• Patients often misinterpret normal bodily processes as symptoms of serious illness

Patients often misinterpret normal bodily processes as symptoms of serious illness, which can significantly impact their lives when hypochondriasis – characterised by persistent fears of having a serious illness despite medical reassurance – develops.

These concerns were raised in a case report on ‘Psychological Interventions for a male with hypochondriacal disorder’ which was authored by J. Galhenage, M. Dayabandara and R. Hanwella (all three attached to the Colombo National Hospital's Professorial Psychiatry Unit), and published in the Sri Lanka Journal of Medicine's 34th Volume's First Issue, last month (April).

Severe health-related anxiety, named hypochondriasis in the World Health Organisation's International Classification of Mental and Behavioural Disorders’ 10th Revision, the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders’ Fifth Edition, and the Cleveland Clinic's Illness Anxiety Disorder (Hypochondria, Hypochondriasis), involves an unfounded dread of having a major illness. The prevalence of hypochondriasis is between 0.02-8.5%, with a population prevalence of 10.7% (F. Creed and A. Barsky's ‘A systematic review of the epidemiology of somatisation disorder and hypochondriasis’). This condition is associated with disability, high healthcare costs, and co-morbid anxiety and depression (G.E. Simon, O. Gureje and C. Fullerton's ‘Course of hypochondriasis in an international primary care study’). Childhood trauma, illnesses, stress, anxiety-related disorders, and abuse are major contributors to hypochondriasis, which is often co-morbid with personality traits of paranoia, avoidance, and obsessive-compulsive disorder (B.A. Fallon, K.M. Harper, A. Landa, M. Pavlicova, F.R. Schneier, A. Carson, K. Harding, K. Keegan, T. Schwartz and M.R. Liebowitz's ‘Personality disorders in hypochondriasis: Prevalence and comparison with two anxiety disorders’).

Case report 

A 42-year-old accountant with persistent health-related concerns was referred to the Psychiatry Clinic of the Colombo National Hospital by a consultant gastroenterologist. He had swallowing-related difficulties for nine years, followed by avoiding solid foods, and fears of contracting human immunodeficiency virus (HIV) for four years. He was worried of having a spinal disc bulge and a parotid (a major salivary gland located in the head and neck region, specifically in front of and below the ear) tumour. He struggled to maintain his job and lived separately from his wife due to health-related anxieties in the backdrop of anxious, avoidant and dependent personality traits. He was not depressed. His physical examination was normal, except for a benign cheek lump of one centimetre with soft rounded margins.

Management

The patient was prescribed an antidepressant medication of the selective serotonin reuptake inhibitor (SSRI) class, which was gradually increased in dosage, and a benzodiazepine medication at night as needed for sleep. He opted to take the medications in ground form due to difficulty in swallowing tablets. Medical records showed no underlying organic issues. He was offered 12 psychotherapy sessions by a postgraduate trainee in the final stage of a Doctor of Medicine in Psychiatry, during which a functional assessment identified his health-related anxiety-related triggers and safety-related behaviours. Negative automatic thoughts and dysfunctional beliefs were explored through Socratic questioning, and Cognitive Behavioural Therapy formulation was prepared (previous attitudes to health – recent stressful events [difficulty in swallowing due to fever and mild lymph node swelling due to viral flu, and a history of genitalia touching a public toilet] – this must be a throat or muscle disease or manifestation – anxiety of HIV – focusing on swallowing-related difficulty and symptoms of HIV, and searching about the illnesses related to the swallowing-related difficulty and HIV).

The patient engaged in therapy through an empathetic interview addressing his physical concerns and distress. He often requested HIV blood tests during sessions, which was managed with reassurance and referral to the formulation. A therapeutic agreement was established for three months, outlining that the patient would consult the therapist before seeking further medical advice, refrain from internet searches about illnesses, and attend sessions punctually with completed homework. Regular summaries were prepared to ensure understanding, and each session began with a review of the previous.

The patient was asked to monitor episodes of health-related concern, triggering symptoms (feverish, neck pain, testicular discomfort), anxiety levels (fear, worry), negative thoughts, and actions taken (meeting a venereologist, avoiding exertion and restricting to bed, consulting an oncologist).

Cognitive restructuring and experiments involved the patient providing evidence for being physically ill and against having major physical illnesses. Idiosyncratic and false evidence were re-evaluated. He was 90% convinced that his neck pain was due to a disc bulge. After listing several illnesses and benign causes, he suggested odd postures as the most common cause. A brief behavioural experiment demonstrated the accuracy of his beliefs. Dysfunctional core and intermediate beliefs were identified to prevent future relapses. He prepared features of a person with an incurable illness and curable minor illnesses, placing himself closer to the curable illness end, convincing him of his true state. Graded exposure and response prevention for swallowing-related difficulty involved preparing a hierarchy of foods from the least to most difficult to swallow (e.g., soft cake to tablets). Anxiety levels were measured using subjective units of distress scales before and after ingestion. He was trained to consume specific meals within a short duration after chewing.

The patient underwent relaxation training for anxiety but was advised against using it during meal intake for phagophobia. Activity scheduling, behavioural activation, and challenging negative automatic thoughts improved the mood and the functional level.

The core belief was challenged by drawing an inverted pyramid of patients with similar symptoms (the percentage of individuals in the world having the same symptoms, the percentage of individuals in the world having serious illness with the same symptoms, the percentage of individuals in the world having incurable illness with the same symptoms, the percentage of individuals dying due to that illness). The main challenges were the patient spending a long time chewing to liquefy foods inside the mouth at graded exposure and the patient’s reluctance to terminate the therapy. The former challenge was overcome by guiding the patient to swallow a maximum within two minutes.

Therapy continued for six months for 12 fortnightly sessions. The patient started to show improvement after the sixth session. His depressive symptoms, health-seeking behaviour, and functional capacity improved. He reunited with his wife and resumed sub-fertility treatment. However, he defaulted on follow-up six months after ending therapy and presented again with relapsing symptoms and inappropriate and frequent health-seeking behaviour. He has breached the therapeutic contract and consulted a surgical specialist for his benign lump on the left cheek. It was surgically removed but resulted in left-sided lower motor neuron facial nerve palsy.

Discussion 

In this case report, a patient presented with multiple hypochondriacal complaints impacting life.

The reported economic burden of hypochondriasis is underestimated (K. Hannah, K. Marie, H. Olaf, B. Stephan, D. Andreas, L.W. Michael, B. Till and D. Peter's ‘The global economic burden of health anxiety/hypochondriasis - A systematic review’). This patient presented to psychiatric services nine years after onset, indicating the long duration taken by such patients to present (V. Markotic, M. Miljko, D. Radancevic, M. Grle, I. Peric, A.K. Arapovic and G. Bogdan's ‘A case report of a long time unrecognised hypochondriac patient wondering through the hospital departments’). For patients with severe hypochondriasis, illness lasted five years or more for 42% and 10 years or more for 24.7% by the time of their diagnosis (P. Fink, E. Ørnbøl, T. Toft, K.C. Sparle, L. Frostholm and F. Olesen's ‘A new, empirically established hypochondriasis diagnosis’). The contribution of multidisciplinary specialists for the analysis of presentations, investigations, and assessment by an experienced psychiatrist would be vital for a final diagnosis.

In T.C.O. Hartman, M.S. Borghuis, P.L.B.J. Lucassen, F.A.v.d. Laar, A.E. Speckens and C.v. Weel's ‘Medically unexplained symptoms, somatisation disorder and hypochondriasis: Course and prognosis. A systematic review’, the recovery rates were between 30% and 50%. The number of somatic symptoms at the baseline and the seriousness of these conditions influenced the course as well as the prognosis. A favourable prognosis is associated with high socioeconomic status, sudden onset, and the absence of medical conditions (A. Syaukat's ‘Hypochondriasis: A literature review’). 

Medscape's ‘Illness anxiety disorder’ has shown that predictors of long-term illness include a history of childhood punishment and the lower use of SSRIs during the treatment period. This patient had poor prognostic factors of personality disorder, childhood adversities, and poor medication-related compliance. Positive factors included a satisfactory socioeconomic background and no major medical illnesses. Main challenges with the therapy were the termination of therapy in a patient with anxious avoidant personality as well as achieving a sustainable remission. Therapy was terminated at six months with the plan of continuing monthly follow-up with therapeutic contact and the supervision of his compliance by his maternal aunt. The relapse of illness-related behaviour after six months highlights the chronic nature of this illness. Easy access to specialist services bypassing primary care doctors further maintains the symptoms. The high risk of iatrogenic (relating to illness caused by medical examination or treatment) harm in hypochondriasis is highlighted in this case.