Classification and Description
Rational treatment in medicine relies on accuracy of diagnosis. Without definitive abnormal anatomic or physiological findings, physicians are generally inclined to doubt the presence of disease. For centuries, a wide variety of “perturbations” were relegated to the realm of the mystical, magical, religious, and philosophical because of a lack of definitive findings related to them. To dispel these nonscientific biases in medicine, efforts have been made to devise more precise, rational diagnostic classifications and definitions of illness from which prescription of treatment could logically flow. Such has been the intent of classification schemes since the early 1950s.

Hypochondriasis was not described in DSM-I (American Psychiatric Association 1952) but was included only as one of the psychoneuroses not otherwise specified. In DSM-II (American Psychiatric Association 1968), it was accorded more visibility as hypochondriacal neurosis, which was defined as “preoccupation with the body and with fear of presumed diseases of various organs….Fears are not of delusional quality [but] persist despite reassurance.” Difficulty in distinguishing hypochondriasis from neurasthenic neurosis and hysterical neurosis suggested a continuing fuzziness of definition. To this day, controversy and dissatisfaction swirl around the classification of somatizing disorders.

Not until DSM-III (American Psychiatric Association 1980) was published was hypochondriasis listed as one of the somatoform disorders, all of which were characterized by the presence of physical symptoms that suggested a physical disorder but for which there were no demonstrable organic findings or known physiological mechanisms and for which there was positive evidence, or a strong presumption, that the symptoms were linked to psychological factors or conflicts. Hypochondriasis was specifically described as a preoccupation with the fear of having, or the belief that one has, a serious disease, based on the person’s interpretation of physical signs or sensations. It was further specified that a thorough physical examination could not explain the symptoms or the patient’s interpretation of them, nor could the patient’s fear or belief be dismissed through repeated medical reassurance. Nonetheless, the strictly held fears or beliefs were not considered of delusional intensity. To accommodate hypochondriacal states without physical symptoms, such as acquired immunodeficiency syndrome (AIDS) phobia, the criterion related to delusional intensity was eliminated from DSM-IV (American Psychiatric Association 1994). The DSM-IV criteria for hypochondriasis are listed in

Table 61-1.

Colorful descriptions and definitions of the hypochondriacal individual have appeared in literature and art throughout the centuries as vivid reminders that whatever treatments are applied - and there are few reports of successes - it is essential to keep in mind the behavior and personality styles of both patient and physician, as well as the quality of the patient-doctor relationship, in all therapeutic efforts.

The following case example of a patient seeking help is a poignant reminder of the importance of the therapeutic relationship in treating somatic preoccupation, whether it presents as severe anxiety or hypochondriasis.

A middle-aged female patient whose life was dominated by a wide variety of somatic discomforts presented herself, in a desperate plight, to a psychiatrist for consultation. “I am 40 years old,” she said, “and I have terrible pains all over my body. I feel anxious all the time and sometimes even panicky. I have had all kinds of therapy - from Freudian to pharmacological - and nothing seems to work. I am depressed, I can’t sleep, and my family is getting fed up with me. Doctors keep telling me that I need more treatment or that I should take more pills or that I should be seen four or five times a week, lying on a couch. They tell me that all my problems are related to sexual anxiety. But none of this helps. I am treated as though I am stupid, but I actually have studied psychology and read lots of books, but none of this helps. I do not want to just be told ‘take these eight pills and call me in a couple of weeks.’ I need to see a doctor who is humane and can accept my heightened illness anxiety without dismissing me with some medication or other, especially if it does not work. I am desperate to find a doctor who understands this, but even psychiatrists don’t seem to have the patience to stay with me.”

The history of treatment interventions with the hypochondriacal patient is extensive but often discouraging. Indeed, Nemiah (1978) described hypochondriasis with the statement, “There is no specific treatment of hypochondriacal symptoms, which are well known for their refractoriness to all therapeutic approaches”. In recent years, however, new discoveries in psychopharmacology and similarities between hypochondriasis and other entities, such as obsessive-compulsive disorder, have resulted in innovative and encouraging treatments.

In this chapter, I review types of treatments, their rationale, and their promise. Included are cognitive-educational, cognitive-behavioral, psychopharmacological, and psychodynamic approaches. In the belief that the patient-physician relationship is a vital part of any treatment and, in fact, may ultimately be the most effective treatment in hypochondriasis, this topic is dealt with first.

Phenomenology of the Patient-Physician Relationship in Hypochondriasis
It is believed that many millions of individuals with some degree of bodily preoccupation never consult a physician; of those who do, it is assumed that most are “neither chronic functional somatizers nor hypochondriacal individuals”. It is usually only after repeated visits to a physician, following which no explanation for a patient’s symptoms can be found, that the label (diagnosis) hypochondriasis is affixed to that patient. Because the diagnosis of hypochondriasis may affect subsequent behavior and feelings in both the patient and the physician - thus affecting treatment - I now consider the process by which this diagnosis emerges.

Every patient enters the medical care system with a chief complaint. Depending on the degree of anxiety attached to this complaint, the patient’s description of the symptom may be distorted, vague, denied, misperceived, and so on. The physician sorts through the complaints and physical findings through the history taking, physical examination, and appropriate laboratory studies. Straightforward physical findings, if part of an identified physical disease, generally respond promptly to appropriate interventions, with an accompanying reduction in the patient’s discomfort, anxiety, and obsessional concern. The patient’s successful response to the treatments gratifies both the patient and the physician and earns the patient the “right” to continuity of care.

However, those patients whose symptoms and complaints reveal no physical findings, even after exhaustive and repeated workups, baffle the physician; sensing the physician’s feelings of helplessness to treat them, patients do indeed feel unhelped. The mutually experienced frustration often leads to further (sometimes extravagant) assessments, referral to other physicians (often specialists), or an impasse that sometimes results in a rupturing of the patient-doctor relationship, either with the patient seeking another physician or the treating physician dismissively announcing, “There is nothing wrong with you.” If neither the physician nor the patient can find ways to communicate other than through somatic focus, there is no opportunity to expand the investigation beyond the narrow physical complaint. Suggestions by the physician that “your problem is emotional” or “your pain is imaginary” are in a language that the patient usually does not know. The physician’s insistence that “there is no disease” merely transfers the physician’s own bafflement to the patient; the physician’s ruling out physical disease leaves unanswered why the patient came to the physician in the first place.

In those cases in which simple reassurance suffices, the encounter is concluded satisfactorily. But when this fails, there develops a fertile soil for anger to be fostered in both parties. The patient projects attitudes of “bad physician” onto the doctor, whereas the physician may be impelled over time to affix pejorative labels such as “crock” or “turkey” to the patient who insists that illness is present when the physician says it is not. Under these conditions, self-esteem diminishes in both parties of the patient-doctor dyad, precluding establishment of a therapeutic alliance. The physician may, at this juncture, curtail efforts to help the patient “organize” his or her presentation of the illness into an acceptable illness composite.

Under optimal circumstances, the patient may be receptive to the suggestion that although the illness is real, it is caused by factors other than physical abnormalities, and the physician may have the breadth of understanding and skill to either undertake a more psychological approach to management of the patient or refer the patient for appropriate psychiatric assessment. Most often, however, this switch toward more psychologically oriented treatment is unsuccessful, even after protracted efforts. One way to help diminish or even eliminate the awkwardness of the referral process is to include psychiatric assessment as part of the initial medical “gatekeeping”. In those rare instances when hypochondriacal patients accept referral to a mental health professional, the treatment selection will depend on the psychiatrist’s orientation, capacity for blending both medical and psychiatric knowledge, tolerance for the patient’s experience of pain and frustration, and interest in what may develop into a long-term relationship.

Although treatment may comprise a blend of approaches, these approaches are addressed separately below. The challenge of summarizing treatment experience with hypochondriasis is made more difficult by the following variables: the treatment setting, whether medical or psychiatric; inconsistent definitions of hypochondriasis; inadequate descriptions of treatment methods; insufficient outcome data; the presence of comorbid disorders; the absence of controlled studies; attitudes of therapists toward treatment of hypochondriasis; and unclear rationale for selection of treatment.

Cognitive, Educational, and Behavioral Approaches
In the first part of the 20th century, most efforts at treating hypochondriasis were based on residual medical folklore or on psychodynamic principles derived from psychoanalytic experience. Therapeutic approaches varied considerably depending on whether the caregiver adopted a psychiatric or a general medical practice orientation. In recent decades, new data have emerged about hypochondriasis and standardized diagnostic criteria, and there has been more pressure to develop briefer and more efficacious treatments as well as an increased emphasis on the here-and-now dimension of psychopathology and its treatment. Family practitioners and other primary care physicians have turned more to nonmedical counselors to treat their “difficult patients,” and “wellness” programs that focus on self-care in health promotion have heightened public awareness of the wide margin between “healthy” and pathological hypochondriasis.

Out of this concatenation of developments has grown a greater interest in behavioral and learning models of psychopathology. Although controlled studies remain scarce, several researchers are exploring new ways of treating hypochondriasis on the assumption that such illness behavior is, for the most part, learned. The rationale for treatment based on cognitive, educational, and behavioral theories is that anything that has been learned (i.e., through conditioning) can be unlearned, deconditioned, reframed, reinforced, and so on. The objective is to replace a maladaptive response or habit with one that is more adaptive.

The Cognitive-Educational Approach
Learning theorists and some clinicians have proposed that hypochondriasis may be a developmental condition resulting from learned behaviors (e.g., helplessness), cognitive misperceptions (e.g., ideas about vulnerability), and distorted beliefs (e.g., convictions about the nature of disease processes) and have subsequently developed cognitive and educational approaches to correct this disordered behavior. There is considerable overlap between “cognitive” and “educational” approaches, with the difference perhaps being more one of emphasis than content. Educational components include use of workbooks, reading assignments, and audiotapes, as well as didactic information. The learning of relaxation and meditation techniques is often a significant part of the treatment approach. Although anecdotal reports have long suggested that the efficacy of these approaches is as good as that of other treatments for hypochondriasis, only in recent years have controlled studies validated their efficacy. Cognitive, educational, and behavioral approaches have the advantages of being relatively brief (often 6-16 sessions of 1 to 2 hours each), offering drug-free intervention, and avoiding some of the intensely frustrating face-to-face patient-physician relationships that often emerge in long-term treatment of patients with unremitting complaints.

Reassurance
Perhaps the most basic of educational approaches is that of reassuring patients of the benign nature of the symptoms they are experiencing, with a variety of accompanying efforts to correct their misperceptions about anatomy, physiology, and neurology. In patients with severe primary hypochondriasis, attempts at reassurance either have no effect or misfire, resulting in an intensification of the original symptoms or the development of new ones. In a similar way, if medications are given, they have no effect or patients report intolerable side effects, resulting in discontinuance of such treatment.

However, at least one author (Kellner 1992) stated that “the effects of explanation and reassurance…appear to have been underestimated by psychiatrists”. Kellner insisted that negative attitudes toward the efficacy of reassurance are most likely attributable to the fact that psychiatrists see most hypochondriacal patients long after repeated attempts at reassurance by general physicians have failed. It is believed that many of those patients who improve with reassurance and education are probably somatizing patients with recent onset who have minimal personality disorder but who present with some anxiety and depression. Although some argue that reassurance offers, through negative physical examination and corrective information, optimal treatment, others point out that the psychodynamics of a need to punish the other and to mother oneself in hypochondriasis would predict that reassurance would fail. Furthermore, few authors who have recommended reassurance as a therapeutic intervention have actually defined what is meant by this intervention. Informing a hypochondriacal patient that he or she has no disease may constitute as little reassurance as telling a paranoid schizophrenic patient that he or she is not being pursued by the FBI.

To qualify as a therapeutically sound intervention, reassurance must be carefully defined and systematically applied, taking into account the patient’s previous experiences, reassurance-seeking behavior, personality factors, and need for a trusting, dependable relationship with an accepting physician. According to Starcevic, the generally accepted belief that hypochondriacal patients fail to respond to reassurance contributes to a negative image of this group of patients and makes physicians reluctant to engage them in treatment; he stated that “failure to respond to medical reassurance has even acquired a status of a diagnostic criterion in ‘official’ definitions and descriptions of hypochondriasis”. House, furthermore, described the importance of timing and emphasis of different kinds of reassurance at various points in the course of hypochondriacal illness; reassurance, according to House, is not a one-step procedure but rather more like a process.

Barsky et al. further elaborated on reassurance as a means of intervention by developing it into a more systematic, cognitive-educational treatment. They argued that physicians must consider the nature of reassurance from patients’ perspectives as much as from their own perspective. For example, it is reassuring to some chronically ill patients who have been frequently disappointed or rejected to know that they will have a continuing, dependable relationship of trust and confidence with a physician or that the alliance will be sustained regardless of the variability of symptom complaints. Thus, it may well be the contextual aspect of “acceptance,” rather than the verbal repetition that “there is nothing wrong,” that provides therapeutic reassurance. Starcevic posited that “consistent provision of reassurance is a basis for ‘relational therapy,’ which then forms a framework within which cognitive or cognitive-educational treatment approaches become most effective”.

Kellner reported on his (uncontrolled) therapeutic experience with 45 hypochondriacal patients over a period of 23 years. His psychotherapeutic interventions included reassurance, repeated physical examinations, explanatory therapy (consisting of dispensing accurate information to the patient), instruction of the patient in disregarding trivial signs, description for the patient of learned behavior, clarification of medical terms in the patient’s experience, insight psychotherapy, distraction and physical exercise, drug treatment, patient desensitization of phobias, and repetition of information as part of the working-through process. Acknowledging the difficulties of comparing his experience with that of others who held that hypochondriasis had a poor prognosis, Kellner claimed a 64% rate of recovery or improved outcome for the 45 patients in his sample. The lack of systematized data in this report makes it virtually impossible to assess the ingredients of successful treatment; nonetheless, it was Kellner’s intent that this “study” might counter the claims of poor prognosis and the general therapeutic pessimism extant in the medical and psychiatric literature.

Educational Consultation
Efforts to teach general physicians to improve their recognition and diagnosis of psychiatric disorders have generally been disappointing (Lipowski 1992). The frequency with which hypochondriacal and other somatizing patients first consult their primary care physician underscores the need for general physicians to develop skills in identifying these patients. Barsky et al., following up their study in a large general teaching hospital clinic, placed the prevalence of hypochondriasis at 4.2%-6.3%, a figure comparable to that of alcohol abuse.

Studies by Smith, although focused on the recognition and management of somatization disorder, nonetheless are relevant to possible treatment intervention in hypochondriasis. A randomized controlled crossover study of 41 patients with somatization disorder determined that primary care physicians could be instructed through a psychiatric consultation for the patient and a detailed management letter to the physician. In this collaborative approach, the primary physician was able to “maintain” somatizing patients in a cost-effective manner. Smith’s recommended management principles included several that are also appropriate for maintaining continuity of care for hypochondriacal patients:

• The physician should be the patient’s major and possibly only caregiver.
• The relationship between the physician and patient should be a trusting and dependable one.
• Appointments should be brief and scheduled at regular, but not frequent, intervals.
• Symptoms should be regarded as “emotional communications.”
• Diagnostic procedures, laboratory tests, and surgical procedures should be avoided unless clearly indicated.

Application of these principles in the treatment of “problem patients” in a specially designed “Integration Clinic” for psychosocial and psychiatric management of complicated “medical” conditions showed that use of health facilities by these patients was significantly curtailed following a total annual treatment time of 6 hours or less (one half-hour visit per month). In both studies (Lipsitt 1964; Smith 1992), psychiatric consultation and physician education were combined in determining a patient management plan. It is assumed that the primary care physician’s greater diagnostic certainty facilitated the ongoing care of otherwise difficult-to-treat patients.

The Cognitive-Behavioral Approach
Since at least the 1980s, increasing interest in hypochondriacal symptoms and syndromes as learned behaviors has spawned several new therapeutic interventions. Successful treatment of phobias and obsessive-compulsive disorder with behavioral approaches has drawn attention to some similarities between hypochondriasis and these other disorders. The hypochondriacal patient’s obsessional rumination, doubts, uncertainties, compulsive reassurance seeking, and illness phobia all suggest the potential for response to cognitive-behavioral interventions.

Most previous attempts at therapy for hypochondriasis in all likelihood included both behavioral and cognitive elements, but the basis of these treatments was more empirical than theoretical, and the application more haphazard and eclectic than by design. Recent efforts have been intentionally based on behavioral techniques such as thought stopping, avoidance of rituals and checking, exposure to the feared situation, desensitization, and extinction.

Reports of treatment of hypochondriasis with cognitive-behavioral therapy have included successful treatment of three cases of “disease phobia” with the technique of thought stopping and treatment of cancer phobia and hypochondriasis with combined hypnosis and implosion (i.e., abrupt exposure to anxiety-provoking conditions). Marks described the use of imaginal flooding by exposure to situations, descriptions, or pictures of the feared physical condition in a controlled manner to gradually diminish patients’ anxiety.

The earliest cognitive-behavioral treatment interventions for phobic disorders relied almost exclusively on behavioral techniques based on learning theory. Because hypochondriasis is a complex state of perceptual and affective, as well as behavioral, components, more recent approaches combined both behavioral and cognitive techniques. Results from contemporary studies of panic disorder have suggested the utility of this combined approach, in which a panic attack is defined as partly caused by major misinterpretations of perceived bodily sensations. For example, in the case of “cardiac hypochondriasis,” Margraf et al. (1987) suggested that panic attacks might be triggered or exacerbated by the internal cue of cardiovascular arousal combined with other factors. In such cases, treatment is directed at both learned mechanisms of control and new ways of processing or reattributing perceptions.

Salkovskis and Warwick reported on the successful treatment of hypochondriasis in two patients with behavioral techniques of exposure and response prevention as part of a comprehensive treatment plan. They also described significant improvement of seven patients with AIDS phobia following cognitive-behavioral treatment.

According to the cognitive hypothesis of health anxiety and hypochondriasis formulated by Salkovskis and Warwick, the patient perceives bodily signs and symptoms as more dangerous than they really are and believes a particular illness to be more probable than it actually is. Treatment based on this model has two major components: 1) identifying and modifying automatic dysfunctional assumptions about health by demonstrating testable alternative explanations for symptoms (e.g., hyperventilation) experienced by the patient, and 2) identifying and modifying abnormal illness behavior by preventing certain behaviors (e.g., compulsive reassurance seeking) as a basis for helping the patient develop reattribution of illness assumptions.

In this model, there is a role for the type of reassurance that provides new and corrective information to the patient in the context of other cognitive interventions. This treatment strives to show the patient that the increased anxiety resulting from a cessation of his or her reassurance-seeking behavior offers opportunities for testing alternative hypotheses for his or her disease phobia. By curtailing the repetitious and ineffective form of medical reassurance received from physical examinations, further studies, laboratory tests, and reminders that “there is no physical disease,” patients allegedly become receptive to new explanatory models.

Treatment also involves the assignment of homework to alter the patient’s behavior, the patient’s keeping a diary of symptoms and events related to health anxiety, modification of responses to the patient’s symptoms by family members and other medical personnel, and prohibitions against the patient’s performing certain activities (e.g., reading medical books). Salkovskis and Warwick (1986) reported on two patients treated in this manner whose long-term reduction in anxiety and panic attacks was greater than would usually occur with the more typical medical reassurance. However, too few cases have been reported to warrant firm conclusions about this therapeutic approach.

In their uncontrolled crossover study, Visser and Bouman compared behavioral interventions of exposure and response prevention with cognitive therapy in six patients with a primary diagnosis of hypochondriasis. In groups of three, the patients were treated first with a block of either behavior or cognitive therapy and then sequentially with the other. Four patients improved significantly, with more improvement attributed to behavioral than to cognitive sessions. The most successful treatment sequence was found to be behavior therapy followed by cognitive therapy.

Group Cognitive-Behavioral Treatment

Group treatment of hypochondriacal patients has received relatively little attention in the research literature. However, it has been reported that somatizing patients may do well in such programs. Although patients who are narcissistically preoccupied with their own bodies might not be expected to relate well in a group, Ford suggested that a group experience fulfills patients’ needs for relational attachments and dependency and has the “potential of providing excellent and cost-effective care for these difficult (somatizing) patients”.

Barsky et al. reported on the successful application of a six-session group treatment for hypochondriasis that used educational and behavioral interventions. Based on the conceptual model of hypochondriasis as a “disorder of cognition and perception [in which] normal bodily sensations, the benign symptoms of trivial disorders, and the somatic concomitants of affect are amplified and experienced as more noxious and intense”, interventions focused on the four key amplifiers of somatic distress: beliefs, attention, context, and mood. Techniques included information, education, discussion, didactic materials, and exercises to modulate the sensation of benign bodily discomfort and normal physiology.

Stern and Fernandez studied the group application of combined cognitive and behavioral treatment for hypochondriasis in six patients between ages 35 and 55 years. These patients were seen in 1-hour sessions for 9 weeks during which education, diary keeping, homework, relaxation exercises, tolerance of uncertainty, identification of reassurance-seeking behavior, recognition of depression, group pressure, and clarification of perception of bodily symptoms were used. The patients’ visits to physicians decreased significantly after treatment, as did the time they spent thinking about illness. Their depression and anxiety scores also decreased, but the decrease did not reach levels of significance in this small group. The authors reported difficulty in gathering members for such groups, having taken 1 year to assemble the one in this study.