Hypochondriasis
Hypochondriasis is preoccupation with the fear of having, or with the idea that one has, a serious disease, based on misinterpretation of nonpathologic physical symptoms or normal bodily functions. Hypochondriasis is nonvolitional; the exact cause is unknown.
Hypochondriasis most commonly begins during early adulthood and appears to occur equally among men and women.
Symptoms: A wide array of fears may derive from misinterpreting nonpathologic physical symptoms or normal bodily functions (eg, abdominal bloating and crampy discomfort, heartbeat, sweating). The location, quality, and duration of symptoms are often described in minute detail, but symptoms are usually not associated with abnormal physical findings. Symptoms impair social and occupational functioning or cause significant distress.
The course is often chronic—fluctuating in some, steady in others. Some patients recover.
Diagnosis: The diagnosis is suggested by the history and confirmed when symptoms persist ≥ 6 months despite appropriate medical evaluation that excludes a physical disorder and reassurance, and when the symptoms are not better accounted for by depression or another mental disorder.
Treatment is difficult because patients believe that something is seriously wrong and that the physician has failed to find the real cause. A trusting relationship with a caring, reassuring physician can nonetheless prove beneficial. If symptoms are not adequately relieved, patients may benefit from a psychiatric referral while continuing under the care of the primary physician.
Treatment with serotonin reuptake inhibitors may be helpful, as may cognitive-behavioral therapy.
VIGNETTE:
A 53 year old woman comes to the office because of a “discrete right-sided breast mass.” She says that she discovered it in the shower 9 months ago, and has been to 6 different physicians for evaluation. None of the other physicians were able to palpate this “mass” and so they told her that it must be “in her head.” This is the first time that you are seeing this patient, so you ask her to review her complete history. She is a married homemaker and is the mother of 2 children who are both at out-of-town colleges. Her husband is a traveling salesman. She has not had any medical problems in the past, and her family history is unremarkable. Menarche was at age 14 and she is still menstruating. She exercises 3 times a week, eats a low-fat diet, and drinks 1-3 glasses of wine a week. She has had normal Pap smears for the past 30 years and has never had a mammogram. She tearfully tells you that her best friend died of breast cancer 2 years ago. She denies any episodes of “sadness”, insomnia, or feelings of hopelessness, helplessness, or guilt. Physical examination is completely normal. You cannot palpate any breast masses, even after she guides you to the “exact location” on the right breast. You send her for a mammogram and a breast sonogram, and tell her that you will let her know the results as soon as they return. The results, which return in 2 days, show normal breast tissue and no abnormalities. You have your nurse call the patient and tell her to schedule an appointment at her convenience to discuss the results. Today, at the return visit, you explain the results of the tests and she still seems to feel that there is “something there.” You try to be as patient as possible and tell her that there is most likely no mass present. She looks at the ground and says that it “will show up” if you order more studies. After you discuss the situation further, the most appropriate next step is to
A. advise her to voluntarily commit herself to the hospital for psychiatric evaluation
B. encourage her to get a “second opinion” from another general physician
C. order a CT scan of the chest
D. order a fine needle aspiration of the right breast
E. schedule regular weekly 15 minute appointments and recommend that she also see a psychiatrist
The correct answer is E. This patient most likely has hypochondriasis, which is a disorder where the patient has a firm conviction of having a serious illness, despite repeated evidence to the contrary. Even when presented with definitive evidence, these patients remain convinced that they are ill. Patience, compassion, regularly scheduled appointments and collaboration with a psychiatrist may be effective in treating these patients.
Since this patient is not depressed, suicidal, or homicidal, hospitalization (choice A) is not indicated. She should probably go to talk to a psychiatrist, and make regularly scheduled appointments to see you.
A “second opinion” (choice B) is not necessary in this case of hypochondriasis because she has already seen 6 other physicians, and does not seem to have a breast mass. She needs regularly scheduled appointments, and she should see a psychiatrist.
Because the clinical breast examination, mammogram, ultrasound, and CT scan were unremarkable, a CT scan (choice C) and a fine needle aspiration (choice D) are not necessary. This patient most likely has hypochondriasis and usually a thorough medical work-up is enough, but unnecessary procedures should be discouraged. Also, a FNA is used when there is a discrete mass, and there is nothing in this case.