Florian Weck
Published online: 10 August 2013 Springer Science+Business Media New York 2013
Abstract Hypochondriasis is characterized by intensive fears of serious disease. Most patients with hypochondriasis worry about physical diseases like cancer, although in rare cases, patients report severe fears of mental disorders (e.g., schizophrenia), a phenomenon described in the literature as mental hypochondriasis. However, little is known about this rare subtype of hypochondriasis and experts have questioned whether mental hypochondriasis has much in common with the type of hypochondriasis in which somatic diseases are the focus of preoccupation. This paper presents, a case report of a woman with a fear of schizophrenia, which was treated with cognitive therapy. This patient fullls the DSM-IV criteria of hypochondriasis and exhibits many characteristics (e.g., selective attention, safety behavior) considered to be maintaining factors in well-established cognitive-behavioral models of hypochondriasis. Cognitive treatment strategies for hypochondriasis (e.g., attention training, behavioral experiments) also proved effective in this case of mental hypochondriasis.
Keywords Hypochondriasis Health anxiety Cognitive therapy Fear
of schizophrenia
The main characteristic of hypochondriasis is a preoccupation with fears of having, or the idea that one has a serious disease, based on a misinterpretation of bodily symptoms. Moreover, this preoccupation persists, despite appropriate medical reassurance and occurs for at least 6 months [1].
Patients with hypochondriasis seek excessive reassurance (e.g., medical consultation, searching for health information online) and safety behaviors (e.g., constant bodily self-examination, weighing themselves) which is considered a maintaining condition for the
F. Weck (&)
Department of Clinical Psychology and Psychotherapy, University of Frankfurt, Varrentrappstrasse 40-42, 60486 Frankfurt, Germanye-mail: weck@psych.uni-frankfurt.de
Treatment of Mental Hypochondriasis: A Case Report
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disorder (e.g., [24]). Particularly the medical reassurance behavior is associated with high costs for the health care system [5].
From a cognitive perspective, hypochondriasis reveals many parallels with anxiety disorders, in particular panic disorder [6]. One familiar cognitive-behavioral model of hypochondriasis [7, 8] hypothesizes that ordinary bodily sensations or illness related information are misinterpreted in a catastrophic manner and as a sign of a serious illness. This catastrophic (mis)interpretation symptoms leads to increased physiological arousal, a focus on ones own body, as well as reassurance, and safety behavior. The physiological changes, self-focused attention as well as the reassurance and safety behaviors lead to an increased preoccupation with the persons own health status, and the irrational conviction of having a serious illness becomes more and more entrenched. The classication of oneself as seriously ill in turn produces further physiological arousal, focused attention on the body, reassurance, and safety behaviors, and so on in a vicious circle.
Cognitive-behavioral treatment strategies for hypochondriasis focus mainly on modifying dysfunctional thinking, beliefs and attitudes towards illnesses and on reducing the excessive reassurance and safety behaviors of patients [7, 9]. In several randomized trials, such treatment has proven to be effective for the treatment of hypochondriasis [10]. Moreover, cognitive-behavioral therapy has demonstrated its superiority to short-term psychodynamic therapy [11], its effectiveness in different therapy settings, like group therapy [12] or internet-based therapy [13], and it seems to be effective in routine clinical settings as well [14].
Patients with a diagnosis of hypochondriasis fear cancer, heart, or neurological diseases like multiple sclerosis most frequently (see [15]). It has been reported that, on rare occasions, patients are afraid of a mental disorder as well, referred to as mental hypochondriasis [16, 17]. This is a reasonable expectation, as some mental disorders (e.g., schizophrenia) are comparable to physical illnesses (like cancer) in terms of severity, impairment, and prognosis. Moreover, in psychiatry, all disorders, as well as hypochondriasis (see [9]), are seen as biopsychosocial. Therefore, it does not seem necessary to distinguish between mental disorders (like schizophrenia) and physical illnesses and instead, all serious diseases should be considered for the diagnosis of hypochondriasis. However, little is known about mental hypochondriasis and it has been questioned whether this subtype of hypochondriasis has anything substantial in common with the type of hypochondriasis1 in which somatic disease is the focus of preoccupation (see [17]). Moreover, it is unclear whether the successful cognitive-behavioral treatment strategies are also effective for mental hypochondriasis.
In this paper, a case report of a woman with fears of schizophrenia is presented. There is rstly a discussion of whether this case actually fullls the criteria of DSM-IV hypochondriasis. Secondly, the course and results of cognitive therapy for (somatic) hypochondriasis are reported, in order to evaluate the usefulness of this approach for mental hypochondriasis.
Case Report
Description of Patient
The main concern of the 24 year old woman (further referred to as Mrs. A.) was of having a serious mental disorder, namely schizophrenia. Moreover, she reported feeling depressed,
1 To be differentiated from mental hypochondriasis, the type of hypochondriasis in which somatic diseases are the focus and referred to in this article as (somatic) hypochondriasis.
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concentration problems, tiredness, and sometimes the experience of feeling unreal (herself) or of the outside world as feeling unreal. She suspected that some of the reported symptoms were early signs of schizophrenia and consequently developed acute health- related fears, further ruminating about the consequences of schizophrenia on her own life. She consulted a psychiatrist who reassured her she did not have schizophrenia. However, thus reassurance only had a short-term effect on her health-related anxieties.
The diagnosis of hypochondriasis was based on the Structured Clinical Interview for DSM-IV (SCID-I) [18]. Table 1 shows the DSM criteria of hypochondriasis and Mrs. A.s accompanying symptoms and behavior. She had catastrophic beliefs about schizophrenia, that it means being isolated and in a psychiatric hospital forever, unable to hear yourself think, and never seeing your family again. She mentioned that this would be a state not better than being dead. Because Mrs. A did not generally recognize that her concerns about having schizophrenia were excessive or unreasonable, the DSM qualier with poor insight can be given. Possible differential diagnoses (e.g., panic disorder, obsessive compulsive disorder) were considered as well, but neither were these diagnostic criteria fullled. Mrs. A. displayed mild depressive symptoms, but did not fulll the diagnosis of a depressive disorder. There was no evidence of a personality disorder measured with the SCID-II [19].
The hypochondriacal beliefs and fears had started 4 years ago. In the beginning, these fears concerned the existence of a heart disease and, over the past 9 months, had focused on a mental disease (schizophrenia). Mrs. A. was married, but had no children. In the past, she had worked as a receptionist and was currently a homemaker. She received no additional psychopharmacological treatment. Mrs. A. described a typical situation concerning her problems, presented in a functional model in Fig. 1. Processes which are considered important for the maintenance of (somatic) hypochondriasis (e.g., selective attention, safety behavior, cognitive processing) were also considered important in the case of Mrs.A.
Self-Report Measures
Several self-report measures were used to evaluate the outcome of the cognitive therapy. For the assessment of hypochondriacal attributes, the illness attitude scales (IAS) [20, 21] were used. The IAS entails a questionnaire consisting of 27 items which are rated on a ve-point scale ranging from 0 (no) to 4 (most of the time). The IAS are considered to be the gold standard for self-rated assessment of hypochondriacal attributes and have demonstrated high reliability, validity, and sensitivity [22]. The German version of the IAS demonstrated high psychometric properties as well [2325].
Aspects of the general psychopathology were assessed with the brief symptom inventory (BSI) [26, 27]. For the assessment of depressive symptoms, the Beck depression inventory-II (BDI-II) [28, 29] was used.
Description of the Treatment
After the diagnostic phase, Mrs. A. received cognitive therapy, which included 12 weekly sessions lasting 50 min each. At the start, Mrs. A. was informed about the clinical picture of hypochondriasis (historical background, continuum of health anxieties, risk factors). Furthermore, she was informed how common physical sensations could be produced by normal bodily processes like homeostasis (see also [9]).
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Table 1 DSM-IV-TR criteria of hypochondriasis and the according pathology of Mrs. A
Criteria of hypochondriasis (DSM-IV-TR) Pathology of Mrs. A
A. Preoccupation with fears of having, or the idea that one has, a serious disease based on the persons misinterpretation of bodily symptoms
Mrs. A. displayed excessive self-focused attention and interpreted mild and temporary experiences of derealization and depersonalization as signs of schizophrenia
B. The preoccupation persists despite appropriate medical evaluation and reassurance
After a detailed interview, a psychiatrist reassured her that there is no evidence supporting a diagnosis of schizophrenia. However, this conrmation reassured Mrs. A. only temporarily
C. The belief in Criterion A is not of delusional intensity (as in delusional disorder, somatic type) and is not restricted to a circumscribed concern about appearance (as in Body Dysmorphic Disorder)
The belief of having schizophrenia was not of delusional intensity. For example, when a member of Mrs. A.s family told her that he or she thought Mrs. A. did not have schizophrenia, she was temporarily reassured
D. The preoccupation causes clinically signicant distress or impairment in social, occupational, or other important areas of functioning
The preoccupation with schizophrenia affected her most of the day. Mrs. A. worried a lot about her mental health and, in consequence, reported concentration problems. She tended to withdraw socially, ruminated about the potential catastrophic consequences of schizophrenia for her life, and had mild depressive symptoms
E. The duration of the disturbance is at least 6 months
The fear of schizophrenia lasted for 9 months
F. The preoccupation is not better accounted for by generalized anxiety disorder, obsessive compulsive disorder, panic disorder, a major depressive episode, separation anxiety, or another somatoform disorder
The main concern was a fear of schizophrenia. There were no other intensive worries, only shorter periods of neutralizing behavior, no panic attacks, and only mild depressive symptoms, which seemed to be a consequence of her fears. Moreover, there were no separation anxieties or intensive somatic symptoms which would suggest that another Somatoform Disorder was present
A behavioral experiment was carried out to demonstrate the importance of selective attention for the perception of bodily processes. Mrs. A. was instructed to hold a book with an outstretched arm, twice for 1 min each time. In the rst run, she was asked to focus on all the sensations in her arm and in the second run (after a short break), she had to form an image of a place she likes (a nice place at the beach). She realized that she was more aware of bodily symptoms after focusing on the sensations in her arm. A discussion then followed as to what extent her selective attention on mental processes might make her aware of such processes of which people are typically unaware and to what extent her selective attention could disturb these mental processes. Attention training was conducted, with the aim of changing Mrs. A.s focus of attention from inner processes to external stimuli (see [30]). Mrs. A. was asked to focus her attention on specic sounds in and outside the room (e.g., the sound of the clock, the noise of trafc). Mrs. A. was instructed to switch between the different sounds more and more rapidly. For the next step, she was supposed to simultaneously listen to as many sounds as possible. Mrs. A. was to practice this attention training every day for at least 15 min. After the attention training, Mrs. A. experienced fewer worrying symptoms like depersonalization and realized once again that selective attention might be maintaining for her problems.
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Situation
Mrs. A. is washing the dishes. She realizes that she
