the treatment does not reduce their anxiety. The patient may present with stacks of medical records, and the patient-clinician relationship often becomes strained.

Although some researchers believe that hypochondriasis and somatization disorder are essentially the same, other researchers believe that they are distinctly different.17,18 The DSM-IV recognizes hypochondriasis and somatization as somatoform disorders.3 A somatization disorder is a polysymptomatic disorder that begins before age 30, extends over a period of years, and is characterized by a combination of pain, gastrointestinal, sexual, and pseudoneurologic symptoms. In contrast, hypochondriasis is preoccupation with the fear of having, or the idea that one has, a serious disease based on the person's misinterpretation of bodily symptoms or bodily functions. 17,18

Clinicians often use the word somatization rather than hypochondriasis when discussing the disorder with patients because this term is more acceptable to patients and families. Patients maybe offended bythe terms hypochondriac or hypochondriasis, or believe that the clinician does not take their symptoms seriously. Use of these terms, which have a social stigma, may damage patient rapport and alienate patients.

The relationship between hypochondriasis, somatization, and depression is unclear. Shared symptomatology exists between somatization disorder and depressive disorders. Fatigue, sleep/rest disturbance, and appetite disturbance are common to both disorders.4 In addition, the chronic, intense frustration of experiencing fear of disease and having those fears discounted can lead to comorbid depression. The clinician should assess the patient for all comorbid conditions and institute appropriate treatment.