A person with hypochondria has a preoccupying fear of having a serious illness. This conviction persists despite appropriate medical evaluation and reassurance of good health.

People with hypochondria are obsessed with bodily functions and interpret normal sensations (such as heart beats, sweating, and bowel movements) or minor abnormalities (such as a runny nose, a small sore, or slightly swollen lymph nodes) as symptoms of serious medical conditions.

They may also focus on vague and ambiguous physical sensations, like "a sore liver" or "tired veins." One form of this disorder involves a preoccupation with a single organ (such as the lungs) or disease (for example, cancer). Negative results of diagnostic examinations do little to decrease a patient's anxiety about his or her health, and he or she continues to seek medical attention.

Because patients with hypochondria usually see their primary care physicians rather than go to mental health clinics or join psychiatric research programs, it is difficult to determine how many people actually suffer from this disorder. Estimates range from 0.8% to 8.5% of the general US population. 2 It seems to occur equally in men and women.

While many people may worry from time to time that minor physical symptoms may be a sign of a serious illness, a diagnosis of hypochondria is reserved for those who have a preoccupying fear of disease that lasts for at least 6 months.

People with hypochondria often have other psychiatric disorders; two thirds of patients also have major depression, panic disorder, obsessive-compulsive disorder, or generalized anxiety disorder. 3

However, the preoccupation with illness is not explained by one of these other disorders. The patient's beliefs are not delusions and are not restricted to concerns about appearance. The preoccupation causes clinically significant distress or impairment.

A patient may have symptoms of hypochondria for several months to several years and then have an equally long period without any symptoms. About one third of patients with hypochondria eventually improve significantly. Those who have a higher socioeconomic status, who have anxiety or depression that responds to treatment, and who don't have a personality disorder or a related nonpsychiatric medical condition seem to have a better chance of recovering. 4

How Does It Begin?

No one knows exactly why someone develops hypochondria. There seem to be many factors that might play a role. Hypochondria usually begins in early adulthood, and symptoms may develop following a serious illness in the patient or a loved one, or after the death of a close friend or relative. Periods of increased stress may have an influence, and a well-publicized disease in the media could affect one's interpretation of physical signs and symptoms.

While any one of these events could be a "trigger" for hypochondria, certain pre-existing personality traits and basic assumptions about health and illness can make one more vulnerable. For example, people who are neurotic, self-critical, introverted, or narcissistic are more likely to develop hypochondria than people who are not. 3 The belief that being healthy means never feeling any pain or discomfort could lead someone to misinterpret normal bodily sensations as being a sign of illness.

Someone who thinks he or she has a specific inherited weakness, such as a weak heart, might also be quick to think the worst of any sensation involving that area. Beliefs about health care habits can also lead to mistaken interpretations, such as thinking that if one doesn't see a doctor as soon as any symptoms occur, it will be too late to treat an illness. One theory about people with hypochondria is that they have a lower threshold for pain tolerance and therefore notice internal sensations that other people may not even feel.

Why Does It Persist?

There are three kinds of factors that cause people with hypochondria to continue worrying about illness after a doctor has found them to be in good health: physiologic, cognitive, and behavioral. 2 The physiologic factors are the physical feelings that make the person think he or she is sick.

Not only do these feelings not go away when a doctor tells the patient nothing is wrong, sometimes they get worse. Anxiety causes many physical symptoms, including increased heart rate, hyperventilation (which can produce breathlessness, choking sensations, chest pain or tightness, dizziness, blurred vision, confusion, and hot flashes), increased perspiration, dry mouth, and a decrease in digestive function (which may make one feel nauseous or constipated).

Muscle tension may result in aches, trembling, shaking, and tiredness. The more concerned a patient becomes about his or her health, the more of these symptoms develop, reinforcing the patient's beliefs. If a doctor dismisses a patient's concerns as "nothing to worry about," the patient may feel he or she is not receiving proper care and may become more anxious about getting treatment for the perceived illness.

Cognitive factors involve how people think about health-related issues. When anxiety over illness arises, people search for information to confirm or refute their fears. Most people err on the side of caution, preferring to assume they are sick when they are well rather than assume they are healthy when they are actually ill.

Therefore, information that supports the idea of sickness is paid more attention to, including information coming from doctors. Also, people with hypochondria regard any doubts about their health as unsettling. They want complete certainty that they are not ill, and if one doctor cannot give a guarantee, they will seek a second opinion.

Finally, the way people with hypochondria behave in relation to their symptoms and beliefs can increase their anxiety. Excessive body checking (such as taking one's temperature) can provide inconsistent results and lead to more anxiety.

Other methods, such as poking at a sore muscle or picking at a wound, can increase physical discomfort. Avoidance of anything perceived to be threatening can prevent self-correction of erroneous beliefs. For example, if a person thinks exercise will cause lung cancer and thus avoids doing it, he or she will never learn that exercise is beneficial rather than harmful.

How Is Hypochondria Treated?

Hypochondria is usually treated by a primary care physician, who may consult with a psychiatrist. The first step is to make sure there is no physical basis for symptoms, such as illness, injury, medication use, or substance abuse.

The patient should also be assessed for a mood disorder, such as depression, and if present, treatment with medication should be considered. Most people with hypochondria are not eager to see a mental-health professional and do not want to be told they have a mental disorder, but their concerns may be addressed by a team of medical and mental-health professionals working together in consultation.

In such an arrangement, medical complaints can be treated seriously; unnecessary, intrusive, and sometimes risky medical tests and procedures can be avoided; and support for coping with what is a real and chronic illness can be provided. The medical complaints probably will never go away, because the physical symptoms are real. A regular schedule of short appointments in which physical complaints are addressed may help to contain the patient's anxiety.

Antidepressants and other medications are sometimes used to treat hypochondriacal beliefs and attitudes, but there is not a lot of evidence to support this practice. Case reports and small studies of medication for hypochondria or related conditions, such as body dysmorphic disorder, suggest that drugs such as fluoxetine (Prozac and others) may be helpful, 5-8 but more rigorous studies are needed.

Most studies of psychosocial approaches to treating hypochondria are limited by few subjects, lack of control groups, and the absence of long-term follow-up. There have, however, been two large, rigorous, randomized controlled studies of cognitive behavior therapy (CBT) that found it to be effective in treating hypochondria. 1,9

Drs. Barsky and Ahern developed a form of CBT that specifically targets the thoughts and behaviors that lead to the misinterpretation of harmless physical symptoms that fuels the cycle of hypochondria. 1 In this form of therapy, patients are assisted in restructuring their beliefs and expectations about health and illness, correcting their misunderstandings about proper medical care, learning to distract themselves from thinking about their symptoms, and changing their behaviors concerning their symptoms and perceived illness.

Patients enrolled in the study were randomly assigned either to a "usual care" control group or the experimental treatment, which consisted of six sessions of CBT and a consultation letter to the patient's primary care physician. Subjects were 80 patients from primary care practices and 107 volunteers, all of whom exceeded a cut-off score on a hypochondria self-report questionnaire. Subjects were assessed just before treatment, and 6 and 12 months after treatment.

Subjects received individual CBT in 90-minute sessions once a week. Each session was devoted to one of five factors that cause patients to magnify physical symptoms and think they are a sign of serious illness: attention and bodily hypervigilance, beliefs about the cause of symptoms, circumstances and context, illness and sick role behaviors, and mood. During each session, the patient was given information about symptom amplification, an illustrative exercise, and a discussion that connected the material to the patient's personal experiences.

In addition to the therapy sessions, a letter was sent to each patient's primary care doctor to coordinate care and augment therapy. The letter contained the five following suggestions: (a) the goal of medical management should be to improve how the patient copes with physical symptoms, not to eliminate them; (b) the patient should see the doctor at regularly scheduled appointments rather than whenever he or she thinks there is a problem; (c) the doctor should give only limited reassurance; (d) a model of cognitive and perceptual symptom amplification should be used to explain physical symptoms to the patient; and (e) the doctor should be conservative in diagnosing and treating any medical condition. More?Institute for Mental Health Research