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CLINICAL PRACTICE

Clinical Practice

This Journal

feature begins with a case vignette highlighting

a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal

guidelines, when they exist. The article ends with the authors clinical recommendations.

T

HE

P

ATIENT

WITH

H

YPOCHONDRIASIS

A

RTHUR

J. B

ARSKY

, M.D.

From the Department of Psychiatry, Brigham and Womens Hospital andHarvard Medical School, Boston. Address reprint requests to Dr. Barsky atthe Department of Psychiatry, Brigham and Womens Hospital, 75 FrancisSt., Boston, MA 02115.

A 39-year-old single woman returns to her in-ternist for the sixth time in nine months with thesame symptoms intermittent paresthesias andswelling" of her hands and feet and belching.The results of physical examinations and labo-ratory studies have remained normal, yet thishas failed to reassure her. She is now concernedthat she has lupus and urgently requests a rheu-matology consultation. How should you managethis problem?

THE CLINICAL PROBLEM

Hypochondriasis is a disabling and chronic disor-der.

1

The associated disability and impairment of rolefunctioning are similar to those accompanying majormood and anxiety disorders and many chronic medicalconditions.

2,3

Not only is hypochondriasis refractory to standard medical management, but treatment oftenleads to complications, side effects, and new symp-toms.

3

Physicians find patients with hypochondriasisdifficult to reassure, and dealing with such patients canbe extremely time consuming. These patients are re-luctant to acknowledge the role of psychosocial factorsin causing their symptoms, and they often provokestrong antipathy on the part of physicians.

4

Recentresearch has provided insight into some strategies thatmay improve outcomes for these patients and has re-

vealed the limitations of such approaches as orderingtests to try to put patients minds at ease.

Patients with hypochondriasis are preoccupied withthe fear or belief that they have a serious, undiagnoseddisease. This concern derives from a misinterpretationof benign physical sensations as evidence of seriousillness, and it persists despite appropriate reassurance

to the contrary. The diagnostic criteria for hypochon-driasis also require that the patients concern about ill-ness persist for at least six months and cause clinically significant distress or functional impairment. Hypo-chondriasis may occur alone (primary hypochondri-asis) or as a secondary feature of some other, morepervasive psychiatric disorder (secondary hypochon-driasis). Somatization, a related phenomenon, refersmore generally to a tendency to focus on the somaticmanifestations of emotional distress and to present

with somatic symptoms that have no demonstrableorganic basis. Patients with hypochondriasis are a sub-group of patients who somatize namely, those

whose medically unexplained symptoms are accom-panied by the unshakeable conviction that they havea serious disease. However, the overlap between hy-pochondriasis and somatization is considerable, andsome of the clinical approaches to patients who so-matize also apply to patients with hypochondriasis.

Hypochondriacal concern spans a spectrum frommild, fleeting worry to persistent and incapacitatingdread. The concern of patients with more severe hy-pochondriasis is persistent, produces a disproportion-ate degree of impairment of role functioning and dis-ability, is unresponsive to repeated reassurance andnegative diagnostic evaluations, and is refractory to thestandard medical treatment of symptoms. These pa-tients somatic symptoms are often normal physiolog-ic sensations (such as orthostatic dizziness) or benign,self-limited ailments (such as transient tinnitus). Al-though not typical of serious disease, these bodily sen-sations are misinterpreted as such and are accompaniedby profound anxiety about health and preoccupation

with disease a syndrome sometimes referred to asillness as a way of life.

1

As a result, hypochondriasisresults in substantial disability and impairment of rolefunctioning.

2

It should be emphasized that patients with hypochondriasis are not malingering or fabricat-ing their symptoms.

Patients with hypochondriasis have a characteris-tically paradoxical history of medical care extensive,

yet unsatisfactory. They have disproportionately highrates of visits to physicians, specialty consultations, lab-oratory tests, and surgical procedures, as well as highhealth care costs.

5

Despite this extensive medical at-tention, however, they find their care frustrating andunsatisfactory. They feel ignored by their previous doc-tors and may often speak disparagingly of them. Phy-sicians, in turn, generally find that such patients dismissefforts to help them and are exceptionally difficult andfrustrating to treat.

4

This combination of anger andfutility experienced by a physician in caring for a pa-tient is often a signal that the patient has hypochondri-

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asis. A diagnosis of hypochondriasis is also suggested when a patient responds to appropriate reassurance with anger rather than relief or when his or her symp-toms are apparently exacerbated by simple palliativetreatment.

Hypochondriasis is found in 4 to 6 percent of gen-eral medical outpatients. Its prevalence does not ap-pear to be elevated among the relatives of persons withhypochondriasis, nor is the condition strongly associ-ated with socioeconomic status, educational level, race,or sex.

6

Approximately two thirds of patients with hy-pochondriasis have another coexisting psychiatric dis-order. These include major depression (found in ap-proximately 40 percent of cases), panic disorder (in 10to 20 percent), obsessivecompulsive disorder (in 5 to10 percent), and generalized anxiety disorder.

7

STRATEGIES AND EVIDENCE

Approaches to the management of hypochondria-sis are summarized in Table 1. The approach to bothprimary and secondary hypochondriasis is similar, butin the latter case, it is crucial to detect and treat thecoexisting disorder as well.

CognitiveBehavioral Therapies

Promising cognitivebehavioral therapies have beendeveloped.

8

Patients use these techniques to identify and alter dysfunctional beliefs and assumptions aboutsymptoms and disease; to modify the maladaptiveforms of behavior that perpetuate their symptoms, in-cluding avoiding their usual activities, seeking reassur-ance from others, and shopping for new physicians;to initiate a program of graduated physical condition-ing; and to learn techniques for relaxation. Therapy ishighly interactive and may be conducted either in agroup setting or individually. Patients are given writ-ten materials that discuss common misunderstandingsand misconceptions that patients with hypochondri-asis tend to have about disease and medical care.

9

Thetopics covered by these materials include the high prev-alence of symptoms in healthy people; stress, normalphysiology, and other nonpathologic sources of so-

matic distress; the use of coping skills to moderate theintensity of symptoms; and the appropriate use of lab-oratory tests in ruling out medical diagnoses. In reg-ular homework assignments between sessions, patientsare asked to record the thoughts or events that precedea symptom, its possible medical and nonmedical caus-es, their responses to the symptom, and possible, moreadaptive responses.

Studies assessing the efficacy of these therapies havereported improvements in anxiety about health, dys-functional beliefs, concern about disease, and impairedsocial functioning as much as one year later.

10

In onestudy, there was a substantial decline in the rate of vis-its to physicians.

11

However, these studies tend to belimited by small samples, the lack of control groups,the absence of long-term follow-up, or dubious gen-eralizability. In the most rigorous study of treatmentto date, 48 patients with hypochondriasis were ran-domly assigned to receive either cognitive therapy ortraining in behavioral stress management or to beplaced on a waiting list.

12

After four months, the groupon the waiting list was randomly reassigned to one of the two treatments. Both active treatments consisted of up to 16 sessions of individual treatment and 3 boost-er sessions, and after long-term follow-up, both weresignificantly more effective than no treatment accord-ing to a wide range of measures of hypochondriasis.

12

The efficacy of these therapies is similar to that report-ed for the cognitivebehavioral treatment of severalfunctional somatic syndromes, such as atypical chestpain and chronic headache.

13

In two studies of suchtreatment, group-based cognitivebehavioral interven-tions led to significantly lower rates of outpatient vis-its and medication use than those found in a controlgroup after six months of follow-up.

14,15

Pharmacotherapy

Although pharmacotherapy for primary hypochon-driasis has not been rigorously evaluated, pharmaco-therapy for patients with a variety of medically unex-plained symptoms (particularly chronic pain) has beenstudied. A recent meta-analysis concluded that anti-depressant therapy was significantly more effective thanplacebo in more than two thirds of carefully selectedstudies of headache, fibromyalgia, irritable bowel syn-drome, chronic pain, tinnitus, and fatigue.

16

There is good evidence to support the vigoroustreatment of the psychiatric disorders that frequently coexist with hypochondriasis. These disorders are re-sponsive to pharmacotherapy, and when they are ade-quately treated, the hypochondriacal symptoms gener-ally resolve as well.

17-19

The standard pharmacotherapy for the common psychiatric disorders that often co-exist with hypochondriasis namely, major depres-sion, panic disorder, and obsessivecompulsive disor-der is outlined in Table 2. Pharmacotherapy forthese disorders in patients with hypochondriasis may require relatively high doses and prolonged therapy (as

T

ABLE

1.

S

UGGESTED

I

NTERVENTIONS

FOR

P

ATIENTS

WITH

H

YPOCHONDRIASIS

.

Cognitivebehavioral therapy Psychopharmacologic treatments (primarily antidepressants)Medical management strategies

Schedule regular primary care visitsPractice diagnostic and therapeutic conservatism

Validate patients symptomsProvide explanatory model to account for patients

symptomsDiagnose and treat coexisting psychiatric conditions

Aim for care rather than cure

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much as eight or more weeks) before an adequate re-sponse is evident.

16,20

Because of side effects, treatmentshould be initiated at subtherapeutic doses, which areincreased very gradually. Such patients are particularly likely not to adhere to the therapeutic regimen, in partbecause of perceived side effects.

18

The potential ben-efits of pharmacotherapy should not be touted or over-emphasized to patients with hypochondriasis, andpossible side effects should be explained carefully inadvance.

Other Management Strategies

Interventions have also been designed that aim toimprove the treatment of patients with hypochondri-asis and those who somatize by primary care physi-cians, but only two rigorous trials of their effectivenesshave been conducted. Smith et al. studied the effec-tiveness of a generic consultation letter sent to the phy-sicians of patients with somatization disorder.

21-23

Theletter suggested that the patient be scheduled for brief but frequent regular visits and advised that as-need-ed visits be avoided whenever possible; that diagnos-

tic procedures, surgery, and laboratory evaluations notbe performed unless they were clearly indicated; thatthe primary care physician limit the number of otherphysicians seen by the patient; and that the physicianexplicitly acknowledge that the patients symptomsare real and not imaginary or fabricated. This inter-

vention improved the patients physical functioningand resulted in a decrease of 33 to 53 percent in theirmedian medical charges.

21,23

AREAS OF UNCERTAINTY

At present, there is not sufficient empirical evidenceto support the effectiveness of specific cognitive, phar-macologic, and other therapies for hypochondriasis.

GUIDELINES

There are no published guidelines relevant to theclinical care of patients with hypochondriasis.

CONCLUSIONS AND RECOMMENDATIONS

There is a general consensus that several strategiesare helpful in the treatment of patients with hypochon-

*Hypochondriasis here includes related somatoform disorders. This list is intended only as a general guide. Specific indications, doses, drug interactions,and precautions must be determined for each case individually.

T

ABLE

2

. P

HARMACOTHERAPY

FOR

C

OEXISTING

P

SYCHIATRIC

C

ONDITIONS

IN

P

ATIENTS

WITH

H

YPOCHONDRIASIS

.*

A

GENT

I

NITIAL

D

OSE

T

HERAPEUTIC

R

ANGE

OF

D

OSES

S

IDE

E

FFECTS

I

NDICATIONS

Selective serotonin-reuptake inhibitors

Citalopram 10 mg/day 2040 mg/day Sexual dysfunction, nausea, dyspepsia, sedation,somnolence, agitation, insomnia, headache,dizziness

Depression, panic disorder, obsessivecompulsive disorder, generalizedanxiety disorder

Fluoxetine 510 mg/day 2080 mg/day Sexual dysfunction, nausea, dyspepsia, sedat ion,somnolence, agitation, insomnia, headache,dizziness

Depression, panic disorder, obsessivecompulsive disorder, generalizedanxiety disorder

Paroxetine 10 mg/day 2050 mg/day Sexual dysfunction, nausea, dyspepsia, sedation,somnolence, agitation, insomnia, headache,dizziness

Depression, panic disorder, obsessivecompulsive disorder, generalizedanxiety disorder

Sertraline 12.525 mg/day 50200 mg/day Sexual dysfunction, nausea, dyspepsia, sedation,somnolence, agitation, insomnia, headache,dizziness

Depression, panic disorder, obsessivecompulsive disorder, generalizedanxiety disorder

Other antidepressants

Bupropion 75 mg/day 100150 mg3 times a day

Anxiety, insomnia, agitation, nausea, anorexia, seizures(at high doses)

Depression

Nefazodone 50 mg/day 150300 mgtwice a day

Sedation, nausea, headache, hypotension, dizziness Depression

Trazodone 25 mg at bedtime 100200 mgtwice a day

Sedation, orthostasis, nausea, priapism (rare), headache Depression

Venlafaxine 25 mg twice a day 75150 mgtwice a day

Nausea, anxiety, tremor, insomnia, sexual dysfunction,hypertension (high doses only), discontinuation ef-fects, dizziness

Depression, generalized anxiety dis-order

Benzodiazepines

Alprazolam 0.25 mg/day 0.52.0 mg4 times a day

Sedation, drowsiness, ataxia, falls (in elderly patients),memory impairment, confusion (especially in elderlypatients), discontinuation effects and symptom re-bound, fatigue, weakness, psychomotor impairment

Panic disorder, generalized anxietydisorder (short-term)

Clonazepam 0.25 mg/day 0.52.0 mgtwice a day

Sedation, drowsiness, ataxia, falls (in elderly patients),memory impairment, confusion (especially in elderlypatients), discontinuation effects and symptom re-bound, fatigue, weakness, psychomotor impairment

Panic disorder, generalized anxietydisorder (short-term)

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driasis.

24,25

These are derived from clinical experienceand empirical intervention trials.

Successful long-term medical management requiresa durable and trusting doctorpatient relationship in

which access to the doctor is not predicated on thepresence of active symptoms. Visits should thereforebe scheduled on a regular, rather than an as-needed,basis. The physician and the patient should agree ona mutually acceptable frequency of appointments andthen try, insofar as clinically possible, not to vary thatfrequency when the number or severity of symptomsincreases or decreases. A few patients may still makeexcessive requests for attention, in which case the phy-sician must set limits in a nonpunitive manner.

The physician must remain alert to the possibility of an organic basis for the patients symptoms, sincepatients with hypochondriasis have levels of medicalillness similar to those of patients without hypochon-driasis in the same practice setting.

26

However, testsand specialty consultations should not be performedsolely for the purpose of reassurance, since tests andprocedures may cause complications and negativefindings provide little lasting reassurance for patients

who already have high levels of anxiety about healthat the outset.

27-29

In view of the higher likelihood of side effects of medication in patients with hypochon-driasis,

30-33

such patients should not be treated forequivocal or incidental findings. Rather, regular visitsto the physician, careful physical examinations, and at-tentive listening are more useful approaches to therapy.Clinical experience suggests that benign remedies,such as lotions, vitamins, elastic bandages, and heat-ing pads, can be helpful because they provide tangi-ble evidence of the patients distress and of the phy-sicians ongoing interest without creating a risk of iatrogenic harm.

Patients with hypochondriasis are disturbed by theimplied illegitimacy of their symptoms when no med-ical diagnosis is forthcoming. Simply reassuring themthat nothing is wrong contradicts their own experi-ence of bodily distress. It may be helpful to explain topatients that they may be exceptionally sensitive tonormal bodily sensations and may therefore misper-ceive these as symptoms of serious illness. This percep-tion then further amplifies the symptoms, perpetuat-ing a cycle (so-called symptom amplification). Any such explanation must be coupled with the explicit as-surance that the physician understands that such symp-toms are real and not imaginary.

The physician should search for evidence of otherpsychiatric disorders in particular, major depres-sion, panic disorder, and obsessivecompulsive disor-der. Occult depression is suggested by such symptomsas anorexia, weight loss, diminished libido, loss of mo-tivation or pleasure, and an apparent lack of interest inrecovery. Underlying panic disorder should be suspect-ed in patients with recurrent acute episodes of intensecardiorespiratory symptoms that have no apparent

medical cause. This disorder is frequently missed, andit is important to detect because the coexistence of hy-pochondriasis and panic disorder is associated with apoorer prognosis and greater disability than panicdisorder alone.

19,34

Since the treatment of coexistingpsychiatric conditions typically ameliorates hypochon-driacal symptoms, appropriate pharmacotherapy is in-dicated. Such therapy should be initiated at low dos-es, with gradual increases after the patient has beeneducated about potential side effects.

Patients with hypochondriasis tend to resist referralto a psychiatrist,

5

which they may perceive as an ac-cusation that they are imagining or fabricating theirsymptoms or as a covert attempt by their physician totransfer their care to another physician; these percep-tions must be discussed explicitly with the patient.Some patients may acknowledge that they have emo-tional distress for which they will accept psychiatrictreatment while insisting that it bears no causal rela-tion to their somatic symptoms. This assertion neednot be contested. Others accept the premise that theirhealth is adversely affected by stress and are willingto participate in stress-management programs.

Although there is no definitive therapy for hypo-chondriasis, physicians can effectively care for patients

with the condition by accepting that somatic symp-toms without a medical basis can be as distressing asthose resulting from demonstrable disease. The goalof treatment should be improved coping with symp-toms rather than their elimination, as in the manage-ment of chronic medical illness. This approach min-imizes the frustration of both the patient and thephysician.

Dr. Barsky has research funding from the Aetna Foundation for Quality Care.

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1.

Ford CV. The somatizing disorders: illness as a way of life. New York:Elsevier Biomedical, 1983.

2.

Escobar JI, Gara M, Waitzkin H, Silver RC, Holman A, Compton W.DSM-IV hypochondriasis in primary care. Gen Hosp Psychiatry 1998;20:155-9.

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Kroenke K, Spitzer RL, Williams JBW, et al. Physical symptoms in pri-mary care: predictors of psychiatric disorders and functional impairment.

Arch Fam Med 1994;3:774-9.

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Barsky AJ, Wyshak G, Latham KS, Klerman GL. Hypochondriacal pa-tients, their physicians, and their medical care. J Gen Intern Med 1991;6:413-9.

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Kellner R. Somatization and hypochondriasis. New York: Praeger, 1986.

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Barsky AJ, Wyshak G, Klerman GL. Psychiatric comorbidity in DSM-III-R hypochondriasis. Arch Gen Psychiatry 1992;49:101-8.

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Sharpe M. Cognitive behavioural therapies in the treatment of function-al somatic symptoms. In: Mayou R, Bass C, Sharpe M, eds. Treatment offunctional somatic symptoms. Oxford, England: Oxford University Press,1995:122-43.

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Warwick HM, Clark DM, Cobb AM, Salkovskis PM. A controlled trialof cognitive-behavioural treatment of hypochondriasis. Br J Psychiatry1996;169:189-95.

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Kroenke K , Swindle R. Cognitive-behavioral therapy for somatizationand symptom syndromes: a critical review of controlled clinical trials. Psy-chother Psychosom 2000;69:205-15.

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Stern R, Fernandez M. Group cognitive and behavioural treatment forhypochondriasis. BMJ 1991;303:1229-31.

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Clark DM, Salkovskis PM, Hackmann A , et al. Two psychologicaltreatments for hypochondriasis: a randomised controlled trial. Br J Psychi-atry 1998;173:218-25.

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Mayou R, Bass C, Sharpe M. Treatment of functional somatic symp-toms. Oxford, England: Oxford University Press, 1995.

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Hellman CJC, Budd M, Borysenko J, McClelland DC, Benson H. A study of the effectiveness of two group behavioral medicine interven-tions for patients with psychosomatic complaints. Behav Med 1990;16:

165-73.

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Rost K , Kashner TM, Smith GR Jr. Effectiveness of psychiatric inter- vention with somatization disorder patients: improved outcomes at re-duced costs. Gen Hosp Psychiatry 1994;16:381-7.

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tween hypochondriasis and medical illness. Arch Intern Med 1991;151:84-8.

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Lucock MP, Morley S, White C, Peake MD. Responses of consecutivepatients to reassurance after gastroscopy: results of self administered ques-tionnaire survey. BMJ 1997;315:572-5.

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Weber BE, Kapoor WN. Evaluation and outcomes of patients withpalpitations. Am J Med 1996;100:138-48. [Erratum, Am J Med 1997;103:86.]

30. Ferguson JM. Alprazolam XR : patient acceptability, safety, and toler-ability. Psychiatr Ann 1993;23:Suppl:20-6.31. Wilson L, Dworkin SF, Whitney C, LeResche L. Somatization andpain dispersion in chronic temporomandibular disorder pain. Pain 1994;57:55-61.32. McNair DM, Fisher S, Kahn RJ, Droppleman LF. Drug-personality in-teraction in intensive outpatient treatment. Arch Gen Psychiatry 1970;22:128-35.33. Barsky AJ, Orav EJ, Ahern DK, Rogers MP, Gruen SD, Liang MH.

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