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Biology 103
2001 Third Web Report
On Serendip

It's All In Your Head...Or Is It? The Workings of Hypochondriasis

H.A.

Headache = Tumor. Cough = Tuberculosis. Mole = Skin Cancer. Such is the thought process of a hypochodriac. As defined in the Diagnostic and Statistical Manual-IV (DSM-IV), hypochondriasis is an unrealistic interpretation of one's bodily sensations as abnormal, leading to the fear and belief that one has a serious disease (1). This preoccupation with having a serious medical condition is one of the somatoform disorders and may be considered more as a symptom than a disease. In fact, hypochondriacal symptoms often appear as a part of other mental disorders, including forms of depression or schizophrenia (2). For this reason, a close investigation of hypochondriacal behavior is necessary to properly diagnose and treat patients.

There are six major components usually associated with these patients: -Misinterpretation of physical symptoms to constitute a serious disease -Persistence of this misinterpretation, regardless of medical reassurance -Preoccupation of lesser intensity than a delusional disorder -Significant distress and social/occupational impairment because of this preoccupation -Disturbance duration of at least 6 months -The ruling out of other anxiety, somatoform, and/or major depressive disorders (3)

It is important to note that, while the patient may not be suffering from any major disease, his/her perception of the symptoms is real. Additionally, while hypochondriacs may admit to being overly concerned, they will most likely remain dissatisfied until diagnosed with an illness. For this reason, many hypochondriacs will "shop" for doctors who will provide them with such an answer. The negative implications of this include a strain on the doctor-patient relationship, feeling the need for multiple health care providers, stacks of medical records, etc. (2).

The statistics among primary care patients show that the prevalence of hypochondriasis ranges from 4% to 20% of the general population, resulting in over $20 billion a year spent on unnecessary medical procedures (4). With numbers such as these, the issue of understanding more about these symptoms has become important within the medical world. These pursuits have resulted in four etiologic theories regarding hypochondriasis, a combination of which could hold the answers to this disorder.

The first of these theories relates to the amplification of normal bodily sensations, or when individuals "...attribute pathologic meanings to normal somatic sensations and functions." An example of this would be to attribute swollen lymph nodes to a malignant disease, as opposed to a simple viral infection. The consequences mostly affect the individual's psychological and behavioral well-being, which leads to the focus of the second theory. Based on Freud's psychodynamic hypotheses, there is a belief that "unconscious conflicts are the result of traumatic or frustrating childhood experiences being reawakened in adult life by similar stress or frustration." Consequently, particularly high-stress/tension situations could arouse subconscious feelings of guilt, anxiety, and fear for a person, and their inability to express these emotions verbally may lead to physical manifestations of conflict.

The remaining two theories take a more behavioral-oriented approach. The third theory suggests that "hypochondriasis is a learned behavior that is consolidated by social reinforcement and need gratification." Finally, the fourth theory considers the familial implications of hypochondriacs, the research for which has shown that those with a genetic predisposition to the disorder "...manifest the disorder subsequent to a somatic experience that is socially reinforced" (3).

Considering the range of theories formulated to explain the symptoms of hypochondriasis, it is evident that there is no single explanation to identify its source and causes. This variation is thus present in the suggested treatments, covering a range of factors from the psychological/emotional to the physical. Generally, there are three types of treatment for the disorder: reassurance/supportive therapy, cognitive/behavioral therapy, and psychopharmacological therapy. The aim of these treatments is to develop a trusting relationship between the doctor and patient, especially in the case of reassurance/supportive therapy. The primary goal of the physician is to acknowledge the fears of the patients and to reassure their relationship rather than the clinical findings. For a doctor to simply play down the patient's perceived symptoms in light of a hypochondriacal circumstance would typically increase the patient's fear and diminish the level of trust " (5).

With cognitive/behavioral therapy, the basis lies in the assumption that hypochondriacal patients magnify somatosensory cues and perceive themselves as unable to cope with the threat of a disease. This is especially useful for hypochondriacs who are willing to undergo formal psychological treatment, in that a large part of it deals with exposure and response prevention through cognitive therapy. By educating the patient who may have an inadequate understanding of health (hypochondriacs often equate health with the absence of any symptoms whatsoever), erroneous perceptual and cognitive interpretations may be eliminated " (4).

Finally, psychopharmacological treatment is used to combat the prominent symptoms of hypochondria, such as depression, anxiety, obsessive-compulsive behavior, etc. The most common type of medication prescribed for hypochondriacs are antidepressants such as Prozac, Tofranil, and Anafranil, as well as MAO inhibitors such as Orap and Sinequan (4).

While considering the etiologic theories behind the basis of hypochondriasis, I support both notions that there are physical and mental factors. I wouldn't necessarily attribute the hypochondriac's thought process to Freud's psychodynamic ideas, although there could realistically be connections between a person's traumatic childhood experiences and the triggering of a response in some form later in life. There is most certainly a psychological factor - how else could a person hold such fears about his/her well-being when medical findings show no valid evidence to support this apprehension? Although there haven't been any particularly conclusive findings on the familial connection with this disorder, as with diseases/illnesses in general, the genetic predisposition must be validly taken into account. Furthermore, while social reinforcement of hypochondriacal behavior and/or ignorance regarding the topic of health/well-being are factors, I do not believe they hold enough weight in themselves to be causes of hypochondriasis.

As with the need for multiple theories to explain its causes, I don't believe there is a one "right way" to treat hypochondriasis either. In general, psychotherapy is somewhat resisted by hypochondriacs, since they are not eager to see a mental health professional (2). For this reason, there is often also an emphasis on pharmaceutical means of treatment in addition to psychological therapy. The most important thing to remember, however, is that the needs of a hypochondriac may be best met by a team of medical and mental health professionals, who work with the collective goal of establishing and maintaining a respectful attitude towards the complaints of the patient while reassuring him/her of the reality of the situation as well. Though much research remains to be carried out on hypochondriasis, understanding that it is in fact a real medical/psychological issue is a step in the right direction.

WWW Sources

1)Hypochondriasis, Brief history of the disorder, including literary associations and modern views

2)Intelihealth: Hypochondriasis , Comprehensive site on hypochondriasis, with material provided by Harvard Medical School

3)Recognizing Hypochondriasis in Primary Care, Report by professors from the Research College of Nursing regarding hypochondria, etiologic theories, forms of the disorder, etc.

4)Hypochondriasis: A Fresh Outlook on Treatment, Article in the Psychiatric Times concerning treatment options for hypochondriacs

5)Psychiatry Matters: Hypochondriasis, basic site with definitions, symptom descriptions, treatments, etc.




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