Recognizing hypochondriasis in primary care

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

Clinical Applications

Although specific hypochondriasis treatment guidelines have not been established, several phases of intervention have been identified.

Phase I: Assessment

Table 2 provides specific steps to guide the clinician through the diagnostic process. 19,20 During the assessment phase, the clinician must rule out all possible medical etiologies, particularly disorders that are difficult to diagnose such as acquired immunodeficiency syndrome, endocrinopathies, myasthenia gravis, multiple sclerosis, degenerative diseases of the nervous system, systemic lupus erythematosus, and occult neoplastic disorders.12

Tension may develop between the clinician, patient, and managed care provider. When the clinician responds to the patient's demand for testing, the delicate balance between cost-containment strategies and safe primary care practice come into conflict. For example, patients may demand expensive diagnostic procedures when routine screenings would suffice. The clinician must be sensitive to cost-containment issues and prudent practice, while seeking to maintain a good relationship with the patient.15

In one study, physicians diagnosed moderate to severe physical disease in many hypochondriacal patients even though the physicians were unclear as to the nature of the physical disease.This finding may partially explain clinician reluctance to diagnose hypochondriasis and only consider the possibility of physical disease.15

Patient contributions may dominate the history-taking process. Clinicians should ask about visits to other health care providers and all significant physical and mental health events. This information may provide evidence of hypochondriasis. The DSM-IV criteria for hypochondriasis can be used to compare a patient's symptoms with the stated criteria.

The diagnostic process should proceed according to the patient's willingness to entertain a hypochondriasis diagnosis: Proceeding toward the diagnosis too quickly may elicit patient resistance. The clinician must exercise caution when discussing the diagnosis and use phrases such as "excessive worry about health" or "illness fear" rather than "hypochondriasis."

Once medical illnesses have been ruled out, the clinician should explore the possibility of comorbid anxiety, depression, or somatoform-based disorders (for example, panic disorder, OCD, or generalized anxiety disorder). Individuals with OCD may acknowledge obsessions and compulsions related to health fears. Hypochondriacal patients may also receive an OCD diagnosis if they ritualize checking physical symptoms.

A clinician giving a patient a hypochondriasis diagnosis must fully explain the condition so that the patient can begin to accept the diagnosis. Patients may fiercely resist accepting the diagnosis because of their disease conviction. The clinician must approach the subject gently. Although hypochondriasis is not life threatening, it is a life-altering, consuming disorder.

Phase II: Education

Education is an integral component of hypochondriasis treatment. First, the clinician should reassure the patient that an organic disease does not exist by sharing laboratory results, x-ray findings, and other tangible evidence. Second, the clinician should establish with the patient that she or he has a disease fear and discuss the characteristics of that experience.