HYPOCHONDRIASIS:
The term hypochondriasis is derived from hypochondrium (the region
below the ribs).
It refers to a state where the person believes that he is suffering from a
serious disease (disease conviction, DSM1V) or afraid of having a serious
disease (disease phobia, ICD1) in spite of repeated negative clinical
examination and investigations.
It has been called medical student disease when a patient reads about an
illness and is convinced that he or she has it.
The use of disease phobia in ICD10 is confusing because there is no
avoidance and the word fear is more appropriate.
Disease conviction and fear of having a disease are based on
misinterpretation of minor physical symptoms (chest pain must be heart
disease, abdominal pain is cancer, boil on the genitalia is syphilis).
The person shows excessive preoccupation and concern about physical
health, which does not respond to repeated reassurance.
Hypochondriacal patients are doctor-shops and resistant to psychiatric
referral.
Epidemiology: 1-3 of the general population.
4-9% of patients in general medical practice.
Clinical course:
The onset is in early adulthood
A chronic,waxing and waning course is typical
Episode may be precipitated by stress especially the death of someone
close
Management
Chronic cases of hypochondriasis are difficult to treat and patients are
sensitive to the clinician’s attitude towards their complaints.
Thorough examination and investigations are necessary to establish the
diagnosis and reassure the patient.
However, excessive and repeated investigations are perceived as
uncertainty of the diagnosis and may enforce the patient’s conviction.
Patients with hypochondriasis are persistent and time-consuming, and the
clinician should be aware of his negative feelings towards them. Negative
feelings may tempt the clinician to refer them elsewhere to get rid of
them.
Treatment of co-exiting disorders as anxiety and depression is helpful.
Regular contact with a caring medical physician should be maintained
with palliation, and not cure,as the goal.
The workups should be based only on objective findings.
Cognitive-behavioral psychotherapy and SSRI have been helpful in some
patients.
DYSMORPHOPHOBIA:
Dysmophophobia
(dys=abnormal,
morpho=shape) is a disorder where the person perceives his appearance
as ugly or part of the body has abnormal shape.
This perception is sometimes based on a minor abnormality.
Other people do not share the person’s perception.
In some cases of this disorder, the person does not perceive a particular
part of the body as defective, but feels he will be happier and contented
without it.
Some cases believe that other people notice and comment on their defect,
whereas other cases have no such belief.
It is not clear whether these beliefs are delusions, over valued ideas, or
distortion of body image as in anorexia nervosa. In one study of 17 cases
(12 men and 5 women), 11 had personality disorder, 5 had schizophrenia,
and one had depression.
However, there are cases without evidence of a psychiatric disorder. The
value of surgical intervention to remove the body part involved is not
uniform, some persons benefit, others not.
Dysmorphopbobia in a setting of a psychiatric disorder may benefit from
the appropriate treatment of the disorder.
Treatment is by SSRI and CBT .Antipsychotic (pimozide) should be used
for delusional disorder.
PAIN DISORDER:
The criteria to qualify pain to be a disorder include pain is the primary
symptom, absence of structural or physiological explanation, chronicity,
and pain is severe enough to cause distress and impairment of
functioning.
In cases where an organic pathology is present, the pathology should be
inadequate to explain the severity of pain and impairment of functioning.
It is difficult to differentiate this disorder from conversion pain
disorder
.
the most frequent sites are head,face,low back, and pelvis.
Treatment:
Emphasize living with pain and not removal of pain
Multimodal treatment(family,group,and CBT)
Avoid iatrogenic complication
Treatment of psychiatric illnesses as they arise