Which disorder involves a person being preoccupied with fear of having a serious disease?

Physical Findings & Clinical Presentation

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Somatic symptoms or signs are not present or are only mild and not concerning; the focus of anxiety is the suspected medical diagnosis itself (i.e., concern for underlying cause of illness rather than symptoms per se).

Mild somatic symptoms, if present, often include nonpathologic physical signs or sensations (e.g., belching, orthostatic light-headedness, nonspecific numbness and tingling).

High health-related anxiety persists despite reassuring clinical evaluation (without the intensity of a delusion).

Patients present to health care setting either seeking repeated reassurance that they do not have the illness or, alternatively, are convinced they have diagnosis and are unable to be convinced otherwise despite clinical signs and data.

Illness anxiety is most likely to revolve around serious medical illnesses rather than minor conditions.

Illness anxiety symptoms often correlate with psychosocial stressors.

Illness preoccupation lasts at least 6 mo (the specific illness feared may vary).

Disruption in health-related quality of life and/or social, occupational, or other important areas of functioning.

May present with cyberchondria phenomenon in which patient incessantly checks body for symptoms and then spends excessive time online researching possible serious causes for symptoms.

Two presentation types: Care-seeking (medical attention frequently sought) and care-avoidant (maladaptive avoidance of health care).

No specific physical examination findings.

A comorbid mental disorder (e.g., generalized anxiety, obsessive-compulsive disorder [OCD], or depression) may affect over two thirds of individuals with illness anxiety disorder; personality disorders and other somatic symptom disorders may also be more common.

Abstract

Hypochondriasis describes a persistent preoccupation with the possibility of having one or more serious and progressive physical disorders. There is a continuum between normal health anxiety and persistent, disabling hypochondriasis. Interviews and self-administered questionnaires used to diagnose hypochondriasis are described and the question whether it is best considered a somatoform or an anxiety disorder is discussed. In DSM-V the diagnosis of Hypochondriasis has been changed to Illness anxiety disorder and Somatic symptom disorder. The best documented treatment is cognitive-behavioral therapy, and how this is performed, including mindfulness techniques, is described. Health anxiety is still underrecognized, and with the advent of focused, time-limited and effective therapy it deserves increased attention even in primary care settings.

Depression, Catastrophic Thinking, and Health Anxiety

Pain intensity and magnitude of limitations are influenced by catastrophic thinking, heightened illness concerns, and depressed feelings.3 For instance, a person who tends to worry about minor matters may dwell on worst-case scenarios and tend to misinterpret symptoms. This “catastrophic thinking” involves a tendency to magnify, feel helpless about, and ruminate on the problem, the nociception in particular. Those with notable heightened illness concern may see a benign issue as a sign of serious pathology despite repeated assurances to the contrary. Symptoms of depression reflect a downward spiral. A person with substantial symptoms of depression may become self-critical (“It’s my fault”), feel pessimistic (“Everything goes wrong”), or feel hopeless (“I will never get over this”). Pain may elicit or intensify symptoms of depression. Pain may also be the somatic manifestation of symptoms of depression.4 Negative thinking increases symptoms and limitations.

There are questionnaires that quantify psychological phenomena. Symptoms of depression can be quantified with the Center for the Epidemiologic Study of Depression (CESD)5 scale, the Beck Depression Inventory (BDI),6 or the Depression Subscale of the Patient Health Questionnaire (PHQ).7 These measures inquire about typical symptoms of depression, and they vary in terms of their emphasis on the somatic versus emotional and cognitive components of depression. Although major depression is a discrete diagnosis, these scales measure depressive traits or symptoms along their spectrum, all meriting attention.

The Pain Catastrophizing Scale (PCS)8 is a 13-item measure of catastrophic thinking in response to nociception. It has three subscales: magnification (belief that pain will worsen), helplessness (a sense of impotence), and rumination (preoccupation with the pain). Catastrophic thinking is one of the strongest predictors of pain intensity and magnitude of limitations.

Health anxiety (hypochondriasis) can be assessed with the Health Anxiety Inventory,9 Whitley Index,10 and Somatic Symptoms Inventory (SSI).11 The latter assesses the extent to which patients experience nausea, vomiting, hot or cold spells, heart pounding, heavy arms, and other bodily symptoms. The Health Anxiety Inventory and Whitley Index assess degree of worry about health and serious illness. Health anxiety seems particularly relevant in nonspecific, activity-related pains.15

Validated measures might facilitate the clinician’s ability to address sensitive topics. Empathy and effective communication strategies gain trust and help people open up. Multidisciplinary teams including surgeon and nonsurgeon specialists, hand therapists, and social workers or behavioral medicine specialists are prepared to address all opportunities for helping people get and stay healthy.12

Abstract

Hypochondriasis describes a persistent preoccupation with the possibility of having one or more serious and progressive physical disorders. There is a continuum between normal health anxiety and persistent, disabling hypochondriasis. Interviews and self-administered questionnaires used to diagnose hypochondriasis are described and the question whether it is best considered a somatoform or an anxiety disorder is discussed. The best documented treatment is cognitive-behavioral therapy, and how this is performed, including mindfulness techniques, is described. Health anxiety is still underrecognized, and with the advent of focused, time-limited and effective therapy it deserves increased attention even in primary care settings.

Anxiety Disorders

Anxiety disorders are the most prevalent form of psychiatric illness in the general community.Anxiety is defined as a subjective sense of unease, dread, or foreboding. It can be a primary psychiatric illness, a reaction to or result of a medical illness, or a medication side effect. Anxiety is associated with distressing symptoms such as nervousness, insomnia, hypochondriasis, and somatic complaints. It is useful clinically to consider anxiety disorders as occurring in two different patterns: (1) generalized anxiety disorder and (2) episodic, often situation-dependent, anxiety. The γ-aminobutyric acid (GABA) neurotransmitter system has been implicated in the pathogenesis of anxiety disorders.

Anxiety resulting from identifiable stressors is usually self-limited and rarely requires pharmacologic treatment. Performance anxiety (stage fright) is a type of situational anxiety that is often treated with β-blockers, which do not produce sedation or allay anxiety but do eliminate the motor and autonomic manifestations of anxiety. The presence of unrealistic or excessive worry and apprehension may be cause for drug therapy. Buspirone, a partial 5-HT2A receptor antagonist, is a nonbenzodiazepine anxiolytic drug that is not sedating and does not produce tolerance or drug dependence. However, its slower onset of action (several weeks until full effect is reached) and the need for thrice-daily dosing have limited its use. Short-term and often dramatic relief is afforded by almost any benzodiazepine, which is not surprising since these drugs bind to GABA receptors. Other drugs with GABAergic properties such as gabapentin, pregabalin, and divalproex may also be effective in treating anxiety disorders. Supplemental cognitive-behavioral therapy, relaxation techniques, hypnosis, and psychotherapy are also very useful in treating anxiety disorders.

Panic disorders are qualitatively different from generalized anxiety. The patient typically experiences recurrent andunprovoked episodes of intense fear and apprehension associated with physical symptoms and signs such as dyspnea, tachycardia, diaphoresis, paresthesias, nausea, chest pain, and fear of impending doom or dying. Such episodes can be confused with, or indeed caused by, certain medical conditions such as angina pectoris, epilepsy, pheochromocytoma, thyrotoxicosis, hypoglycemia and cardiac dysrhythmias. Several classes of medications are effective in reducing panic attacks, including SSRIs, benzodiazepines, cyclic antidepressants and MAOIs. These drugs have comparable efficacy. Psychotherapy and education increase the effectiveness of drug treatment.

6.24.2.2 Hypochondriasis

Hypochondriasis is a Greek word meaning “below the cartilage.” The ancient Greeks derived the concept of hypochondriasis from humoral theories of disease and considered it a special form of melancholia resulting from an excess of black bile. In the seventeenth century, Thomas Sydenham, an English physician, argued that hypochondriasis occurred only in men and was equivalent to hysteria occurring in females. Also around this period, Descartes proposed that the mind and body were separate entities, and there could be no causal relation between the two. Subsequent psychodynamic views suggested that hypochondriacal patients direct their libido inwards, whereas healthy persons typically direct their libido at external objects. Eventually, internally directed libido would build up and result in physical symptoms (Freud, 1956).

Abstract

Health anxiety or hypochondriasis is characterized by pathological worries of harboring a severe disease and preoccupation by bodily sensations and function. Hypochondriasis has been known since antiquity but in different meanings. Research has now shown that is a distinct phenotype that can be demarked from other conditions, but this approach is not fully adopted in the illness anxiety disorder and somatic symptom disorder of the DSM-V or hypochondriasis in the ICD-10 /11. Health worries are prominent in various mental disorders (depression, anxiety, psychosis, or functional disorders), and therefore a meticulous diagnostic assessment is important in establishing the diagnosis. A symptom of high differential diagnostic importance is obsessive rumination about ones health which has been shown to be specific for health anxiety. Other symptoms are increased suggestivity, fear of becoming contaminated or infected, fear of taking prescribed medication, and fascination with health information, and some patients may be difficult to reassure that there is nothing wrong physically.

Hypochondriasis

The hallmark of hypochondriasis is the belief that one has a serious illness or is preoccupied with the fear that one has a serious illness (see Case Example 2). This preoccupation is based on a misinterpretation of bodily signs or symptoms. The preoccupation in hypochondriasis can be focused on a variety of different issues. Patients with hypochondriasis may be preoccupied with normal bodily functions (e.g., heart rate, sweating, peristalsis). They may be preoccupied with a minor physical symptom (e.g., occasional cough, a small skin lesion such as a freckle or pimple). Alternatively, the preoccupation may be with physical symptoms which they have a difficult time articulating, and their descriptions may be vague and ambiguous. Whatever the physical symptom preoccupation is, all hypochondriacal patients then make cognitive interpretations that these bodily experiences are symptoms or signs of a serious disease. Some persons may be preoccupied around a single, central disease theme such as heart disease or cancer, and other persons may be concerned about different diagnoses reflecting various bodily symptoms (Box 12-4).

In making the diagnosis of hypochondriasis, it is assumed that the patient has received “appropriate medical evaluation and reassurance.” As discussed earlier, it is easy to see the potential problems associated with this criterion. Often, physicians can feel that they have appropriately explained symptoms, but it is clear that patients have not understood their physician's explanations. Occasionally, the psychiatric interviewer can “cure hypochondriasis” during an assessment interview by providing a clear explanation for symptoms, that the patient can understand. Trying to come up with an explanation that suits and can be understood by a particular patient can be intellectually challenging. I personally enjoy the creative task of trying to size up a particular patient and then figure out what type of explanation or metaphor is going to be most helpful to him.

I.C. Hypochondriasis

The essential feature of hypochondriasis is fear or worry that a symptom (often a minor physiologic sensation) represents a serious illness. This disorder is equally common in men and women. By definition, this preoccupation with disease must be present for longer than 6 months. The same general principles of conservative management with the primary care physician as principle clinician apply. Treatment of concurrent anxiety and depression is important. Cognitive therapies aimed at diminishing the focus and attention of these patients on physical sensations and reinterpreting these sensations as non-disease events has been used individually and in a group therapy format. Framing these therapies as techniques for dealing with physical distress, rather than a more direct psychological approach, may have positive results.

Triggers

Previous studies have suggested that hypochondriasis (not specifically health anxiety) is precipitated by traumatic events (Seivewright, Tyrer, Ferguson, Murphy, & Johnson, 2000) and, in our own clinical experience, these are often related to sudden death. There is a great element of superstition here (e.g., “both my father and uncle died of heart attacks at the age of 50, and I am sure the same is going to happen to me”). The responsibility of becoming the main monitor of health is reinforced by these thoughts, and this consequently reinforces health anxiety.

A large proportion of patients with health anxiety also have high levels of generalized anxiety, and study of these associations has led Scarella, Laferton, Ahern, Fallon, and Barsky (2016) to the conclusion that health anxiety belongs firmly with the anxiety disorders.