Hypochondriasis vs. anxiety disorders: why should we care?

Abstract

In a recent popular book about hypochondria, Weingarten [1] asks the reader to consider the question: “How do you think you will die?” The choices: “1) in bed surrounded by weeping children; 2) flying through the windshield of a car; or 3) flying through the windshield after suffering a cerebrovascular accident, possibly linked to undiagnosed lupus erythematosus, polycythemia rubra vera, or thrombotic thrombocytopenic purpura.” Answer (3), meant to identify the hypochondriac, reveals the catastrophic, anxiety-ridden mindset of the individual plagued by illness fears. The article by Russell Noyes in this month’s issue of General Hospital Psychiatry examines this mindset in a more thoughtful and scholarly way, carefully reviewing the literature on the relationship between hypochondriasis and anxiety disorders [2]. If primarily an anxiety disorder, then the location of the disorder “hypochondriasis” in the APA’s diagnostic manual should be moved from the Somatoform section to the Anxiety Disorders section [3]. Why should we care? What difference does it make whether hypochondriasis falls within the domains of the anxiety, mood, or somatoform sections of our diagnostic manuals? Is this anything other than nosological nitpicking? I think not. To the extent that nosological refinements contribute to drawing legitimate distinctions between disorders, enhance our overall conceptualization of a disorder, and lead to a more appropriate selection of therapeutic intervention, such analytic efforts are crucial. Consider the status of hypochondriasis currently. Granted legitimacy as a separate psychiatric disorder, hypochondriasis is included in the Somatoform Disorders section of DSM-III and IV. Its principal section mates include Somatization Disorder, Conversion Disorder, Pain Disorder, and Body Dysmorphic Disorder (BDD). Each of the somatoform disorders shares “the presence of physical symptoms that suggest a general medical condition and are not fully explained by a general medical condition” ([3] p. 445). Certainly hypochondriasis meets that description. While sharing the cognitive overconcern seen among patients with Body Dysmorphic Disorder, hypochondriasis also shares some of the multisymptom physical sensations most commonly seen with Somatization Disorder. One recent family study [4] identified somatization disorder as being the only DSM-IV psychiatric disorder more frequently found among the relatives of patients with hypochondriasis. Why then is there such interest in the anxiety components of hypochondriasis? As demonstrated by Noyes et al. [4], the phenomenological similarities and extensive anxiety disorder comorbidity between hypochondriasis and other anxiety disorders are considerable. Phobic responses to illness thoughts and a heightened alertness to somatic sensations are common across many anxiety disorders. The link with anxiety disorders is further strengthened by the data indicating that many patients with hypochondria also suffer from concurrent panic disorder, agoraphobia, and/or generalized anxiety disorder. If hypochondria is placed within the Anxiety Disorder domain, then that may help clinicians and researchers to consider that treatments applicable to anxiety disorders might also be appropriate for patients with hypochondria. For the anxiety disorders, these include cognitive therapy and pharmacotherapies (both shared by the mood disorders) as well as exposure and response prevention behavior therDirector, Somatic Disorders Program, NYS Psychiatric Institute, 1051 Riverside Drive #13, New York, NY 10032.