INTRODUCTION:

Usually, we refer someone as hypochondriac who has an unfounded belief that he is not well. Some may avoid hypochondriacs as they are such terrible bores: since even when greeted with a polite “How are you?” continue to converse at length.

Hypochondriacs become unduly alarmed about any physical symptoms they detect, no matter how minor the symptom may be. They are convinced that they have or are about to be diagnosed with a serious illness.^[^2] Even sounds produced by organs in the body, such as those made by the intestines, seem like symptoms of a very serious illness to patients with hypochondriasis.^[3]

Hypochondriasis is a preoccupation the person has with his / her physical health, with fears or concerns of a serious disease based on misinterpretation of physical signs or symptoms and not demonstrable by any medical condition. Diagnostic criteria for hypochondriasis also includes the fear or belief of the person which persists for at least six months despite medical testing, evaluation and reassurance, though not delusional in intensity (APA, 2000) ^[4].

Hypochondria is often characterized by fears that minor bodily symptoms may indicate a serious illness, constant self-examination and self-diagnosis, and a preoccupation with one's body. Many individuals with hypochondriasis express doubt and disbelief in the doctors' diagnosis, and report that doctors’ reassurance about absence of a serious medical condition is unconvincing, or short-lasting.

Additionally, many hypochondriacs experience elevated blood pressure, stress, and anxiety in the presence of doctors or while occupying a medical facility, a condition known as "white coat syndrome." ^[5]

Historical perspectives

When Hippocrates used the term hypochondrion 2,400 years ago, it meant the region below the chondral (rib) cartilages. Anatomically, this part of the body contains the liver and gallbladder on the right side and the spleen on the left side. “Splenic” and “hypochondriacal” came to be synonymous in ancient Greece. Hypochondrium was regarded as the male counterpart of hysteria in women for hundreds of years. A hypochondrium was due to vapors from the spleen; hysteria (from the Greek hysteria, meaning “womb”) was due to vapors from the uterus. The question whether the spleen and uterus caused bizarre behavior in men and women, respectively, was argued up to the twentieth century, despite there being no rational anatomical or physiological terms in men and the inconvenient fact that women also had spleen. ^[1]

Robert Burton, an English clergyman, wrote The Anatomy of Melancholy in 1621. Burton himself was subject to “a sorrow without cause”, explaining, “I writ of melancholy, by being busy to avoid melancholy.” This long and complex book contained a classic description of hypochondria (melancholy), which had come to be associated with general malaise and unexplained gloom. ^[1]

Burton narrated the features, causes and cures of melancholy-his remedies including, sensibly enough, keeping merry company, dancing, kissing and making love. The fact that The Anatomy was a best-seller, going through six editions in thirty years is indicative of its popularity. ^[1]

Poet John Donne, Burton’s contemporary also suffered from hypochondria. However, he wrote with a cynical insight. Although he agreed there was nothing wrong in his pulse, urine or sweat and there was no evidence of any dangerous sickness and though his strength and appetite were good and his mind clear, he recorded: “I feel that insensibly the disease prevails. The disease hath established a Kingdom and Empire in mee.” In the most famous of his ‘Devotions’ he expressed his own death as the greatest fear. ^[1]

Some hypochondriacs have occasional bouts of illness; while others are afflicted all their lives. In the eighteenth century James Boswell, wrote on Samuel Johnson’s life-long hypochondria: “He felt himself over-whelmed with an horrible hypochondria, with perpetual irritation, fretfulness and impatience; and with a dejection, gloom, and despair, which made existence miserable.” Meanwhile, Johnson himself wrote in his diary in 1777: “When I survey my past life I discover nothing but a barren waste of time with some disorders of body and disturbances of the mind very near to madness.” ^[1]

One of the great poets Shelley was also a hypochondriac. His wife Mary Shelley records “a martyr to ill-health and constant pain wound up his nerves to a pitch of susceptibility that rendered his view of life different from those of a man in the enjoyment of healthy sensations”. ^[1]

Sigmund Freud (founder of psychoanalysis) felt that hypochondia is neurosis. Freud himself was hypochondriac. His biographer Ernest Jones (1958) documents: “He was a chronic sufferer from an obscure abdominal complaint…increased discomfort, with various other symptoms of general maiaise. These symptoms always preceded Freud’s best work”. Freud recognized this: “I have long known that I can’t be industrious when I am in good health; on the contrary, I need a degree of discomfort which I want to get rid of.”^[6]

Hypochondrias as of today

Surprisingly very little is written in modern textbooks of psychiatry. But many of us know what a hypochondrias is. Indeed, patients with severe organic problems, sometimes delay seeing their physicians lest they be thought of as hypochondriacs.

The symptom most commonly displayed by the hypochondriac is a morbid preoccupation with his bodily functions (bowels, heartbeat, body odor, sweating) together with exaggerated anxieties about ailments real or imaginary (bodily or mental). Naturally, we all know a little of the terrors of this state of mind. We suddenly wonder if it is normal to hear our own heartbeats or imagine that our common cold is really pneumonia and quite possibly cancer. Even the fittest are not immune. Athletes, who have a tremendous spiritual and financial investment in health, are notorious worriers about minor symptoms. In their walk of life, the lightest ache assumes terrifying proportions, implying, as it does, a loss of form, of grace, of money and of self-respect.

The true hypochondriacal patient has a conviction, rather than a fear of disease or of malfunction of one of his systems, unlike the merely anxious patient who fears rather than believes.

The patient may be disgruntled, discontented and peevish and he is usually convinced that his own symptoms are not merely of paramount interest to himself but should also be the only interest of his diminishing number of friends and of his increasing number of doctors. The patient may arrive with a meticulous list of dates, times, symptoms and remedies taken. Frequently he seeks no sympathy, merely confirmation and applause. The symptoms are usually clearly bizarre and inappropriate. They do not hang together anatomically or physiologically and are often contradictory. “My whole body is flooding up; my catarrh is upsetting my nervous system. I scrape my tongue every day, and it’s the wrong color. My gallbladder hurts. My eyes are yellow and I see spots which threatens fainting. All my muscles are tight, I’m constipated all the time, my brain is melting away, and this affects my ascending colon and makes my flatulence worse. I have got diarrhea on most of the days. My temperature is always low in the morning; my kidneys are blocked. I have a stench from my larynx”

Frequently out of a brown paper bag spill 10 or 20 different bottles of tablets, capsules, suspensions and fluids, which the physician reads glumly, like a witch doctor scanning bones. To complicate matters for the doctor, there are varied ways hypochondriasis can manifest.

Issues in classification: There are many classifications of hypochondriasis; most are based on poorly understood, ill-defined, and inadequately investigated symptoms.

The subspecialist attempts to classify hypochondriasis as quaint and unscientific. Some authors divide it up by organ or complaint (nasal, abdominal, cardiac and so on). While this is impractical, it has led to some glorious terms-Schoenheitshypochondrie- is hypochondria about beauty (“Mirror, mirror on the wall, who is the fairest of them all?”) and Haesslichkeitskummer- preoccupation with ugliness. The trouble is that, in some people, the problem may always be the same, for example, an obsessive interest in chronic backache, while others have different complaints every week-or simply settle for total body malfunction from eyes to toes. Some hypochondrias are related to age; thus adolescents worry more about their genitalia or elderly people about hardening of their arteries.

A nose hypochondrium is a particular oddity. It occurs only in male patients and is plausibly associated with a fear of castration. Freud’s famous ‘Wolf man’ went through an episode of it. The Great Russian author Nikolai Gogol wrote a short story, “The Nose.” Here the hero finds on waking up one morning that his nose had disappeared. He immediately thought that he could never be able to marry. Later he meets his nose, now clad in the full dress of a privy councilor. It snubs him and then, just as he is about to approach it in church, a beautiful girl appears and he feels unable to do so. Poor Gogol: he had a terrible complex about his own nose, a complex that he held up for the world to laugh at. One is of course reminded of the wretched Cyrno de Bergerac in Edmond Rostand’s Play; “No girls could ever love him because of his enormous nose”. But the difference is that Gogol’s nose looked entirely normal, despite his convictions.

Recognizing that depression, often heavily disguised, is the underlying theme of hypochondriasis and the psychiatrist Lipsitt (1968) finds it unfortunate that the “familiar facts” in a clinic are frequently labeled “chronic complainers,” “problem patient.” Or “crooks,” with all their complaints or “organ recitals” (terms revealing of the doctors’ frustrations, if not prejudices). Lipsitt describes these unfortunate patients as “hospital orphans”, wandering on their own accord or by exasperated referral, from clinic to clinic. ^[7]

The psychiatrist obviously sees a very different population from the internist, but to varying degrees most physicians agree on two general types. First, there is the hypochondriac whose symptoms are a sudden expression of some crisis or unresolved inner struggle and who, at this stage, may well be saved from a career or hypochondriasis by a sympathetic and knowledgeable physician. Second, there is the chronic depressive who appears in many guises, often deriving smug satisfaction from a lengthy rehearsal of his or her innumerable illnesses and of sacrifices for others (perhaps in order to atone for guilt feelings reaching back into childhood). This patient is prepared to debate and do battle over the treatment with as many physicians as he or she can find.

The first group is easier to understand because it is generally comprises generally of middle-aged people with middle-age health problems, and they tend to respond more readily to therapy. The chronically depressed groups, on the other hand, are dependent and clinging and rely on a doctor’s office staff or clinic personnel for ceaseless sympathy. Without the ritual of chat, examination and bottle of medicine, these patients fall apart.

Causes

The exact cause is not clearly established. May involve biologically based hypersensitivity to internal stimuli. Somatic complaints may be a mechanism that the client has learned to deal with feelings such as anxieties, or conflicts. The client may not be able to relinquish hypochondriacal behaviour until his or her anxiety decreases or until he or she develops other behaviours to deal with these feelings.

Hypochondriacal symptoms may be found in clients who have difficulty expressing anger satisfactorily, including those with several types of psychiatric disorder, such as depression, schizophrenia, neurosis or personality disorders. The client may be using defense mechanisms and attempting subconsciously to turn emotions like anger into physical ailments.

As in somatic disorders there may be a history of childhood illness, parental illness, or excess medical attention-seeking in the parents. Child sexual abuse and other emotional abuse or neglect are associated. In one etiological model, individuals with combination of anxiety symptoms and predisposition to misattribute psychical symptoms sought medical advice. The resulting medical reassurance provides temporary relief of anxiety which acts as a ‘reward’ and makes further medical attention seeking more likely.

Overly protective caregivers and an excessive focus on minor health concerns have been implicated as a potential cause of hypochondriasis development.^[^12]

Family studies of hypochondriasis do not show a genetic transmission of the disorder. Among relatives of people suffering from hypochondriasis only somatization disorder and generalized anxiety disorder were more common than in average families.^[8] Other studies have shown that the first degree relatives of patients with OCD have a higher than expected frequency of a somatoform disorder (either hypochondriasis or body dysmorphic disorder).^[9]

Clinical features:

Hypochondriac syndrome is categorize as a disorder of "perception and cognition” which involves a hyper-vigilance of the body's situation and a tendency to react to the initial perceptions in a negative manner that is further debilitating. The central and diagnostic clinical feature is the pre-occupation with the idea of having a serious medical condition, usually one which will lead to death or serious disability. The patient may repeatedly ruminate on this possibility and minor insignificant bodily abnormalities, normal variants, normal functions and minor ailments will be interpreted as signs of serious disease. Some people will consequently seek medical advice and investigation but is unable to be reassured in a sustained fashion by negative investigations. Yet others live in despair and depression, certain that they have a life-threatening disease and no physician can help them. Some consider the disease as a punishment for past misdeeds.^[^8]

Diagnosis:

The ICD-10 defines hypochondriasis as follows: ^[9]

A. Either one of the following:

· A persistent belief, of at least six months duration, of the presence of a maximum of two serious physical diseases (of which at least one must be specifically named by the patient).

· A persistent preoccupation with a presumed deformity or disfigurement (body dysmorphic disorder).

B. Preoccupation with the belief that the symptoms cause persistent distress or

interference with personal functioning in daily living, and leads the patient to

seek medical treatment or investigations (or equivalent help from local

healers).

C. Persistent refusal to accept medical advice that there is no adequate physical cause for the symptoms or physical abnormality, except for short periods of up to a few weeks at a time immediately after or during medical investigation.

D. Most commonly used exclusion criteria: not occurring only during any of the schizophrenia and related disorders (F20-F29, particularly F22) or any of the mood disorders (F30-F39).

The DSM-IV defines hypochondriasis according to the following criteria:^[4]

A. Preoccupation with fears of having, or the idea that one has, a serious disease based on the person's misinterpretation of bodily symptoms.

B. The preoccupation persists despite appropriate medical evaluation and reassurance.

C. The belief in Criterion A is not of delusional intensity (as in Delusional Disorder, Somatic Type) and is not restricted to a circumscribed concern about appearance (as in Body Dysmorphic Disorder).

D. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

E. The duration of the disturbance is at least 6 months.

F. The preoccupation is not better accounted for by Generalized Anxiety Disorder, Obsessive-Compulsive Disorder, Panic Disorder, a Major Depressive Episode, Separation Anxiety, or any another Somatoform Disorder.

It may be further specified as "with poor insight if, for most of the time during the current episode, the person does not recognize that the concern about having a serious illness is excessive or unreasonable."^[4]

A proposed change in the next revision of the DSM (DSM-V), scheduled for publication in May 2013, would combine hypochondriasis with somatization disorder, pain disorder, and undifferentiated somatoform disorder under a single classification known as complex somatic symptom disorder.^[^10]

Differential diagnosis: The main differentiation is from the feared physical disease. In most cases this is straightforward, but the possibility of an early, insidious disease with vague physical signs and normal baseline investigations should be considered.

Co-morbidity: Hypochondriasis is often accompanied by other psychological disorders. Clinical depression, obsessive-compulsive disorder (OCD), phobias, and somatization disorder are the most common accompanying conditions in people with hypochondriasis, as well as a generalized anxiety disorder diagnosis at some point in their life.^[11]

Management - Historical

Three people who became famous largely because of the defense afforded them by their hypochondriasis illustrate some complexities in the issue of treatment. Several authors have suggested that the illness from which Charles Darwin began to suffer when he was 22, (in 1831) before his famous voyage on the HMS “Beagle” (1836), and which continued & until he died in 1882, 51 years later, was Chagas’ disease (South American trypanosomiasis). This theory has been demolished by Woodruff, who proved that Darwin’s illness was psychological. Darwin was certainly a hypochondriac: he even kept a health diary, scoring days and nights for “goodness,” Sir George Pickering has shed considerable light on Darwin’s illness as well; as that of Florence Nightingale, the founder of nursing as a profession and one of the most effective of health reformers, who was bedridden from the age of 37 until she died at her ninetieth year of age. Lying on her couch year after year, she was totally devoted to her many pioneering activities – establishing schools of nursing, inaugurating training for midwives and nurses, reforming workhouses, even advising Indian viceroys. Both Darwin &Florence Nightingale, used their neuroses-their persistent hypochondriasis as a defense and excuse to keep the world completely at bay so that there was never the least interruption to the full and exclusive pursuit of their classical work. ^[1]

Marcel Proust is an example of a hypochondriac who also had a physical illness (bronchial asthma). As best man at his brother’s wedding he was so padded beneath his three overcoats that he couldn’t squeeze into his pew and had to stand in the aisle during the service. After his mother’s death he became a recluse free to work out his obsession-himself-in his one vast novel. It was, in Pickering’s words, another “creative malady”. In each case, one suspects the world would have lost greatly from the sufferers had they been treated with an effective cure.

Management-current: Management is difficult. However, can be managed under three heads: Initial, Pharmacology & Psychotherapy. ‘Initial’ allows time for the patient to ventilate their illness anxieties; clarify that symptoms with no structural basis are real and severe; aim to plan continuing relationship and review, not contingent upon new symptoms; explain negative tests and resist the temptation to be drawn into further exploration. Patients will, in the early stages, often change or expand symptomatology. Emphasize aim to improve function. Break cycle of reassurance and repeat presentation-family education may help in this. ‘Pharmacological’ is an uncontrolled trials that demonstrates antidepressants benefit, even in the absence of depressive symptoms. Trifluoxetine 20 mg increasing to 60mg or imipramine up to 150mg. ‘Psychotherapy, Behavioral therapy’ (response prevention and exposure to illness cues): Cognitive Behaviour Therapy identify and challenge misinterpretations, substitution of realistic interpretation, graded exposure to illness-related situations, and modification of core illness-beliefs. In one controlled trial, a 7.5% reduction of symptoms was noted. ^[12]

Role of nurses in the management of hypochondriasis

Nurses should make every effort to encourage the patients to express their feelings at ease rather than repress them. Nurses should also help the patients to manage their condition to minimize distress including those at an imaginary level by non-pharmacologic strategies such as relaxation, hypnosis, bio-feedback, massage and meditation. Wherever needed it is better to train them by using assertive techniques.

Before concluding, it would be quite relevant to point out an important aspect of hypochondriasis, reported by Russel Noyce. It has been indicated that physicians play an important role in the development and persistence of hypochondriasis. Often they contribute by making alarming statements or ordering anxiety-provoking tests or procedures. Also, when perceived as uncaring or unskilled, their reassurance may be ineffective. When physicians tell hypochondriacal patients there is nothing wrong, they challenge them and contribute to their alienation from the medical system.

In the same article, Russel Noyce has pointed out the result & outcome of treating patients with hypochondriasis. There may be an improvement due to natural fluctuation in the symptoms or non-specific factors associated with contact with the consultants. A few patients who showed improvement during follow up reported that they had responded to reassurance by the consultants and in some cases with symptomatic treatment. However, others claimed benefit from fortuitous changes in life circumstances or from self-treatment regimens. And, in a few instances, serious medical illness appeared to relieve hypochondriasis by legitimizing symptoms and sanctioning the sick role. ^[13] Russel Noyce in the same article makes an important statement at the end.“Hypochondriasis is, thus, a significant medical condition for which treatment is now available”.

CONCLUSION:

Hypochondriasis is a condition known to mankind from a very longtime. Historically some great personalities who were suffering from this have contributed a good deal in various fields so much so one wonders that if that they had access to an effective cure would the world have remembered their contributions. It is better to manage hypochondriasis by non-pharmacologic strategies unless it is imperative to use drugs.

REFERENCES:

1. Drummond Rennie ‘Hypochondria’ in: Medical and health annual, Encyclopedia Britannica, INC 1979, pp. 6 – 20.

2. Kring A.M. et. al. Abnormal Psychology. 10th ed. USA: Wiley. 2007.

3. "Hypochondriasis". Care Notes. Thomson Healthcare, Inc., 2011. http://go.galegroup.com.myaccess.library.utoronto.ca/ps/i.do?id=GALE%7CA246451296&v=2.1&u=utoronto_main&it=r&p=HRCA&sw=w. Retrieved 6 April 2012.

4. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed., text revised, Washington, DC, APA, 2000.

5. Escobar JI, Gara M, Waitzkin H, Silver RC, Holman A, Compton W (1998). "DSM-IV hypochondriasis in primary care". Gen Hosp Psychiatry 20 (3): 155–9. doi:10.1016/S0163-8343(98)00018-8. PMID 9650033. http://linkinghub.elsevier.com/retrieve/pii/S0163-8343(98)00018-8.

6. Jones Ernest Sigmund Freud: Life & Work Vols 1-3. London: The Hogarth Press, 1957.

7. Lipsitt RL “The rotating patient” Journal of Geriatric Psychiatry 2 1968, 51 – 61

8. Fallon BA, Qureshi, AI, Laje G, Klein B: Hypochondriasis and its relationship to obsessive-compulsive disorder. Psychiatr Clin North Am 2000; 23:605-616.

9. World Health Organization (1993). The ICD-10 classification of mental and behavioural disorders: diagnostic criteria for research. World Health Organization, Genera.

10. "Complex Somatic Symptom Disorder". American Psychiatric Association. January 14, 2011. http://www.dsm5.org/ ProposedRevisions/Pages/proposedrevision.aspx?rid=368. Retrieved February 19, 2011.

11. Barsky AJ: Hypochondriasis and obsessive-compulsive disorder. Psychiatr Clin North Am 1992; 15:791-801.

12. Russel Noyes Jr. “Hypochondriasis” In New Oxford text book of psychiatry “Eds Gelder MG, Loper – 160 Jr, Andreasen Nancy C. Volume 2, 2004, P 1098-1106.

13. Barsky A.J., Fama, J.M. Bailey, D., and Ahern, D.K. (1998). A prospective 4-to-5 year study of DSM-III-R hypochondriasis. Archives of General Psychiatry, 55, 737-44.

Received on 31.07.2013 Modified on 25.08.2013

Asian J. Nur. Edu. and Research 3(4): Oct.- Dec., 2013; Page 216-218