Using the statistical tools of factor analysis, Pilowsky (1967) identified three key components of hypochondriasis: bodily preoccupation, disease phobia, and disease conviction. Depending on which feature is predominant in a particular patient, the disorder might appear strikingly different. For example, a patient with a high level of bodily preoccupation might check his or her body repeatedly or emphasize physical ailments when talking to others. A patient with a high level of disease phobia might avoid seeing a physician because he or she is terrified of hearing the physician confirm the fear: "Yes, you do have cancer." A patient with a high level of disease conviction may be the most difficult for a physician to tolerate, because such a patient responds with hostility to the physician's reassurance that no disease underlies the physical sensations. As the patient's mistrust and frustration rise, the physician in turn may come to resent the patient's anger, time demands, and disrespect of his or her medical authority (Barsky 1991). Such a strained doctor-patient relationship raises the risk that the patient with hypochondriasis may get a poor medical evaluation when in fact he or she may have a legitimate undetected physical illness.
The most common age at onset of hypochondriasis is in early adulthood, although it may occur at any age (Fallon et al. 1993). The course of hypochondriasis without treatment is thought to be chronic for the majority of patients, with symptoms waxing and waning in severity. With treatment, patients can do very well both in the short and long term. In a 4-year follow-up study (Bar-sky et al. 2000), patients with poor outcome tended to have a higher baseline tendency to amplify benign bodily sensations and attribute ambiguous sensations to bodily disease.
When the course is chronic, hypochondriasis may appear similar to lifetime obsessive-compulsive disorder (OCD) or a personality disorder. When the course is intermittent (Barsky et al. 1990) or of new onset, the physician should search for predisposing stressful life events as the cause (e.g., the sudden death of a loved one). Henry Maudsley, the great British anatomist of the 19th century, referred to this type of grief-induced hypochondria in poetic terms: "The sorrow that has no vent in tears makes other organs weep."
Patients with hypochondriasis frequently perform repetitive checking behaviors, such as asking family members and health care practitioners for reassurance, scheduling multiple doctor visits, and consulting medical books, to alleviate some of the anxiety caused by the somatic obsessions. In addition, many have a tendency to compulsively scan their bodies for signs of disease. Excessive probing and checking often aggravate the affected area and leave behind deceptive lumps and bumps, causing the patient and the physician to suspect the existence of disease. With the advent of the Internet, checking rituals may now include scanning medical Web sites for the signs and symptoms of illness and communicating online with other individuals who are experiencing anxiety. The Internet chat rooms can be particularly troubling sources of misinformation, leading one journalist who wrote about hypochondriasis to use the term "cyberchondria" (Carrns 1999).
An individual's degree of insight into the excessiveness of his or her fear of illness ranges from excellent to poor. For diagnostic purposes, patients with hypochondriasis who have little awareness of the unreasonable nature of their concerns should be diagnosed as having "hypochondriasis, with poor insight" (American Psychiatric Association 1994). Declining insight may lead to "overvalued ideation," which in turn may develop into hypochondria-cal convictions of delusional intensity. If there is no insight at all into the possibility that the fear may be unfounded, and this lack of insight is sustained for long periods, patients should be diagnosed as having delusional disorder or major depression with psychotic features, not hypochondriasis.
The differential diagnosis of hypochondriasis is important to keep in mind when evaluating the patient. First, a medical condition must be excluded. Given that some medical diseases may be hard to exclude completely because their early stages are less apparent or because adequate laboratory diagnostic tools are unavailable for them (e.g., multiple sclerosis, systemic lupus erythematosus, Lyme disease, occult malignancies), the physician working with a patient whose hypochondriasis does not improve with psychiatric treatment should reconsider the possibility that a diagnosis of medical illness has been missed. Similar to somatization disorder, hypochondriasis is characterized by the presence of unexplained symptoms or sensations. However, the patient with hypochondriasis takes these symptoms one step further by leaping to a catastrophic cognitive misinterpretation of the significance of these symptoms.
One group of patients with hypochondriasis appears to have much in common with patients who have OCD (Barsky 1992; Fallon et al. 1991, 2000), particularly the intrusive obsessions about illness and the compulsive urges to check for reassurance. Patients with this OCD-like subtype of hypochondriasis are plagued by a heightened expectation of harm in the form of illness and pathological doubt over whether they were thorough enough in explaining their symptoms. The obsessional form of hypochon-driasis needs to be considered when a patient asks a question such as "But doctor, how can I be sure?" This distinct subtype of hypochondria may have important therapeutic ramifications, because some medications particularly helpful for patients with OCD may also be helpful for patients with hypochondriasis.
Bienvenu et al. (2000) confirmed a relationship between OCD and hypochondriasis by demonstrating a higher frequency of hypochondriasis in patients with OCD and their first-degree family members than in control subjects and their first-degree family members.
Another group of patients with hypochondriasis appears to have symptoms of depression (Kellner et al. 1986b). The degree of insight of these patients tends to wax and wane less than that of patients with the obsessional form of hypochondriasis, and these patients have a more intense conviction that the illness is actually destroying them from within. Typically, these patients are tearful and suffer from concomitant major depression that emerged after the onset of hypochondriasis.
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