The reluctance of somatizing patients to accept psychiatric referral and treatment is familiar to both psychiatrists and nonpsychiatrist physicians and often is a concomitant of frustrating interactions for both patients and physicians (Lin et al. 1991; Lipsitt 1970, 1987; Schwenk and Romano 1992). House (1989) emphasized the need to address, in the first consultative visit, patients’ attitudes toward prior medical experience, physical examinations, and the referral process itself to improve acceptance of psychiatric treatment. Referral and treatment have the best chance of success, according to some authors, when carried out in medical rather than mental health settings. The suggestion has been made that conjoint evaluation by both a psychiatrist and an internist at the beginning instead of later in the process may abolish the sometimes awkward and ineffective referral effort.

House (1989) reported that of 100 hypochondriacal patients referred for psychiatric assessment, 77 followed through with treatment, with 79% doing so as outpatients. Of the 77 patients treated, 62 (81%) showed marked or moderate improvement, with most of the marked improvement in social functioning. These 77 patients were treated with a cognitive-behavioral approach in which the techniques of an insistence on discontinuation of other medical contact or investigation, confrontation regarding misconceptions, efforts to redirect attribution of bodily experience through provocation tests (e.g., hyperventilation, muscle tension), relaxation and breathing exercises, and education were applied. The 24 patients who had a coexisting major depression and who were younger than 40 years showed the best results. The author concluded that “in those who do attend for treatment, the prognosis for improvement in bodily preoccupation and personal distress may be better than is usually assumed, even in those with disorders of considerable duration”.

Psychopharmacological Approach
Medications have always been part of the armamentarium of medical practice, and their use in the treatment of hypochondriasis is no exception. Before the well-studied and controlled drugs of the 20th century, all types of substances were used to treat hypochondriasis, with caregivers holding a strong belief in their curative powers. The rationale was that the “good stuffs” (medications) would counteract the negative effects of “bad stuffs” (distressing thoughts and feelings). In all likelihood, any benefits were placebo related. Before the discovery of psychoactive pharmacological agents, barbiturates were used for emotional or psychiatric disorders. With the advent of anxiolytics and antidepressants, treatment became much more sophisticated, targeted, and effective.

The current rationale for psychopharmacologically treating hypochondriasis is that symptoms (including thoughts and feelings) are determined by neuroendocrine abnormalities that can be reversed by specific chemical agents acting on specific receptor sites in the central nervous system. There have been few controlled studies of the efficacy of these agents on hypochondriasis as defined in DSM-IV, but some reports have provided important and interesting data. Especially promising is the application of selective serotonin reuptake inhibitors in a wide range of disorders. Reports on the efficacy of these substances have begun to appear in the literature, with documented effects on a broad spectrum of psychiatric disorders. Fallon et al. (1994) reported that fluoxetine in dosages similar to those used for treatment of obsessive-compulsive disorder (60-80 mg/day) is effective in the treatment of hypochondriasis without accompanying major depression.

In Kellner’s report of a series of 45 patients seen over a period of 23 years, all but 3 patients were prescribed antianxiety drugs at least intermittently. Six patients received antidepressants prior to referral; any patients identified as having endogenous depression were excluded from the study. Kellner favored the temporary use of benzodiazepines in treating generalized anxiety states to allay anticipatory anxiety as a way of avoiding panic attacks or to interrupt the vicious cycle of fear, somatic symptoms, and more fear; he nonetheless cautioned that drugs be given only in conjunction with psychotherapy so that integrated treatment, explanation, and monitoring can take place.

The paucity of controlled drug studies on the treatment of hypochondriasis is attributable partly to the confusion over the distinction between primary and secondary hypochondriasis and partly to the presence of comorbid disorders. Until recently, these comorbid states were described anecdotally on the basis of clinical observation. Use of assessment tools, such as DSM-III-R (American Psychiatric Association 1987) criteria, the Structured Clinical Interview for DSM-III-R (Williams et al. 1992), and the Illness Behavior Questionnaire, has permitted a more precise identification of hypochondriasis and its associated disorders. Other screening instruments include the Whitely Index, the Illness Attitude Scales, and the Somatosensory Amplification Scale. Noyes et al. (1994) reported a 62% lifetime comorbidity of hypochondriasis with other psychiatric disorders, with major depression the most frequent (40%) disturbance found and panic disorder with agoraphobia the most common of the anxiety disorders (16%) noted. They found that depression usually followed the onset of hypochondriasis, whereas anxiety frequently preceded it. Further complicating the differential challenge is the introduction of the notion that hypochondriasis may be, in fact, a personality disorder encompassing a host of depressive, anxious, and obsessive-compulsive symptoms.

The results from the Noyes et al. (1994) and other studies (e.g., Barsky et al. 1992) have suggested that although primary hypochondriasis does exist, it is probably rare; this finding heightens the importance of treating comorbid primary conditions such as depression and anxiety. It is perhaps the reality of this co-occurrence that accounts for findings that panic disorder, other anxiety states, depression, and obsessive-compulsive disorder respond to medications described primarily as antidepressants. Kellner summarized evidence indicating that a variety of drugs decrease somatic symptoms when the primary disorder is depression, anxiety, or panic disorder. This effect is observed with benzodiazepines, imipramine, phenelzine, propranolol, and alprazolam in anxious patients and tricyclic antidepressants and monoamine oxidase inhibitors in depressed patients. The small numbers of patients in most pharmacotherapy studies confound the interpretation of results and do not rule out the possibility of high levels of placebo response in hypochondriacal patients.

Psychodynamic Approaches
Freud’s interest in hypochondriasis seemed fleeting and of little more consequence to him than as a model of pathology that might shed light on the nature of narcissism. His most extensive comments appeared in connection with the Schreber case and in his paper on narcissism (Freud 1914/1959). In those papers, he advanced the notion that hypochondriasis resulted from a withdrawal of libidinal attachment to external objects, which was then reinvested and dammed up in internal organs. Describing this condition as actual neuroses or organ neuroses, Freud expected that one day an anatomic component to such states would be discovered.

Few authors have explored the psychoanalytic understanding of hypochondriasis in the psychoanalytic literature. Macalpine and Hunter, in reassessing the Schreber case, stated that Freud considered physical symptoms little more than “organ pleasure” or “masturbatory equivalents”; they chastised other psychoanalytic authors for commonly treating physical symptoms “with less interest, respect and understanding than mental symptoms”. Freud’s theories, nonetheless, left a rich legacy for subsequent psychotherapeutic intervention.

Most subsequent psychodynamic formulations of hypochondriasis have included references to the element of distrust; the need to mother oneself as a substitute for lost mothering; the reluctance to relinquish a symptom that appears essential to maintaining bodily (and mental) integrity; the narcissistic regression to passivity and dependence; the sadomasochistic help-seeking, help-rejecting style of relating to physicians and others; and the defensive nature of obsessionality in physical preoccupation.

Vaillant (1977) described hypochondriasis as an immature defense that protects the individual from retribution that might be expected from the wish to reproach others for their perceived lack of interest and caring. In this sense, Vaillant’s position is similar to the Kleinian concept of the paranoid-schizoid position (Kernberg 1980), in which the “bad object” is projected outside the self and then by reintrojection becomes the source of internal bodily distress through which the hypochondriacal process “eats oneself up.” In other words, anxiety escalates so rapidly in hypochondriacal individuals that they lose some sense of their own bodily integrity. It is through their complaints that they then punish the disappointing object and coerce caretaking from it (as in the case of the “incurable” patient who “challenges” the physician to help him). Both passivity and aggression are thereby expressed in this behavior. These patients, through their suffering, extract care from others, often in the matrix of considerable resentment.

Other psychoanalytic concepts about hypochondriasis link it to death anxiety, a fear of disintegration of the self, or a narcissistic response to the threat of change. The signal function of hypochondriacal anxiety as a response to threats to the integrity of the self is illustrated in the cases of the Wolf Man and Schreber, who experienced both neurotic and psychotic forms of hypochondriasis.

There have been anecdotal reports of successful treatment of hypochondriacal patients with psychodynamic and psychoanalytic approaches. The rationale of such treatment approaches is based on the psychoanalytic premise that symptoms are compromise formations intended to reduce or resolve anxiety caused by intrapsychic conflict. Treatment addresses defenses, transference, and a working through toward the goals of insight and symptom alleviation. However, no methodological studies recommend this type of treatment in preference to others. Indeed, it has long been postulated that hypochondriasis of moderate severity may be a contraindication to psychoanalytic treatment. On the one hand, hypochondriacal patients seldom seek this form of treatment, and on the other hand, the development of an adequate transference neurosis for psychoanalytic cure is unlikely. Valenstein (1973) wrote that the need of some patients to remain attached to pain usually gives rise to negative therapeutic reactions.

In a series of 23 patients with hypochondriasis treated by psychodynamic psychotherapy or psychoanalysis, Ladee (1966) reported satisfactory to good results in only 4; in 3 of these patients, the hypochondriacal focus was cardiovascular, which is believed to have a better prognosis than other types of somatic preoccupation. Despite generally poor results in intensive psychotherapy, individual case reports have provided much enlightenment for the management if not the cure of the hypochondriacal patient. A variety of supportive psychotherapies owe their success to the incorporation of an understanding of transferential and countertransferential responses that can be used for ameliorative interventions.

Further contributions of psychoanalytic theory derive from studies of illness behavior, states of helplessness and hopelessness, and symptom attribution or meaning. Insights from these studies are useful in assessing any patients whose defense structure includes hypochondriasis of one degree or another. In that regard, Ladee (1966) cautioned against the risk of iatrogenesis in these individuals by stating that “anyone who consults a doctor can be or become a potential hypochondriac” and that “the doctor should realize at all times the power to influence which his verbal and nonverbal expressions have on a very varied population”. Appreciation of the complexities of the patient-physician relationship in hypochondriasis derives largely from psychoanalytic theory and clinical experience.