Functional somatic syndrome? Fibromyalgia and chronic fatigue syndrome do not represent hypochondriasis,8 although they may be exacerbated by comorbid psychiatric disorders. Both disorders have diagnostic criteria and specified courses and have been studied to identify psychiatric comorbidity.
Transient or sustained? After it is clear that the patient is not suffering from a medical problem, determine whether hypochondriasis is transient or fully diagnostic:
- If transient, the patient may only need to be educated about how overattention may amplify symptoms; reassure him or her that a full medical workup has been negative.
- If fully diagnostic, reassurance may work for only a few days or weeks; the return of the fear or conviction helps establish the diagnosis.
Somatoform disorder? Distinguish hypochondriasis from other somatoform disorders (Table 2). In practice, the terms “hypochondriac” and “somatizer” are commonly used interchangeably, but the distinction needs to be clear. Hypochondriasis is primarily a disorder of abnormal cognition, in which symptom meaning is of greatest concern. Somatization is primarily a disorder of abnormal sensation, in which the symptoms themselves are the overwhelming focus of attention.
Anxiety disorder? Patients with generalized anxiety disorder may worry about illness, but they also worry about other life issues. Patients with panic disorder may have intense hypochondriacal concerns (such as having a heart attack), but these worries tend to be related to panic symptoms and resolve when the panic disorder is treated.
Obsessive compulsive disorder? Like obsessive-compulsive disorder (OCD), hypochondriasis is characterized by recurrent intrusive thoughts that create heightened anxiety and distress. To relieve their anxiety, patients with hypochondriasis engage in compulsions, such as:
- undergoing extensive medical tests
- seeking habitual reassurance from doctors and family
- consulting medical literature
- performing repeated body checks for perceived lumps or bumps
- avoiding activities that trigger their health-related stress.9
Table 2
How to distinguish somatoform disorders
| Disorder | Patient focuses on… |
|---|---|
| Hypochondriasis | physical symptoms’ meaning (abnormal cognition) |
| Somatization disorder | multiple unexplained physical symptoms (abnormal sensation) |
| Body dysmorphic disorder | perceived abnormal bodily appearance |
| Conversion disorder | motor or sensory function abnormalities that develop soon after life stressors or conflict |
| Pain disorder | intense pain, in which psychological factors contribute to pain onset, severity, or maintenance |
OCD and hypochondriasis also may share the diagnostic feature of pathologic doubt; patients’ uncertainty in appraising a situation leads to additional checking and reassurance-seeking behaviors. The immediate relief gained by these compulsions reinforces the patient’s urge to engage in more maladaptive behaviors and sends a stronger message to the brain that these behaviors are needed to prevent harm.
Ironically, the emergence of a real medical ailment—despite hypochondriacal worry—may force the patient to re-evaluate the usefulness of behaviors motivated by trying to avoid harm. A hypochondriacal patient who was diagnosed with optic neuritis and possible multiple sclerosis recently said to these authors, “I had always thought that by being vigilant I could keep illnesses away. Now I know that’s not true.”
Although hypochondriasis and OCD have similarities, certain clinical distinctions exist. Patients with hypochondriasis worry about having an illness, whereas OCD patients with somatic obsessions fear developing or transmitting an illness. A hypochondriacal patient might fear having AIDS or cancer despite reassurance from doctors, while an OCD patient more typically would fear contracting or transmitting the disease (a contamination obsession) and would engage in excessive behaviors to reduce the risk of developing the disease.
Depressive disorder? Unlike the anxious-worrying version of hypochondriasis, the depressive version is more fatalistic. Patients may be convinced they are dying of a dreaded disease, often believing it to be punishment for an indiscretion, such as marital infidelity. Or they may suddenly become hypochondriacal with mild depressive features, unaware that the actual problem is unresolved bereavement (hypochondriasis with secondary depression). The appropriate diagnosis is primary depressive disorder with secondary hypochondriacal features when depression dominates the presentation and preceded the illness fears.
Table 3
Recommended dosages for treating primary hypochondriasis
| Drug | Starting dosage | Maximum dosage |
|---|---|---|
| Fluoxetine | 10 mg/d if panic symptoms are present; 20 mg/d otherwise | 80 mg/d |
| Fluvoxamine | 50 mg at bedtime | 150 mg bid |
| Nefazodone | 100 mg bid | 300 mg bid |
| Paroxetine | 20 mg once daily | 50 mg once daily |
Delusional disorder? To distinguish hypochondriasis from delusional disorder (somatic type), consider the patient’s pattern of insight:
- Hypochondriacal patients often vacillate between poor and excellent insight, depending on their distress level.10 They may acknowledge the irrationality of their fears, then later be convinced they have a disease.
- Patients with delusional disorder are convinced they have a serious health threat, despite the absence of medical confirmation. These patients are considered to have a primary psychotic disorder that requires antipsychotic treatment.
TREATING PRIMARY SYMPTOMS
Drug therapy. When hypochondriasis is secondary—such as to depression or panic disorder—treat the primary condition first.11,12 For primary hypochondriasis, selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine, paroxetine, or fluvoxamine have shown benefit, mostly in open-label studies. An uncontrolled case series suggests that nefazodone—with mixed serotonin reuptake inhibition and agonist properties—also may help patients with hypochondriasis.13 In the only published controlled study, fluoxetine was more effective than placebo for treating hypochondriasis.10