C LINICA L PRAC TIC E

Clinical Practice

This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the author’s clinical recommendations.

T HE P ATIENT WITH H YPOCHONDRIASIS
ARTHUR J. BARSKY, M.D.

A 39-year-old single woman returns to her internist for the sixth time in nine months with the same symptoms — intermittent paresthesias and “swelling" of her hands and feet and belching. The results of physical examinations and laboratory studies have remained normal, yet this has failed to reassure her. She is now concerned that she has lupus and urgently requests a rheumatology consultation. How should you manage this problem?
THE CLINICAL PROBLEM

Hypochondriasis is a disabling and chronic disorder.1 The associated disability and impairment of role functioning are similar to those accompanying major mood and anxiety disorders and many chronic medical conditions.2,3 Not only is hypochondriasis refractory to standard medical management, but treatment often leads to complications, side effects, and new symptoms.3 Physicians find patients with hypochondriasis difficult to reassure, and dealing with such patients can be extremely time consuming. These patients are reluctant to acknowledge the role of psychosocial factors in causing their symptoms, and they often provoke strong antipathy on the part of physicians.4 Recent research has provided insight into some strategies that may improve outcomes for these patients and has revealed the limitations of such approaches as ordering tests to try to put patients’ minds at ease. Patients with hypochondriasis are preoccupied with the fear or belief that they have a serious, undiagnosed disease. This concern derives from a misinterpretation of benign physical sensations as evidence of serious illness, and it persists despite appropriate reassurance
From the Department of Psychiatry, Brigham and Women’s Hospital and Harvard Medical School, Boston. Address reprint requests to Dr. Barsky at the Department of Psychiatry, Brigham and Women’s Hospital, 75 Francis St., Boston, MA 02115.

to the contrary. The diagnostic criteria for hypochondriasis also require that the patient’s concern about illness persist for at least six months and cause clinically significant distress or functional impairment. Hypochondriasis may occur alone (primary hypochondriasis) or as a secondary feature of some other, more pervasive psychiatric disorder (secondary hypochondriasis). Somatization, a related phenomenon, refers more generally to a tendency to focus on the somatic manifestations of emotional distress and to present with somatic symptoms that have no demonstrable organic basis. Patients with hypochondriasis are a subgroup of patients who somatize — namely, those whose medically unexplained symptoms are accompanied by the unshakeable conviction that they have a serious disease. However, the overlap between hypochondriasis and somatization is considerable, and some of the clinical approaches to patients who somatize also apply to patients with hypochondriasis. Hypochondriacal concern spans a spectrum from mild, fleeting worry to persistent and incapacitating dread. The concern of patients with more severe hypochondriasis is persistent, produces a disproportionate degree of impairment of role functioning and disability, is unresponsive to repeated reassurance and negative diagnostic evaluations, and is refractory to the standard medical treatment of symptoms. These patients’ somatic symptoms are often normal physiologic sensations (such as orthostatic dizziness) or benign, self-limited ailments (such as transient tinnitus). Although not typical of serious disease, these bodily sensations are misinterpreted as such and are accompanied by profound anxiety about health and preoccupation with disease — a syndrome sometimes referred to as “illness as a way of life.”1 As a result, hypochondriasis results in substantial disability and impairment of role functioning.2 It should be emphasized that patients with hypochondriasis are not malingering or fabricating their symptoms. Patients with hypochondriasis have a characteristically paradoxical history of medical care — extensive, yet unsatisfactory. They have disproportionately high rates of visits to physicians, specialty consultations, laboratory tests, and surgical procedures, as well as high health care costs.5 Despite this extensive medical attention, however, they find their care frustrating and unsatisfactory. They feel ignored by their previous doctors and may often speak disparagingly of them. Physicians, in turn, generally find that such patients dismiss efforts to help them and are exceptionally difficult and frustrating to treat.4 This combination of anger and futility experienced by a physician in caring for a patient is often a signal that the patient has hypochondri-

N Engl J Med, Vol. 345, No. 19 · November 8, 2001 · www.nejm.org · 1395
The New England Journal of Medicine Downloaded from nejm.org on October 20, 2013. For personal use only. No other uses without permission. Copyright © 2001 Massachusetts Medical Society. All rights reserved.

10 In one study. and obsessive–compulsive disorder — is outlined in Table 2. the use of coping skills to moderate the intensity of symptoms. including avoiding their usual activities.8 Patients use these techniques to identify and alter dysfunctional beliefs and assumptions about symptoms and disease.12 After four months. Copyright © 2001 Massachusetts Medical Society. it is crucial to detect and treat the coexisting disorder as well. Studies assessing the efficacy of these therapies have reported improvements in anxiety about health. and the appropriate use of laboratory tests in ruling out medical diagnoses.6 Approximately two thirds of patients with hypochondriasis have another coexisting psychiatric disorder. or dubious generalizability. These include major depression (found in approximately 40 percent of cases). its possible medical and nonmedical causes. both were significantly more effective than no treatment according to a wide range of measures of hypochondriasis. and other nonpathologic sources of so- matic distress. 345. All rights reserved. Its prevalence does not appear to be elevated among the relatives of persons with hypochondriasis. and impaired social functioning as much as one year later. major depression. A diagnosis of hypochondriasis is also suggested when a patient responds to appropriate reassurance with anger rather than relief or when his or her symptoms are apparently exacerbated by simple palliative treatment. seeking reassurance from others. Therapy is highly interactive and may be conducted either in a group setting or individually. group-based cognitive–behavioral interventions led to significantly lower rates of outpatient visits and medication use than those found in a control group after six months of follow-up. These disorders are responsive to pharmacotherapy. their responses to the symptom.7 STRATEGIES AND EVIDENCE Approaches to the management of hypochondriasis are summarized in Table 1. and after long-term follow-up. The approach to both primary and secondary hypochondriasis is similar. to initiate a program of graduated physical conditioning.16 There is good evidence to support the vigorous treatment of the psychiatric disorders that frequently coexist with hypochondriasis. more adaptive responses. Pharmacotherapy for these disorders in patients with hypochondriasis may require relatively high doses and prolonged therapy (as 1396 · N Engl J Med.9 The topics covered by these materials include the high prevalence of symptoms in healthy people. chronic pain. SUGGESTED INTERVENTIONS FOR PATIENTS WITH HYPOCHONDRIASIS. pharmacotherapy for patients with a variety of medically unexplained symptoms (particularly chronic pain) has been studied. there was a substantial decline in the rate of visits to physicians. Both active treatments consisted of up to 16 sessions of individual treatment and 3 booster sessions. but in the latter case. patients are asked to record the thoughts or events that precede a symptom. Patients are given written materials that discuss common misunderstandings and misconceptions that patients with hypochondriasis tend to have about disease and medical care. panic disorder (in 10 to 20 percent). irritable bowel syndrome. to modify the maladaptive forms of behavior that perpetuate their symptoms. For personal use only. No. .org on October 20. Cognitive–Behavioral Therapies Promising cognitive–behavioral therapies have been developed. Hypochondriasis is found in 4 to 6 percent of general medical outpatients. the hypochondriacal symptoms generally resolve as well. 2013. tinnitus. race. 19 · November 8. and fatigue. normal physiology. educational level. fibromyalgia. and “shopping” for new physicians. these studies tend to be limited by small samples. In the most rigorous study of treatment to date. the lack of control groups. or sex.The Ne w E n g l a nd Jo u r n a l o f Me d ic i ne asis. No other uses without permission. stress. and when they are adequately treated. A recent meta-analysis concluded that antidepressant therapy was significantly more effective than placebo in more than two thirds of carefully selected studies of headache.11 However. and to learn techniques for relaxation. and generalized anxiety disorder. 48 patients with hypochondriasis were randomly assigned to receive either cognitive therapy or training in behavioral stress management or to be placed on a waiting list. Vol.12 The efficacy of these therapies is similar to that reported for the cognitive–behavioral treatment of several functional somatic syndromes. dysfunctional beliefs. panic disorder.14. such as atypical chest pain and chronic headache. and possible. obsessive–compulsive disorder (in 5 to 10 percent). the group on the waiting list was randomly reassigned to one of the two treatments.17-19 The standard pharmacotherapy for the common psychiatric disorders that often coexist with hypochondriasis — namely.13 In two studies of such treatment.15 Pharmacotherapy TABLE 1. In regular homework assignments between sessions.nejm. Cognitive–behavioral therapy Psychopharmacologic treatments (primarily antidepressants) Medical management strategies Schedule regular primary care visits Practice diagnostic and therapeutic conservatism Validate patient’s symptoms Provide explanatory model to account for patient’s symptoms Diagnose and treat coexisting psychiatric conditions Aim for care rather than cure Although pharmacotherapy for primary hypochondriasis has not been rigorously evaluated. concern about disease. 2001 · www. nor is the condition strongly associated with socioeconomic status. the absence of long-term follow-up.org The New England Journal of Medicine Downloaded from nejm.

treatment should be initiated at subtherapeutic doses.* AGENT INITIAL DOSE THERAPEUTIC RANGE OF DOSES SIDE EFFECTS INDICATIONS Selective serotonin-reuptake inhibitors Citalopram 10 mg/day 20–40 mg/day Fluoxetine Paroxetine Sertraline 5–10 mg/day 10 mg/day 12. and other therapies for hypochondriasis. weakness. CONCLUSIONS AND RECOMMENDATIONS There is a general consensus that several strategies are helpful in the treatment of patients with hypochon- TABLE 2. memory impairment.0 mg 4 times a day 0.5–2. panic disorder. that diagnos- At present. obsessive– compulsive disorder. and possible side effects should be explained carefully in advance. Vol. agitation. generalized anxiety disorder (short-term) Clonazepam 0. insomnia. headache.org · 1397 The New England Journal of Medicine Downloaded from nejm. 345. tremor. panic disorder. PHARMACOTHERAPY FOR COEXISTING PSYCHIATRIC CONDITIONS IN PATIENTS WITH HYPOCHONDRIASIS. headache. obsessive– compulsive disorder. and laboratory evaluations not be performed unless they were clearly indicated.CLINICA L PRAC TIC E much as eight or more weeks) before an adequate response is evident. headache. . anxiety. memory impairment. hypotension. panic disorder. discontinuation effects and symptom rebound. and that the physician explicitly acknowledge that the patient’s symptoms are real and not imaginary or fabricated.5–2. seizures (at high doses) Sedation. generalized anxiety disorder Other antidepressants Bupropion 75 mg/day Nefazodone Trazodone Venlafaxine 50 mg/day 25 mg at bedtime 25 mg twice a day 100–150 mg 3 times a day 150–300 mg twice a day 100–200 mg twice a day 75–150 mg twice a day Benzodiazepines Alprazolam 0. drowsiness. agitation. generalized anxiety disorder Depression Depression Depression Depression. hypertension (high doses only). falls (in elderly patients). For personal use only. panic disorder. dizziness Sexual dysfunction. dyspepsia.nejm.16. ataxia. anorexia. dizziness Sexual dysfunction. generalized anxiety disorder (short-term) Panic disorder. N Engl J Med. Copyright © 2001 Massachusetts Medical Society. falls (in elderly patients). insomnia. Other Management Strategies tic procedures. agitation. headache. priapism (rare). This intervention improved the patients’ physical functioning and resulted in a decrease of 33 to 53 percent in their median medical charges.25 mg/day 0. agitation. somnolence. Specific indications. and precautions must be determined for each case individually. psychomotor impairment Sedation. sedation. nausea. insomnia. generalized anxiety disorder Depression. dyspepsia. confusion (especially in elderly patients). weakness. nausea. orthostasis. headache. insomnia. which are increased very gradually. Smith et al. somnolence. 2013.21-23 The letter suggested that the patient be scheduled for brief but frequent regular visits and advised that “as-needed” visits be avoided whenever possible. agitation. that the primary care physician limit the number of other physicians seen by the patient. generalized anxiety disorder Depression. sedation. insomnia. 19 · November 8.20 Because of side effects. nausea. nausea. ataxia. sexual dysfunction. psychomotor impairment Depression. 2001 · www. nausea. but only two rigorous trials of their effectiveness have been conducted. there is not sufficient empirical evidence to support the effectiveness of specific cognitive. doses. fatigue. nausea. dyspepsia. dyspepsia. No. dizziness Anxiety. studied the effectiveness of a generic consultation letter sent to the physicians of patients with somatization disorder. somnolence.18 The potential benefits of pharmacotherapy should not be touted or overemphasized to patients with hypochondriasis. insomnia. surgery.25 mg/day *Hypochondriasis here includes related somatoform disorders. dizziness Sedation.23 AREAS OF UNCERTAINTY Interventions have also been designed that aim to improve the treatment of patients with hypochondriasis and those who somatize by primary care physicians. in part because of perceived side effects.5–25 mg/day 20–80 mg/day 20–50 mg/day 50–200 mg/day Sexual dysfunction. confusion (especially in elderly patients). sedation. nausea. dizziness Sexual dysfunction. GUIDELINES There are no published guidelines relevant to the clinical care of patients with hypochondriasis. sedation. obsessive– compulsive disorder.21. dizziness Sedation. Such patients are particularly likely not to adhere to the therapeutic regimen. headache Nausea. somnolence. drug interactions.0 mg twice a day Panic disorder. pharmacologic. generalized anxiety disorder Depression. discontinuation effects and symptom rebound.org on October 20. drowsiness. This list is intended only as a general guide. All rights reserved. discontinuation effects. No other uses without permission. obsessive– compulsive disorder. fatigue.

panic disorder. rather than an as-needed. Some patients may acknowledge that they have emotional distress for which they will accept psychiatric treatment while insisting that it bears no causal relation to their somatic symptoms. For personal use only. and an apparent lack of interest in recovery. Psychiatric comorbidity in DSMIII-R hypochondriasis. Sharpe M. since tests and procedures may cause complications and negative findings provide little lasting reassurance for patients who already have high levels of anxiety about health at the outset. major depression. Dr. not to vary that frequency when the number or severity of symptoms increases or decreases. regular visits to the physician. vitamins. 5. Stern R. Williams JBW. weight loss. The somatizing disorders: illness as a way of life. Somatization and hypochondriasis. perpetuating a cycle (so-called symptom amplification). Successful long-term medical management requires a durable and trusting doctor–patient relationship in which access to the doctor is not predicated on the presence of active symptoms. Holman A. Treatment of functional somatic symptoms. In: Mayou R. 2001 · www. Occult depression is suggested by such symptoms as anorexia. tests and specialty consultations should not be performed solely for the purpose of reassurance.19. The physician must remain alert to the possibility of an organic basis for the patient’s symptoms. REFERENCES 1. Warwick HM. insofar as clinically possible. Fernandez M. Rather. Sharpe M. 1995:122-43.30-33 such patients should not be treated for equivocal or incidental findings. Hypochondriacal patients. Salkovskis PM. Wyshak G. elastic bandages. Barsky AJ. since patients with hypochondriasis have levels of medical illness similar to those of patients without hypochondriasis in the same practice setting. Clinical experience suggests that benign remedies. their physicians. Psychother Psychosom 2000. Vol. Arch Gen Psychiatry 1992. Any such explanation must be coupled with the explicit assurance that the physician understands that such symptoms are real and not “imaginary. as in the management of chronic medical illness. A controlled trial of cognitive-behavioural treatment of hypochondriasis. BMJ 1991. Br J Psychiatry 1996. Patients with hypochondriasis are disturbed by the implied illegitimacy of their symptoms when no medical diagnosis is forthcoming. It may be helpful to explain to patients that they may be exceptionally sensitive to normal bodily sensations and may therefore misperceive these as symptoms of serious illness. Bass C. No. This approach minimizes the frustration of both the patient and the physician. can be helpful because they provide tangible evidence of the patient’s distress and of the physician’s ongoing interest without creating a risk of iatrogenic harm. Underlying panic disorder should be suspected in patients with recurrent acute episodes of intense cardiorespiratory symptoms that have no apparent medical cause. Group cognitive and behavioural treatment for hypochondriasis. and heating pads. 11. Gara M. Silver RC. Cognitive-behavioral therapy for somatization and symptom syndromes: a critical review of controlled clinical trials. 4. The physician and the patient should agree on a mutually acceptable frequency of appointments and then try. Simply reassuring them that “nothing is wrong” contradicts their own experience of bodily distress. 2.” The physician should search for evidence of other psychiatric disorders — in particular.org The New England Journal of Medicine Downloaded from nejm. Gen Hosp Psychiatry 1998. Visits should therefore be scheduled on a regular. Simon G. and their medical care.69:205-15. and it is important to detect because the coexistence of hypochondriasis and panic disorder is associated with a poorer prognosis and greater disability than panic disorder alone.24. Psychiatric disorders and functional somatic symptoms as predictors of health care use. England: Oxford University Press. appropriate pharmacotherapy is indicated. .6: 413-9. New York: Praeger. J Gen Intern Med 1991. basis. All rights reserved. 8.25 These are derived from clinical experience and empirical intervention trials. diminished libido.org on October 20. Psychiatr Med 1992. Arch Fam Med 1994. Copyright © 2001 Massachusetts Medical Society. Spitzer RL.10:49-59. 10.49:101-8. et al. 345. Ford CV. Cognitive behavioural therapies in the treatment of functional somatic symptoms. This perception then further amplifies the symptoms. 6. Others accept the premise that their health is adversely affected by “stress” and are willing to participate in stress-management programs. Kroenke K.The Ne w E n g l a nd Jo u r n a l o f Me d ic i ne driasis. Klerman GL. Escobar JI. with gradual increases after the patient has been educated about potential side effects. Wyshak G. Kroenke K. these perceptions must be discussed explicitly with the patient. Barsky has research funding from the Aetna Foundation for Quality Care. Swindle R. A few patients may still make excessive requests for attention. Oxford.5 which they may perceive as an accusation that they are imagining or fabricating their symptoms or as a covert attempt by their physician to transfer their care to another physician. in which case the physician must set limits in a nonpunitive manner. such as lotions.26 However. Although there is no definitive therapy for hypochondriasis. 19 · November 8. The goal of treatment should be improved coping with symptoms rather than their elimination. careful physical examinations. physicians can effectively care for patients with the condition by accepting that somatic symptoms without a medical basis can be as distressing as those resulting from demonstrable disease. Patients with hypochondriasis tend to resist referral to a psychiatrist. 2013. Klerman GL.34 Since the treatment of coexisting psychiatric conditions typically ameliorates hypochondriacal symptoms. Cobb AM. and attentive listening are more useful approaches to therapy.nejm. Clark DM. Waitzkin H. 9.169:189-95.20: 155-9.3:774-9. 1398 · N Engl J Med. This disorder is frequently missed. loss of motivation or pleasure. 7. Latham KS. Compton W. New York: Elsevier Biomedical. Kellner R. Such therapy should be initiated at low doses.27-29 In view of the higher likelihood of side effects of medication in patients with hypochondriasis. Barsky AJ. No other uses without permission. Physical symptoms in primary care: predictors of psychiatric disorders and functional impairment.303:1229-31. 3. eds. and obsessive–compulsive disorder. DSM-IV hypochondriasis in primary care. 1983. This assertion need not be contested. 1986.

org) and register by entering their names and subscriber numbers as they appear on their mailing labels. 23. Oxford. White C. 19 · November 8. . Somatization: diagnosis and management. 13.16:381-7.9:46-54. Santoro J. 26. Reich J. 32.173:218-25. Clancy J. 2001:89-102. and tolerability. a full-text search capacity. Liang MH. Arch Gen Psychiatry 1995. Lidbeck J.4:790-5. Kashner TM. For personal use only. Shinoda N. Balden E. BMJ 1997. Rost K. et al. Arch Gen Psychiatry 1970. Hypochondriasis and anxiety disorders. Hypochondriasis: modern perspectives on an ancient malady.103: 86.org · 1399 The New England Journal of Medicine Downloaded from nejm. Sakamoto T. After this one-time registration. FULL TEXT OF ALL JOURNAL ARTICLES ON THE WORLD WIDE WEB Access to the complete text of the Journal on the Internet is free to all subscribers. Barsky AJ. 24. McNair DM.315:572-5. 18. Smith GR Jr. O’Gorman TW. LeResche L. Predictors of 1-year outcome for patients with panic disorder. Bass CM. 57:55-61. Salkovskis PM. Fisher S.nejm.32:607-11. Bass C. Hellman CJC. Vol. Ray DC.] 30. England: Oxford University Press. Am J Med 1996. N Engl J Med. Hackmann A. 34. Psychopharmacol Bull 1996. In: Starcevic V. Beginning six months after publication the full text of all original articles and special articles is available free to nonsubscribers who have completed a brief registration. Lipsitt DR. 27. Smith GR Jr.C LINICA L PRAC TIC E 12. Keeley R. Somatoform symptoms and treatment nonadherence in depressed family medicine outpatients. Br J Psychiatry 1986. Jackson JL. Kodama K. The relationship between hypochondriasis and medical illness. Noyes R Jr. All articles can be printed in a format that is virtually identical to that of the typeset pages. Features include a library of all issues since January 1993 and abstracts since January 1975. Sharpe M. Evaluation and outcomes of patients with palpitations. To use this Web site. Kahn RJ. Arch Intern Med 1991. Compr Psychiatry 1999.23:Suppl:20-6. Arch Fam Med 2000. 16. Clark DM. Weber BE. safety.22: 128-35. 2001 · www. Kapoor WN. Wyshak G.48:980-90. England: Oxford University Press. Drug-personality interaction in intensive outpatient treatment. Acta Psychiatr Scand 1997. Borysenko J. et al. 345. Responses of consecutive patients to reassurance after gastroscopy: results of self administered questionnaire survey. 28. 33.149:631-5. Kathol RG. and a personal archive for saving articles and search results of interest. McClelland DC. Am J Med 1997. Mayou R. 29.96:14-24.100:138-48. Potts SG. Psychiatric consultation in somatization disorder: a randomized controlled study. Fallon BA. Copyright © 2001 Massachusetts Medical Society. No other uses without permission. Gruen SD. Miller J. Reduction in hypochondriasis with treatment of panic disorder. Marshall R. 14. Arch Fam Med 1995. 20.40:39-43. Antidepressant therapy for unexplained symptoms and symptom syndromes. Klerman GL. Pain 1994. subscribers should go to the Journal’ s home page (http://www.151:84-8. Morley S. Whitney C. Somatization and pain dispersion in chronic temporomandibular disorder pain. Kashner TM. Wilson L. A study of the effectiveness of two group behavioral medicine interventions for patients with psychosomatic complaints. 2013. No.16: 165-73. Ahern DK.52:238-43. 25. Alprazolam XR: patient acceptability. 17. A trial of the effect of a standardized psychiatric consultation on health outcomes and costs in somatizing patients. 314:1407-13.org on October 20. All rights reserved. Orav EJ. Kroenke K. Smith GR Jr. Latham KS. Noyes R. 22. Dworkin SF. Tomkins G. Lucock MP. et al. J Fam Pract 1999.86:583-93. Benson H. subscribers can use their passwords to log on for electronic access to the entire Journal from any computer that is connected to the Internet. eds. Two psychological treatments for hypochondriasis: a randomised controlled trial. Schneier FR. The pharmacotherapy of hypochondriasis. 31. Psychosomatics 1999. 19. Rost K. Treatment of functional somatic symptoms. Budd M. JAMA 1997. Effectiveness of psychiatric intervention with somatization disorder patients: improved outcomes at reduced costs. 21. Smith M. Holt CS. Oxford. 15. Somatic style and symptom reporting in rheumatoid arthritis. Gen Hosp Psychiatry 1994. N Engl J Med 1986. O’Malley PG. Monson RA. [Erratum. Rogers MP. A 37-year-old man with multiple somatic complaints. Peake MD. 1995.278:673-9. Group therapy for somatization disorders in general practice: effectiveness of a short cognitive-behavioural treatment model. Ferguson JM. Mangelli L. Br J Psychiatry 1998.40:396-403. Droppleman LF. Barsky AJ. Q J Med 1993. Psychiatr Ann 1993.nejm. Barsky AJ. Psychosocial outcome and use of medical resources in patients with chest pain and normal or near-normal coronary arteries: a long-term follow-up study. Copyright © 2001 Massachusetts Medical Society. Behav Med 1990. Fava GA.