Hypochondriasis

Hypochondriasis is the fear or the belief that one has a serious disease based on the misinterpretation
of bodily symptoms. Anxiety and fear about the disease persist despite normal medical evaluations and
reassurance (American Psychiatric Association 2000).

Clinical Features:
The core feature of hypochondriasis is fear of disease or conviction that one has a disease despite
normal physical examination findings and physician reassurance. Bodily preoccupation (i.e., increased
observation of and vigilance toward bodily sensations) is common. Patients with hypochondriasis
believe that good health is a symptom-free state, and they are more likely than control patients to
believe that symptoms mean disease (Barsky et al. 1992). Concern about the feared illness “often
becomes a central feature of the individual’s self-image, a topic of social discourse, and a response to
life stresses” (American Psychiatric Association 2000, p. 504). Central clinical features of
hypochondriasis are summed up by the four D’s, which are as follows:

1. Disease conviction,
2. Disease fear,
3. Disease preoccupation, and
4. Disability.

According to DSM-IV-TR (American Psychiatric Association 2000), 6 months of symptoms are

required before making the diagnosis.

Associated Features:
Barsky et al. (1992) found that 88% of the hypochondriacal patients in a general medical outpatient
clinic had one or more concurrent Axis I diagnoses; the most common were generalized anxiety
disorder (71.4%), dysthymia (45.2%), major depression (42.9%), somatization disorder (21.4%), and
panic disorder (16.7%). Patients with hypochondriasis are high utilisers of medical services and have
the potential for iatrogenic complications from repeated investigations (Abbey 2002). Interestingly,
research has shown that relatives of patients with hypochondriasis do not have a greater frequency of
hypochondriasis than is found in the general population (Noyes et al. 1997).

etiology:
Several works of research indicates that patients with hypochondriasis augment and amplify their
somatic sensations. These patients have low threshold for and low tolerance of physical discomfort.
For example, what people normally perceive as abdominal pressure, patients with hypochondriasis
experience as abdominal pain. They may focus on bodily sensations, misinterpret them and become
alarmed by them because of faulty cognitive schemas. A second theory is that hypochondriasis is
understandable in terms of the social learning model.

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According to the psychodynamic school of thought, aggressive and hostile wishes toward others are
transferred through repression and displacement into physical complaints. The anger of patients with
hypochodriasis originates in past disappointments, rejections and loses. The patients however express
their anger in the present by soliciting the help and concern of other people and then rejecting them as
ineffective. Hypochndriasis is also viewed as a defense against guilt, sense of innate badness, an
expression of low self esteem and a sign of excessive self concern. Pain and somatic suffering thus
become means of atonement through the use of undoing and can be experienced as deserved
punishment for past undoing (either real or imagined) and for a person’s sense of wickedness and
sinfulness.

Pain disorder

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Pain disorder in DSM-IV-TR evolved from the previous concepts of somatoform pain disorder (DSM-
III-R; American Psychiatric Association 1987) and psychogenic pain disorder (DSM-III; American
Psychiatric Association 1980). In pain disorder, psychological factors are important in the onset,
severity, exacerbation, or maintenance of the pain; if a medical disorder is also present, psychological
factors exacerbate the pain.

Clinical Features
Chronic pain patients who were given the previous diagnoses of psychogenic or somatoform pain
disorder was described as having “the disease of the D’s”, which are as follows:

1) Disability,
2) Disuse and degeneration of functional capacity secondary to pain behavior,
3) Drug misuse,
4) Doctor shopping,
5) Dependency (emotional),
6) Demoralization,
7) Depression, and
8) Dramatic accounts of illness (brena and chapman 1983).

DSM-IV-TR lists three forms of this diagnosis: pain disorder associated with psychological factors,
pain disorder associated with both psychological factors and a general medical condition, and pain
disorder associated with a general medical condition.

Patients with pain disorder are not a uniform group, but a heterogeneous collection of people
who present with low back pain, headache, atypical facial pain, chronic pelvic pain and other
kinds of pain. The patients appear completely immersed in and preoccupied with their pain and
cite it as the source of all their misery. Such patients often deny any other sources of emotional
dysphoria and insist that their lives are blissful except for their pain. Their clinical pictures may
further be complicated by the presence of substance use disorders, because these patients
attempt to reduce the pain through the use of alcohol and other substances.

Etiology:
 Psychodynamic factors – patients who express bodily aches and pains without identifiable
and adequate physical causes may be symbolically expressing an intra-psychic conflict
through the body. Patients suffering from alexithymia, who are unable to articulate their
internal feeling states in words, express their feelings with their bodies. Other patients may
unconsciously regard emotional pain as weak and somehow lacking legitimacy. By displacing
the problem to the body, they feel that they have a legitimate claim to the fulfilment of their
dependency needs. The symbolic meaning of body disturbances may also relate to atonement
for perceived sin, to expiation of guilt or to suppressed aggression. Pain can function as a
method of obtaining love, a punishment for wrongdoing and a way of expiating guilt and
atoning for an innate sense of badness. Among the defense mechanisms used by patients

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 with pain disorder are displacement, substitution and repression. Identification plays a
part when a patient takes on the role of an ambivalent love object who also has pain, such as a
parent.
 Behavioural factors – pain behaviours are reinforced when rewarded and are inhibited when
ignored or punished.
 Interpersonal factors – Intractable pain has been conceptualised as a means for manipulation
and gaining advantage in interpersonal relationships, for example to ensure the devotion of a
family member or to stabilise a fragile marriage. Such secondary gain is most important to
patients with pain disorder.

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