In the latest Case Record of the Massachusetts General Hospital, a 40-year-old woman was seen in the ED because of abdominal pain, anorexia, and weight loss. She said, “I think I have pancreatic cancer.” Physical examination, routine laboratory studies, and abdominal imaging were normal. Management decisions were made.
The challenge of caring for a patient with hypochondriasis is providing appropriate evaluation of physical symptoms while avoiding unnecessary specialty consultations and costly, potentially harmful, diagnostic studies.
• What are the features of hypochondriasis?
Hypochondriasis is characterized by “disease conviction,” which is a preoccupation with fears of having a serious disease based on misinterpretation of bodily sensations that persists despite medical evaluation and reassurance. Behaviors include frequent doctor visits, doctor shopping, “cyberchondria” (Internet searches), and body checking. Hypochondriacal symptoms typically occur after periods of stress, illness, or loss. Hypochondriasis may also be associated with mood disorders and personality disorders.
• How does hypochondriasis differ from somatic symptom disorder?
According to the new DSM-5 nomenclature, somatic symptom disorder is a diagnosis that subsumes several somatoform disorders described in DSM-IV, including hypochondriasis, pain disorder, and somatization disorder. The changes in diagnostic criteria attempt to clarify and reorganize the somatoform disorders in order to minimize overlap and confusion in terminology and facilitate their use by non-psychiatric providers, since many of these patients are initially seen in general medical settings. The new criteria shift the emphasis from medically unexplained symptoms to the disproportionate and excessive nature of a patient’s thoughts, feelings, and behaviors concerning their somatic symptoms. The majority of patients diagnosed with hypochondriasis in DSM-IV would meet DSM-5 criteria for somatic symptom disorder.
Morning Report Questions
Q: How may hypochondriasis be treated?
A: There is a small body of evidence that selective serotonin-reuptake inhibitors (fluoxetine, fluvoxamine, and paroxetine) and tricyclic antidepressants (clomipramine, imipramine) are effective in alleviating symptoms of hypochondriasis, including disease fears and beliefs, pervasive anxiety, somatic symptoms, and reassurance seeking behaviors. Although the use of antipsychotic medication has not been studied explicitly for hypochondriasis, there is some support for the use of atypical antipsychotics as adjunctive treatment for refractory anxiety disorders. Medications may be most useful when targeting accompanying illness, like depression, generalized anxiety or obsessive-compulsive disorder. Overall, the efficacy of medications in hypochondriasis is modest compared with interventions like cognitive-behavioral therapy.
Q: What is mediate arcuate ligament syndrome (or celiac compression syndrome)?
A: The median arcuate ligament is a fibrous arch composed of the diaphragmatic crura on either side of the aortic hiatus, which usually passes over the aorta, superior to the origin of the celiac axis. A high origin of the celiac artery axis or low insertion of the median arcuate ligament can lead to CT evidence of celiac compression as an incidental finding in as many as 10 to 24% of asymptomatic patients. The existence of a clinical syndrome due to this finding is controversial. Female sex and symptoms of nausea, vomiting (particularly when postprandial), as well as weight loss are typical symptoms of median arcuate ligament syndrome, also known as celiac-artery compression syndrome. Treatments have included lysis of ligaments, angioplasty, vascular reconstruction, stenting, and ganglion plexus removal. However, symptoms persist or recur in more than 30% of patients.