Hypochondriacal Disorder

A 34-year-old operating room assistant has presented you in the outpatient department; his physician—to whom he reported ninth time in last three months with a dread that he has human immune virus infection—sent him to you for psychiatric assessment and management. The physician notes he requested him to examine and re-test him for AIDS. He explained that his roommate in the mess recently confessed to having homosexual relationships with multiple partners. The patient never had a homosexual contact nor carries a factor for human immune virus infection. He had anankastic traits; remains worried about his health, however, he has no depression or disturbed biological functions.

1. What will be the differential diagnosis in this case?
2. What is the most likely diagnosis? Justify.
3. How would you manage this case?

Differential Diagnosis

1. Hypochondriasis/Illness Anxiety Disorder
2. Obsessive-compulsive disorder, these could be intrusive thoughts, but this is less likely.
3. Monosymptomatic hypochondriacal delusional disorder
4. Somatization disorder (but few physical symptoms stated in the stem)

Justification

He has a strong preoccupation with the possibility of having AIDS

Does not have risk factors for or evidence of AIDS

His physician can not reassure him as this is his 9th time

Young age

Medical help-seeking behaviour e.g. repeatedly requests investigations

Obsessional-traits

Prominent anxiety and fear

He only has a fear of having AIDS, therefore requests testing and examination and NOT a belief (delusion)

There is no evidence other psychiatric disorder e.g. depression where also such preoccupations may occur.

Unlike somatization disorder, it does not preoccupy him with symptoms but with fear of having a disease. Unlike this patient, those who have somatization disorder request for treatment of symptoms, not investigations. Similarly, the patient does not have any evidence of drug use, as in patients with somatization disorder.

Differentiate between somatization disorder, conversion, hypochondriasis, and psychosomatic disorder. Give an example of each in the patient's language (verbatim) to highlight the difference between the conditions.

Somatization Vs Hypochondriasis

1. Patients with somatization disorders put the emphasis on the symptoms themselves and their individual effects, patients with the hypochondriacal disorder, direct attention more to the underlying progressive and serious disease process and its consequences.
2. In hypochondriacal disorder, the patient asks for investigations to determine or confirm the nature of the underlying disease, whereas the patient with somatization disorder asks for a treatment to remove the symptoms. 
3. Patients with somatization disorder misuse drugs and may show noncompliance over extended periods. Patients with hypochondriacal disorder fear drugs and their side-effects and seek reassurance by frequent visits to different physicians.

Disorders Which Must be Excluded to Diagnose Hypochondriasis

To diagnose hypochondriasis, one must exclude Panic Disorder and Delusional Disorder by the conventions of ICD-10.

Panic disorder
Delusional disorder

Trauma MCQ
The Gene Associated with Antisocial Behaviour
Child Psychiatry MCQ for MRCPsych Paper B



ICD-10 Version:2019 Hypochondriasis