A middle-aged man is chronically preoccupied with his health A middle-aged man is chronically preoccupied with his health. For many years he feared that his irregular bowel functions meant he had cancer. Now he is very preoccupied about having a serious heart disease, despite his physician’s assurance that the occasional “extra beats” he detects when he checks his pulse are completely benign. What is his most likely diagnosis? A. Somatization disorder B. Hypochondriasis C. Delusional disorder D. Conversion disorder

Hypochondriasis (Illness Anxiety Disorder) Psychiatry Fatimah AlMuhanna ID:131220197

Objectives : Definition Associated Features Associated Psychiatric Disorders Epidemiology Aetiology Differential Diagnosis Comorbidity Course and Prognosis Management

Hypochondriasis Hypochondriasis is the preoccupation (> 6 months) with the fear of having a serious disease (e.g. cancer, organ failure, AIDS, etc.) which persists despite negative medical investigations and appropriate reassurance with subsequent distress and impaired function.

Associated Features: Doctor – shopping and deterioration in doctor-patient relationships, with frustration and anger on both sides.  The patient often believes that he is not getting a proper medical care and may resist referral to psychiatry.  Physical complications may result from repeated diagnostic procedures.  Family and social relationships may become disturbed because the patient expects special consideration.

Associated Psychiatric Disorders: major depression dysthymic disorder generalized anxiety disorder or adjustment disorders Most of such patients have obsessional and anxiety personality traits.

Epidemiology: Age: it can begin at any age. However, onset is thought to be most common between 25 – 45 years.  It is thought to be more common in men, and those closely associated with the disease (e.g. relatives of a patient with cancer).  The true prevalence is uncertain, but it is common amongst patients attending general medical clinics.?????

Aetiology No specific cause has been detected, however, there are some etiological theories: There may be a history of childhood illness, parental illness, or excess medical attention-seeking in the parents. Childhood sexual abuse and other emotional abuse or neglect are associated. In one etiological model, individuals with a combination of anxiety symptoms and predisposition to misattribute physical symptoms, seek medical advice. The resulting medical reassurance provides temporary relief of anxiety which acts as a ‘reward’ and makes further medical attention-seeking more likely.

Differential Diagnosis: 1. Physical diseases (e.g. endocrinopathy). Somatization disorder (the focus is on the symptoms and not on the over concern with a disease). Underlying other psychiatric disorders (depression – anxiety). Monosymptomatic hypochondrical delusion : e.g. delusion of internal parasitosis or disturbance of body image. This delusion can be part of any psychotic disorder, e.g. schizophrenia.

Comorbidity High (>50%) incidence of generalized anxiety disorder. Also coexist with major depressive illness, OCD, and panic disorder.

Course and Prognosis Usually chronic course with waxing and waning symptoms.  Complete recovery occurs in some cases specially if there is underlying depressed or anxious mood.  Presence of personality problems are unfavorable prognostic factors.

Management 1-Exclude a possible organic pathology. Search for and teat any underlying depression or anxiety. (Hypochondriasis often will improve when these conditions are treated), exclude substance abuse or thyroid problem (TSH). 2-A cognitive-educational approach:  provide a more realistic interpretation of complaints.  explain the role of psychological factors in symptoms origin and fluctuation. 3-Pharmacological treatment : From their clinical experience some psychiatrists suggest trial of tricyclic antidepressant in all patients (even if no underlying depressive features). Try fluoxetine 20mg, increasing to 60mg, or imipramine up to 150mg.

Summary

References PreTest Self-Assessment and Review – Ninth Edition Dr- mohammed Al-sughyir Oxford Handbook of Psychiatry 3rd Ed