Mohammed T. Abou-Saleh

Principles and Practice of Geriatric Psychiatry.Editors: Professor John R. M. Copeland, Dr Mohammed T. Abou-Saleh and Professor Dan G. BlazerCopyright & 2002 John Wiley & Sons LtdPrint ISBN 0-471-98197-4 Online ISBN 0-470-84641-0105Hypochondriacal DisorderAndree Allen 1 and Ewald W. Busse 21 Dorothea Dix Hospital, Raleigh, NC, USA,and 2 Duke University Medical Center, Durham, NC, USAThe term ‘‘hypochondriasis’’ has its origins in the ancientGreek language. Anatomically, the hypochondrium refers tothat part of the body between the ribs and the xiphoidcartilage. The ancient Greeks believed that this part of thebody, especially the spleen, was the seat of morbid anxietyabout one’s health, depression, bad mood and simulateddisease 1,2 . This old theory has not withstood the passage oftime, but the term ‘‘hypochondriasis’’ has survived and ispart of our modern diagnostic nomenclature 3–5 . Hypochondriasishas joined the ranks of syndromes known assomatoform disorder in DSM-IV, with the following diagnosticcriteria:1. The predominant disturbance is preoccupation with the fear ofhaving or the belief that one has a serious disease based on theindividual’s interpretation of physical signs or sensations asevidence of physical illness (do not include misinterpretationof physical symptoms of panic attack).2. Appropriate physical evaluation does not support thediagnosis of any physical disorder that can account for thephysical signs or sensations or the individual’s unwarrantedinterpretation of them, and the symptoms in (1) are not onlythe symptoms of panic attacks.3. The fear of having, or the belief that one has, a disease persistsdespite medical reassurance.4. The duration of the disturbance is at least 6 months.5. The belief in (1) above is not a fixed delusion, as in delusionaldisorder, somatic type.There are issues regarding hypochondriasis as a diagnosticentity. Some clinicians and the International Classification ofDiseases regard it as a specific non-psychotic psychiatricdisorder, while others hold that it is a syndrome (a collectionof similar symptoms that occur together but are of multipleetiology). It is evident that hypochondriacal symptoms may bepart of another disorder, such as a mood disorder or a defensemechanism, as well as a character trait. Starcevic 6 has dissectedthe hypochondriacal syndrome into potentially useful constructsthat represent a stepwise progression. The ‘‘hypochondriacalcore’’, as the preoccupation with bodily sensations andfunctioning, gives rise to a state of ‘‘somatic uncertainty’’, aninsecurity feeling resulting in intense anxiety which is poorlytolerated by the individual. This leads to the ‘‘diseasesuspicion’’, which represents the fear of having a disease.‘‘Hypochondriacal behaviors’’ ensue as the patient obsessivelyseeks a medical work-up to uncover the cause of his/hersymptoms and is generally dissatisfied, as it is found that thereis either an absence of physical disease or that the symptomsare out of proportion to the pathology. Starcevic points outthat the hypochondriacal syndrome is a heterogeneous entitywith varying degrees of bodily preoccupation, fear, suspicionand a variety of complaints.Hypochondriasis, with its state of uncertainty, may be seenas a feature of an anxiety disorder. It may be part of a mooddisorder, such as a masked depression, where the patient willdeny feeling depressed but respond to antidepressant medication.Starcevic 6 makes the point that hypochondriasis may beincorporated into a long-standing, maladaptive pattern offunctioning and that many personality disorders may have ahypochondriacal manifestation. There is a fine line to becrossed when the disease suspicion turns into ‘‘disease conviction’’and the syndrome is no longer hypochondriasis, but apsychotic disorder, such as paranoid delusional disorder,paranoid schizophrenia or major depression with psychoticfeatures.In his 1987 review article on the subject matter, Lipowski 7considers that predisposing factors such as genetics, developmentallearning, personality and sociocultural environmentplay a role in hypochondriasis. Swedish investigators havegathered data from adoption studies in regard to familialsomatization patterns. The subjects of their studies weredrawn from 912 women born out of wedlock in Stockholm,Sweden, during 1930–1949. Between 1965 and 1973, themedical records of 859 subjects were reviewed for durationand number of sick leaves, chief complaint and diagnosis 8–10 ;144 were found to be somatizers. This study suggests thatsomatization is more common in adopted women than innon-adopted women. This raises the issue of genetic predispositionto somatization, as adoptees are known to have ahigher percentage of biological parents with alcoholism andcriminality compared to non-adoptees. There may be acomplex interaction between the type of somatizers, alcoholismand antisocial behavior and sex differences. Theinteraction between biological predisposition and environmentalinfluences requires additional attention.Theories that conceptualize the genesis of hypochondriasis tolearned behavior from childhood sound intuitively correct 11 .Children who grow up in families where a serious or chronicillness is present, or who are exposed to a hypochondriacalrelative, may well learn a way to obtain attention, sympathyand support, or get the message that physical complaints areacceptable, while complaints of emotional distress are not.Children suffering from physical disorders may get anxiousattention from parents. They may also learn that being sick isto avoid unpleasant duties. Somatization may serve as a wayPrinciples and Practice of Geriatric Psychiatry, 2nd edn. Edited by J. R. M. Copeland, M. T. Abou-Saleh and D. G. Blazer&2002 John Wiley & Sons, Ltd