Hypochondriasis

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Hypochondriasis
Other namesHypochondria, health anxiety (HA), illness anxiety disorder, somatic symptom disorder
Le Malade imaginaire.jpg
Honoré Daumier, The Imaginary Illness (c. 1860–1862)
Specialty Psychiatry, psychology   OOjs UI icon edit-ltr-progressive.svg
Symptoms Excessive and persistent fear of, or preoccupation with, having or developing a severe illness; excessive health care seeking
Usual onsetEarly childhood
Differential diagnosis panic disorder, obsessive-compulsive disorder, generalized anxiety disorder
Treatment Cognitive behavioral therapy (CBT)
Medication SSRI, antidepressants
Prognosis ~50% meet criteria after ~1-5 years
Frequency~5%

Hypochondriasis or hypochondria is a condition in which a person is excessively and unduly worried about having a serious illness. Hypochondria is an old concept whose meaning has repeatedly changed over its lifespan. [1] It has been claimed that this debilitating condition results from an inaccurate perception of the condition of body or mind despite the absence of an actual medical diagnosis. [2] An individual with hypochondriasis is known as a hypochondriac. Hypochondriacs become unduly alarmed about any physical or psychological symptoms they detect, no matter how minor the symptom may be, and are convinced that they have, or are about to be diagnosed with, a serious illness. [3]

Contents

Often, hypochondria persists even after a physician has evaluated a person and reassured them that their concerns about symptoms do not have an underlying medical basis or, if there is a medical illness, their concerns are far in excess of what is appropriate for the level of disease. It is also referred to hypochondriaism which is the act of being in a hypochondriatic state, acute hypochondriaism. [4] Many hypochondriacs focus on a particular symptom as the catalyst of their worrying, such as gastro-intestinal problems, palpitations, or muscle fatigue. To qualify for the diagnosis of hypochondria the symptoms must have been experienced for at least six months. [5]

International Classification of Diseases (ICD-10) classifies hypochondriasis as a mental and behavioral disorder. [6] In the Diagnostic and Statistical Manual of Mental Disorders, DSM-IV-TR defined the disorder "Hypochondriasis" as a somatoform disorder [7] and one study has shown it to affect about 3% of the visitors to primary care settings. [8] The 2013 DSM-5 replaced the diagnosis of hypochondriasis with the diagnoses of somatic symptom disorder (75%) and illness anxiety disorder (25%). [9] [10]

Hypochondria is often characterized by fears that minor bodily or mental symptoms may indicate a serious illness, constant self-examination and self-diagnosis, and a preoccupation with one's body. Many individuals with hypochondriasis express doubt and disbelief in the doctors' diagnosis, and report that doctors’ reassurance about an absence of a serious medical condition is unconvincing, or short-lasting. Additionally, many hypochondriacs experience elevated blood pressure, stress, and anxiety in the presence of doctors or while occupying a medical facility, a condition known as "white coat syndrome". Many hypochondriacs require constant reassurance, either from doctors, family, or friends, and the disorder can become a debilitating challenge for the individual with hypochondriasis, as well as their family and friends. [11] Some individuals with hypochondria completely avoid any reminder of illness, whereas others frequently visit medical facilities, sometimes obsessively. [12] Some may never speak about it.

A research based on 41,190 people, and published in December 2023 by JAMA Psychiatry, found that people suffering from hypochondriasis had a five-year shorter life expectancy compared to those without symptoms. [13]

Signs and symptoms

Hypochondriasis is categorized as a somatic amplification disorder—a disorder of "perception and cognition" [2] —that involves a hyper-vigilance of situation of the body or mind and a tendency to react to the initial perceptions in a negative manner that is further debilitating. Hypochondriasis manifests in many ways. Some people have numerous intrusive thoughts and physical sensations that push them to check with family, friends, and physicians. For example, a person who has a minor cough may think that they have tuberculosis. [14] Or sounds produced by organs in the body, such as those made by the intestines, might be seen as a sign of a very serious illness to patients dealing with hypochondriasis. [15]

Other people are so afraid of any reminder of illness that they will avoid medical professionals for a seemingly minor problem, sometimes to the point of becoming neglectful of their health when a serious condition may exist and go undiagnosed. Yet others live in despair and depression, certain that they have a life-threatening disease and no physician can help them. Some consider the disease as a punishment for past misdeeds. [16]

Hypochondriasis is often accompanied by other psychological disorders. Bipolar disorder, clinical depression, obsessive-compulsive disorder (OCD), phobias, and somatization disorder, panic disorder are the most common accompanying conditions in people with hypochondriasis, as well as a generalized anxiety disorder diagnosis at some point in their life. [17]

Many people with hypochondriasis experience a cycle of intrusive thoughts followed by compulsive checking, which is very similar to the symptoms of obsessive-compulsive disorder. However, while people with hypochondriasis are afraid of having an illness, patients with OCD worry about getting an illness or of transmitting an illness to others. [16] Although some people might have both, these are distinct conditions. [16]

Patients with hypochondriasis often are not aware that depression and anxiety produce their own physical symptoms, and mistake these symptoms for manifestations of another mental or physical disorder or disease. For example, people with depression often experience changes in appetite and weight fluctuation, fatigue, decreased interest in sex, and motivation in life overall. [18] Intense anxiety is associated with rapid heartbeat, palpitations, sweating, muscle tension, stomach discomfort, dizziness, shortness of breath, and numbness or tingling in certain parts of the body (hands, forehead, etc.). [19]

If a person is ill with a medical disease such as diabetes or arthritis, there will often be psychological consequences, such as depression. Some even report being suicidal. [20] In the same way, someone with psychological issues such as depression or anxiety will sometimes experience physical manifestations of these affective fluctuations, often in the form of medically unexplained symptoms. [21] Common symptoms include headaches; abdominal, back, joint, rectal, or urinary pain; nausea; fever and/or night sweats; itching; diarrhea; dizziness; or balance problems. Many people with hypochondriasis accompanied by medically unexplained symptoms feel they are not understood by their physicians, and are frustrated by their doctors’ repeated failure to provide symptom relief. [22]

Cause

The genetic contribution to hypochondriasis is probably moderate, with heritability estimates around 10–37%. Non-shared environmental factors (i.e., experiences that differ between twins in the same family) explain most of the variance in key components of the condition such as the fear of illness and disease conviction. In contrast, the contribution of shared environmental factors (i.e., experiences shared by twins in the same family) to hypochondriasis is approximately zero. [23]

Although little is known about exactly which non-shared environmental factors typically contribute to causing hypochondriasis, certain factors such as exposure to illness-related information are widely believed to lead to short-term increases in health anxiety and to have contributed to hypochondriasis in individual cases. An excessive focus on minor health concerns and serious illness of the individual or a family member in childhood have also been implicated as potential causes of hypochondriasis. Underlying anxiety disorders, such as general anxiety disorder, also increases an individual's risk. [15]

In the media and on the Internet, articles, TV shows, and advertisements regarding serious illnesses such as cancer and multiple sclerosis often portray these diseases as being random, obscure, and somewhat inevitable. In the short term, inaccurate portrayal of risk and the identification of non-specific symptoms as signs of serious illness may contribute to exacerbating fear of illness. Major disease outbreaks or predicted pandemics can have similar effects.

Anecdotal evidence suggests that some individuals become hypochondriac after experiencing major medical diagnosis [24] or death of a family member or friend. Similarly, when approaching the age of a parent's premature death from disease, many otherwise healthy, happy individuals fall prey to hypochondria. These individuals believe they have the same disease that caused their parent's death, sometimes causing panic attacks with corresponding symptoms. [15]

Diagnosis

The ICD-10 defines hypochondriasis as follows:

A. Either one of the following:
  • A persistent belief, of at least six months' duration, of the presence of a minimum of two serious physical diseases (of which at least one must be specifically named by the patient).
  • A persistent preoccupation with a presumed deformity or disfigurement (body dysmorphic disorder).
B. Preoccupation with the belief and the symptoms causes persistent distress or interference with personal functioning in daily living and leads the patient to seek medical treatment or investigations (or equivalent help from local healers).
C. Persistent refusal to accept medical advice that there is no adequate physical cause for the symptoms or physical abnormality, except for short periods of up to a few weeks at a time immediately after or during medical investigations.
D. Most commonly used exclusion criteria: not occurring only during any of the schizophrenia and related disorders (F20–F29, particularly F22) or any of the mood disorders (F30–F39).

The DSM-IV defines hypochondriasis according to the following criteria: [7]

A. Preoccupation with fears of having, or the idea that one has, a serious disease based on the person's misinterpretation of bodily symptoms.
B. The preoccupation persists despite appropriate medical evaluation and reassurance.
C. The belief in Criterion A is not of delusional intensity (as in Delusional Disorder, Somatic Type) and is not restricted to a circumscribed concern about appearance (as in Body Dysmorphic Disorder).
D. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
E. The duration of the disturbance is at least 6 months.
F. The preoccupation is not better accounted for by Generalized Anxiety Disorder, Obsessive-Compulsive Disorder, Panic Disorder, a Major Depressive Episode, Separation Anxiety, or another Somatoform Disorder.

In the fifth version of the DSM (DSM-5), most who met criteria for DSM-IV hypochondriasis instead meet criteria for a diagnosis of somatic symptom disorder (SSD) or illness anxiety disorder (IAD). [9]

Classification

The classification of hypochondriasis in relation to other psychiatric disorders has long been a topic of scholarly debate and has differed widely between different diagnostic systems and influential publications. [25]

In the case of the DSM, the first and second versions listed hypochondriasis as a neurosis, whereas the third and fourth versions listed hypochondriasis as a somatoform disorder. The current version of the DSM (DSM-5) lists somatic symptom disorder (SSD) under the heading of "somatic symptom and related disorders", and illness anxiety disorder (IAD) under both this heading and as an anxiety disorder. [25]

The ICD-10, like the third and fourth versions of the DSM, lists hypochondriasis as a somatoform disorder. [26] The ICD-11, however, lists hypochondriasis under the heading of "obsessive-compulsive or related disorders". [27]

There are also numerous influential scientific publications that have argued for other classifications of hypochondriasis. Notably, since the early 1990s, it has become increasingly common to regard hypochondriasis as an anxiety disorder, and to refer to the condition as "health anxiety" or "health related obsessive-compulsive disorder." [28]

Treatment

Approximately 20 randomized controlled trials and numerous observational studies indicate that cognitive behavioral therapy (CBT) is an effective treatment for hypochondriasis. [29] [30] [31] [32] Typically, about two-thirds of patients respond to treatment, and about 50% of patients achieve remission, i.e., no longer have hypochondriasis after treatment. [32] The effect size, or magnitude of benefit, appears to be moderate to large. [32] CBT for hypochondriasis and health anxiety may be offered in various formats, including as face-to-face individual or group therapy, via telephone, [33] or as guided self-help with information conveyed via a self-help book [34] or online treatment platform. [35] Effects are typically sustained over time. [36] [32]

There is also evidence that antidepressant medications such as selective serotonin reuptake inhibitors can reduce symptoms. [37] [38] In some cases, hypochondriasis responds well to antipsychotics, particularly the newer atypical antipsychotic medications. [39]

Etymology

Among the regions of the abdomen, the hypochondrium is the uppermost part. The word derives from the Greek term ὑποχόνδριος hypokhondrios, meaning "of the soft parts between the ribs and navel" from ὑπό hypo ("under") and χόνδρος khondros, or cartilage (of the sternum). Hypochondria in Late Latin meant "the abdomen". [40]

The term hypochondriasis for a state of disease without real cause reflected the ancient belief that the viscera of the hypochondria were the seat of melancholy and sources of the vapor that caused morbid feelings. [41] Until the early 18th century, the term referred to a "physical disease caused by imbalances in the region that was below your rib cage" (i.e., of the stomach or digestive system). For example, Robert Burton's The Anatomy of Melancholy (1621) blamed it "for everything from 'too much spittle' to 'rumbling in the guts'". [42]

Immanuel Kant discussed hypochondria in his 1798 book, Anthropology from a Pragmatic Point of View , like this:

The disease of the hypochondriac consists in this: that certain bodily sensations do not so much indicate a really existing disease in the body as rather merely excite apprehensions of its existence: and human nature is so constituted – a trait which the animal lacks – that it is able to strengthen or make permanent local impressions simply by paying attention to them, whereas an abstraction – whether produced on purpose or by other diverting occupations – lessens these impressions, or even effaces them altogether.

See also

Related Research Articles

<span class="mw-page-title-main">Anxiety disorder</span> Cognitive disorder with an excessive, irrational dread of everyday situations

Anxiety disorders are a cluster of mental disorders characterized by significant and uncontrollable feelings of anxiety and fear such that a person's social, occupational, and personal functions are significantly impaired. Anxiety may cause physical and cognitive symptoms, such as restlessness, irritability, easy fatigue, difficulty concentrating, increased heart rate, chest pain, abdominal pain, and a variety of other symptoms that may vary based on the individual.

Specific phobia is an anxiety disorder, characterized by an extreme, unreasonable, and irrational fear associated with a specific object, situation, or concept which poses little or no actual danger. Specific phobia can lead to avoidance of the object or situation, persistence of the fear, and significant distress or problems functioning associated with the fear. A phobia can be the fear of anything.

Abnormal psychology is the branch of psychology that studies unusual patterns of behavior, emotion, and thought, which could possibly be understood as a mental disorder. Although many behaviors could be considered as abnormal, this branch of psychology typically deals with behavior in a clinical context. There is a long history of attempts to understand and control behavior deemed to be aberrant or deviant, and there is often cultural variation in the approach taken. The field of abnormal psychology identifies multiple causes for different conditions, employing diverse theories from the general field of psychology and elsewhere, and much still hinges on what exactly is meant by "abnormal". There has traditionally been a divide between psychological and biological explanations, reflecting a philosophical dualism in regard to the mind–body problem. There have also been different approaches in trying to classify mental disorders. Abnormal includes three different categories; they are subnormal, supernormal and paranormal.

<span class="mw-page-title-main">Obsessive–compulsive personality disorder</span> Personality disorder involving orderliness

Obsessive–compulsive personality disorder (OCPD) is a cluster C personality disorder marked by a spectrum of obsessions with rules, lists, schedules, and order, among other things. Symptoms are usually present by the time a person reaches adulthood, and are visible in a variety of situations. The cause of OCPD is thought to involve a combination of genetic and environmental factors, namely problems with attachment.

<span class="mw-page-title-main">Somatization disorder</span> Mental disorder consisting of clinically significant somatic symptoms

Somatization disorder was a mental and behavioral disorder characterized by recurring, multiple, and current, clinically significant complaints about somatic symptoms. It was recognized in the DSM-IV-TR classification system, but in the latest version DSM-5, it was combined with undifferentiated somatoform disorder to become somatic symptom disorder, a diagnosis which no longer requires a specific number of somatic symptoms. ICD-10, the latest version of the International Statistical Classification of Diseases and Related Health Problems, still includes somatization syndrome.

<span class="mw-page-title-main">Body dysmorphic disorder</span> Mental disorder

Body dysmorphic disorder (BDD), also known in some contexts as dysmorphophobia, is a mental disorder defined by an overwhelming preoccupation with a perceived flaw in one's physical appearance. In BDD's delusional variant, the flaw is imagined. When an actual visible difference exists, its importance is disproportionately magnified in the mind of the individual. Whether the physical issue is real or imagined, ruminations concerning this perceived defect become pervasive and intrusive, consuming substantial mental bandwidth for extended periods each day. This excessive preoccupation not only induces severe emotional distress but also disrupts daily functioning and activities. The DSM-5 places BDD within the obsessive–compulsive spectrum, distinguishing it from disorders such as anorexia nervosa.

Generalized anxiety disorder (GAD) is a mental and behavioral disorder, specifically an anxiety disorder characterized by excessive, uncontrollable and often irrational worry about events or activities. Worry often interferes with daily functioning, and individuals with GAD are often overly concerned about everyday matters such as health, finances, death, family, relationship concerns, or work difficulties. Symptoms may include excessive worry, restlessness, trouble sleeping, exhaustion, irritability, sweating, and trembling.

Dhat syndrome is a condition found in the cultures of South Asia in which male patients report that they suffer from premature ejaculation or impotence, and believe that they are passing semen in their urine. The condition has no known organic cause.

Impulse-control disorder (ICD) is a class of psychiatric disorders characterized by impulsivity – failure to resist a temptation, an urge, or an impulse; or having the inability to not speak on a thought. Many psychiatric disorders feature impulsivity, including substance-related disorders, behavioral addictions, attention deficit hyperactivity disorder, autism spectrum disorder, fetal alcohol spectrum disorders, antisocial personality disorder, borderline personality disorder, conduct disorder and some mood disorders.

Thought broadcasting is a type of delusional condition in which the affected person believes that others can hear their inner thoughts, despite a clear lack of evidence. The person may believe that either those nearby can perceive their thoughts or that they are being transmitted via mediums such as television, radio or the internet. Different people can experience thought broadcasting in different ways. Thought broadcasting is most commonly found among people who have a psychotic disorder, specifically schizophrenia.

Somatization is a tendency to experience and communicate psychological distress as bodily and organic symptoms and to seek medical help for them. More commonly expressed, it is the generation of physical symptoms of a psychiatric condition such as anxiety. The term somatization was introduced by Wilhelm Stekel in 1924.

Olfactory reference syndrome (ORS) is a psychiatric condition in which there is a persistent false belief and preoccupation with the idea of emitting abnormal body odors which the patient thinks are foul and offensive to other individuals. People with this condition often misinterpret others' behaviors, e.g. sniffing, touching their nose or opening a window, as being referential to an unpleasant body odor which in reality is non-existent and cannot be detected by other people.

Nosophobia, also known as disease phobia or illness anxiety disorder, is the irrational fear of contracting a disease, a type of specific phobia. Primary fears of this kind are fear of contracting HIV infection, pulmonary tuberculosis (phthisiophobia), sexually transmitted infections, cancer (carcinophobia), heart diseases (cardiophobia), and catching the common cold or flu.

Somatosensory amplification (SSA) is a tendency to perceive normal somatic and visceral sensations as being relatively intense, disturbing and noxious. It is a common feature of hypochondriasis and is commonly found with fibromyalgia, major depressive disorder, some anxiety disorders, Asperger syndrome, and alexithymia. One common clinical measure of SSA is the Somatosensory Amplification Scale (SSAS).

<span class="mw-page-title-main">DSM-5</span> 2013 edition of the Diagnostic and Statistical Manual of Mental Disorders

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), is the 2013 update to the Diagnostic and Statistical Manual of Mental Disorders, the taxonomic and diagnostic tool published by the American Psychiatric Association (APA). In 2022, a revised version (DSM-5-TR) was published. In the United States, the DSM serves as the principal authority for psychiatric diagnoses. Treatment recommendations, as well as payment by health care providers, are often determined by DSM classifications, so the appearance of a new version has practical importance. However, not all providers rely on the DSM-5 for planning treatment as the ICD's mental disorder diagnoses are used around the world and scientific studies often measure changes in symptom scale scores rather than changes in DSM-5 criteria to determine the real-world effects of mental health interventions. The DSM-5 is the only DSM to use an Arabic numeral instead of a Roman numeral in its title, as well as the only living document version of a DSM.

Primarily obsessional obsessive–compulsive disorder, also known as purely obsessional obsessive–compulsive disorder, is a lesser-known form or manifestation of OCD. It is not a diagnosis in the DSM-5. For people with primarily obsessional OCD, there are fewer observable compulsions, compared to those commonly seen with the typical form of OCD. While ritualizing and neutralizing behaviors do take place, they are mostly cognitive in nature, involving mental avoidance and excessive rumination. Primarily obsessional OCD takes the form of intrusive thoughts often of a distressing, sexual, or violent nature.

<span class="mw-page-title-main">Obsessive–compulsive disorder</span> Mental and behavioral disorder

Obsessive–compulsive disorder (OCD) is a mental and behavioral disorder in which an individual has intrusive thoughts and feels the need to perform certain routines (compulsions) repeatedly to relieve the distress caused by the obsession, to the extent where it impairs general function.

Functional disorders are a group of recognisable medical conditions which are due to changes to the functioning of the systems of the body rather than due to a disease affecting the structure of the body.

Somatic symptom disorder, also known as somatoform disorder, is defined by one or more chronic physical symptoms that coincide with excessive and maladaptive thoughts, emotions, and behaviors connected to those symptoms. The symptoms are not deliberately produced or feigned, and they may or may not coexist with a known medical ailment.

Masked depression (MD) was a proposed form of atypical depression in which somatic symptoms or behavioural disturbances dominate the clinical picture and disguise the underlying affective disorder. The concept is not currently supported by the mental health profession.

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  42. ↑ Mann L (July 11, 2012). "New book tries to explain the roots of hypochondria". Chicago Tribune.

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