discussion

Psychiatr Q (2014) 85:5764

DOI 10.1007/s11126-013-9270-6

ORIGINAL PAPER

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: [email protected]

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 is distracted and is daydreaming.

Cognitive processing

"Something is wrong with my mental health". "I have schizophrenia". Having schizophrenia is like being dead.

Affective reactions

Intensive illness-related fears; depressive symptoms

Perceptual reactions

Selective attention to own mental processes

Behavioral reactions

Checking her own mental processes; searching for reassurance in the Internet

Consequences

Short-term: a subjective feeling of control and consequently a reduction of the fears Long-term: intensive preoccupation with her mental health, perception and disturbance of automatic mental processes via selective attention, finding further alarming information in the Internet, which was falsely interpreted as evidence of schizophrenia, curious behavior (checking her own mental processes by trying to remember her own name and address) which is an object of further worry; increased risk of interpreting normal mental processes as signs of schizophrenia

Fig. 1 Functional model of a typical situation concerning her health anxieties reported by Mrs. A

The negative consequences of reassurance (e.g., asking family members for their opinions of her mental health, searching in the Internet for descriptions of schizophrenia) and checking behavior (e.g., checking her own mental processes by remembering her own name and address) for the maintenance of her health anxieties, were all discussed (see Fig. 1). Another structured behavioral experiment (see [31]) was planned in order to demonstrate the negative consequences of reassurance behavior. Mrs. A. was instructed no longer ask to her family for reassurance. This behavioral experiment was intended to clarify whether reassurance behavior is effective in reducing health-related anxieties long-term or whether it in fact increases selective attention towards ones own health status, making oneself more and more unsure, therefore maintaining health anxieties. As a result of the behavioral experiment, the reduction of Mrs. A.s reassurance behavior further reduced her selective attention on her own mental processes and led to a reduced preoccupation with schizophrenia, thus decreasing health-related anxieties. Further behavioral experiments were planned. For example, Mrs. A. had to go on her own for a walk near the river. She had previously avoided this, because she feared that she might attempt to drown herself in the river (she believed that people with schizophrenia tend to commit suicide). However, there was no evidence of Mrs. A. really wanting to commit suicide. The behavioral experiment was further proof for Mrs. A. that she would not irrationally and that she did not suffer from schizophrenia.

Mrs. A. repeatedly had the negative image of forever being trapped on a clinic bed in a psychiatric hospital. Therefore, this image was picked up in the therapy and rescripted (see

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Fig. 2 Scores of Mrs. A. in the illness attitude scales (IAS), the general severity index of the brief symptom inventory (BSI), and the Beck depression inventory II (BDI-II) before and after treatment

[32]). Firstly, the correspondence of this image with reality was questioned and discussed with Mrs. A. Secondly, an alternative scenario was constructed. In this scenario, Mrs. A. leaves the clinic bed, because she has no symptoms of schizophrenia and goes home to her own room. Thirdly, the alternative scenario was imagined, and the associated feelings explored. Fourthly, the alternative scenario was imagined regularly and whenever the old one occurred. Consequently, the frequency and intensity of the negative image of being held in a psychiatric hospital gradually diminished.

Rational arguments for and against Mrs. A. having schizophrenia were gathered. It became obvious that the more convincing arguments were against her suffering from schizophrenia (e.g., most of the necessary symptoms did not prevail). Therefore, an alternative explanation of Mrs. A.s symptoms was considered, which included experiences from current psychotherapy (e.g., selective attention makes people excessively aware of their own mental processes). In the end, helpful strategies were recapitulated and the therapist and Mrs. A. discussed how to use them in the future for relapse prevention.

Figure 2 shows the sum scores of Mrs. A. for the IAS, BSI, and BDI-II before and after treatment. In addition to a substantial reduction of hypochondriacal fears, a reduction of the general pathology and depression was also evident.

Discussion

Mental hypochondriasis is a rarely described phenomenon and some experts have questioned whether its occurrence has much in common with (somatic) hypochondriasis, in which somatic diseases are the focus of preoccupation. In the current article, the case of Mrs. A., who had fears of schizophrenia, was presented. It could be shown that her fears of schizophrenia were so extensive that she fullled the DSM-criteria for hypochondriasis.

Maintaining factors for mental hypochondriasis (e.g., selective attention, checking and reassurance behavior) were similar to those considered in cognitive-behavioral models [7, 8]. Thus, mental hypochondriasis seems to have much in common with (somatic) hypochondriasis after all. Therefore, it does not seem necessary to distinguish between mental and somatic hypochondriasis, but that it is appropriate rather to consider and treat patients with fears of mental disorders as one manifestation of hypochondriasis. However, an interesting nding is that Mrs. A. only has a score of 42 in the IAS, even though she fullled the

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diagnostic criteria for hypochondriasis and exhibited signicant impairment (e.g., high scores in the BSI). In previous studies, a cut-off of 45 or 50 was found to be optimal for differentiating between patients with hypochondriasis and other samples [23, 25]. Measures like the IAS may be more appropriate for (somatic) hypochondriasis and underestimate the prevalence and severity of mental hypochondriasis, because of their explicit focus on somatic disorders (e.g., Do you believe that you have a physical disease but the doctors have not diagnosed it correctly?). Therefore, issues relating to measures of health anxiety and hypochondriasis should be revised and address all diseases, rather than only physical diseases.

Cognitive therapy for (somatic) hypochondriasis has also proven effective for mental hypochondriasis. This result emphasizes that maintaining factors for mental and (somatic) hypochondriasis can be addressed effectively with the same treatment strategies. Moreover, mild depressive symptoms were also reduced by the applied cognitive therapy. This result was also found for the treatment of (somatic) hypochondriasis [10].

Overall, mental and (somatic) hypochondriasis seem to have much in common after all (e.g., pathology, impairment, maintaining processes), so that there is no need for a different classication for these two hypochondriasis phenomena. Cognitive therapy seems to be appropriate for the treatment of mental hypochondriasis as well. Possibly, the prevalence and severity of mental hypochondriasis have been underestimated, because the focus of current measures is on fear of somatic disease. Further empirical research (and diagnostic instruments) should therefore not be limited to physical diseases, but extend to all serious diseases.

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Author Biography

Florian Weck PhD is a clinical psychologist and assistant professor of the Department of Clinical Psychology and Psychotherapy at the University of Frankfurt (Germany). He has been interested in health anxiety and hypochondriasis for many years and his doctoral dissertation focused on the effectiveness of a cognitive-behavioral group treatment for hypochondriasis. He published several articles and a book on health anxiety and hypochondriasis. Currently he investigates the efcacy of cognitive therapy versus exposure therapy for patients with hypochondriasis in a randomized controlled trial.

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