Mismanagement of a hypochondriacal patient.

Hypochondriasis is a persistent preoccupation that despite appropriate medical evaluations and assurance of patient's physical health, the patient insists on having a serious disease. The case which is discussed in this article is a 39-years-old woman that hospitalized for half of her life and no one can perceive her disorder according to her assertions. The mentioned case is a "difficult patient" with fear of oxygen shortage and being choked (Pnigophobia) which leads to continuous tendency to wear oxygen device even during sleep. There is no benefit in exaggerating her condition for herself so there is no fictitious disorder considered. During the therapy she has been assured that she does not have a serious disease and she has learnt to decrease oxygen intake and breath with his mouth. The point that makes this study different from the others is that most of hypochondriacal patients have a fear of getting HIV, cancers, hepatitis and MS but our patient has phobia of pulmonary embolism.

INTRODUCTION

Misperception of one or more physical feeling or detailed symptoms in patients with hypochondriasis causes strong belief in having a serious disease. This disorder is heterogeneous and usually chronic.[12] Hypochondriasis often begins in first period of adulthood and its prevalence is equal in both sexes.[23] Since this disorder has not been considered in epidemiological studies; the prevalence of hypochondriasis is unknown in community. In a systematic review in four population-based samples the prevalence of hypochondriasis has the range of 0.02-7.7 %.[3]

The pathogenesis of hypochondriasis is still unknown and among psychological and biological causes the former have been more studied. The main specification of this disorder is patient's too much resistant concern about his health This concern is made because of some bad feelings about physical state that is considered as a serious problem and ismislinked to a particular somatic disease.[45] Risk factors for hypochondriasis include dysfunctional assumptions and beliefs about the prevalence and communicability of severe illnesses, the meaning of bodily symptoms, and the course and treatment of illnesses.[6] The patients may think health is a state in which there is no disease symptoms or they might overestimate their vulnerability to developing diseases.[478] Incidents like reading an article or hearing about a particular disease can lead to misinterpretation and cause hypochondriacal thoughts. Hypochondriasis symptoms are in a range from normal to pathological.[910] The state with these symptoms is considered as a disorder when the concern of being healthy causes distress and overt clinical disorder.[1] Transient hypochondriacal preoccupation is not known as hypochondriasis. Indeed the essential feature of hypochondriasis is Preoccupation with fear of having an undiagnosed disease despite a normal examination and negative medical tests.[15]

Medical evaluation of hypochondriasis includes medical history, physical examination, diagnostic tests, psychiatric history and mental state examination. The purpose is evaluation of the patient with respect to general medicine (especially first stages of endocrine glands), Immunology, neurology, oncology and rheumatology diseases.[15] If we want to specify more accurate diagnostic aspects for this disorder; according to American psychiatric association diagnostic, criteria for hypochondriasis are as follows:

Preoccupation with fears of having, or the idea than one has, a serious disease based on the person's misinterpretation of bodily symptoms.

The preoccupation persists despite appropriate medical evaluation and reassurance.

The belief in the first criterion 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 preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

The duration of disturbance is at least 6 months.

The preoccupation is not better accounted for by Generalized Anxiety Disorder, Obsessive-Compulsive Disorder, Unipolar Major Depression or another Somatoform Disorder.

CASE REPORT

A 39-years-old housewife, with history of prolonged hospitalization has spent half of her life in hospital, as she said, and believed that despite lots of examinations, no one could realize her problem. She is undereducated and has a low social and financial level.

Her symptoms are both hands and feet edema, shortness of breath, complaint aboutsore throat, heavy head feeling, oral ulcers, strong dependency on nasal oxygen (which cause nasal mucosa dryness), 4 times severe epistaxis and also arthritis and photosensitivity. In the last hospitalization of the patient in the psychiatric unit she had nose bleeding for two times. She also had several complaints about physicalpains, breath shortness especially in the night, and difficulty in falling asleep with interrupted sleeping. The patient suffers from death phobia, and fear from having a severe and dangerous disease like cancer.

She shows symptoms of hyperventilation syndrome such as asphyxia, agitation, chronic pain, palpitation, feeling dizzy and perioral, head, finger and toes paresthesias.

In study of her family history, her mother's hypertension has been seen. At the age of 23 she has been cystectomies because of ovarian cyst. A significant decrease in the number of platelets [59000] which caused haemorrhage and diagnosed as ITP has been reported when she was 37. The patient is hypersensitive to eggplant, tomato, melon, grapes and antibiotics.

In her examinations lips are not cyanotic and nails and fingers are not deformed. Exophthalmos has been diagnosed but the thyroid test is normal. Decreased libido, truncal and abdominal obesity and bradykinesia have been reported. The patient has exhibitionism and when she want to explain or complain from a pain she expose the respective area. She looks anxious and panic.

The patient has been hospitalized in the following units:

Pulmonary: 4 times

Blood: 2 times

Heart: 3 times

Psychology: 4 times

Rheumatology: 2 times

Following actions has been done:

5 times echocardiography with almost similar results

1 times pulmonary perfusion scan

4 times pelvic and abdominal sonography

8 times chest X-ray

3 times chest CT scan

2 times brain CT scan

1 times brain MRI

In gallbladder sonography some 1-5 mm and two big (8 and 9.5 mm) gallstone has been seen. These gallstones are in the middle and inferior part of left renal sinus. The right index contained a modest 35 mm cyst. In the anterior part of left kidney a hypoechoic mass with echoic region has been observed.

Echocardiography results illustrate:

A12 + MR1+ EF = 55%

RVH LVH TR 2+

Cardiac perfusion scan: Chronic Thrombo-Emboli/vasculitis

Tests:

Antiphospholipid Ib.IgG = 6.9 (Normal)

Anti-dsDNA = 1.2 (High)

ANA = 0.7

Pulmonary function test (PFT): Obstruction and possible restriction

A dermal test has been carried out to determine the type of sensitivity.

Tests:

Bill (Normal)

MCV = 69.2

MCH = 21.57

MCHC31.1

PT = 18.5

Hb = 10.3

TIBC = 325

CRP = 3+

DISCUSSION

Hypochondriacal patients are divided into two categories. Some of them are concerned too much about their health despite not having any physical impairment. The others may have some somatic disorders, but their concern is not matched to their disease situation.[11] Patients usually emphasize on a specific organ of their body whichmay differ from another hypochondriacal patient.[2] These conditions are not considered as simulation or malingering.

Most of the hypochondriacal patients are concerned about HIV, cancers, hepatitis or multiple sclerosis[121314]; but inthis study the patient was concerned about getting pulmonary embolism, which is a new case, while she was not cyanotic and hypoxic. In a study was mentioned that a 72-year-old woman believed that her primary care provider shown that she has an infectious disease. She had a morning cough for many years; she was a current smoker and has a history of 45 pack year smoking. The patient insisted that she had a bronchial infection despite all of negative tests which demonstrates that she has nothing more than evidences that related to smoking. Or in another study, a 34-year-old woman who had recurrent vaginal candidiasis was aware that prevalence of HIV is more common in patient which had vaginal candidiasis by reading an article. So she asked three times from different infectious disease doctor for HIV infection test. All of them were negative but she could not believe any of them.[11]

Most of the hypochondriacal cases remain undiagnosed.[15] We performed some new actions to treat the patient, such as consideration of her pains and problems; and also we installed a panel above her bed with this message:” I don’t need oxygen device and I can live without it”. We gradually have reduced her usage of oxygen device and made her believe that oxygen even can be toxic to her cells.

Despite all of mentioned creative actions, the patient did not improve significantly because of her concerns and fears.

CONCLUSION

Some physicians, who don’t have enough Psychiatric knowledge, should have learnt to recognize this disorder and disorders like this. They must care about the patient's pain and keep away from ineffective tests. Using this model it is suggested that treatment should consist of the following components:

Education of patient;

A ban on medical reassurance;

Cognitive restructuring to alter faulty beliefs;

Behavioral testing of hypothesis.

In somatoform disorders like hypochondriasis, if thephysician does not care about patient's concerns and does not examine the patient and prescribe several tests, at the end, patient will believe that he has a seriousdisease, orphysicians didn’t recognize his illness or may they want to repulse him. We hope that mostphysicians can be flexible enough with these patients.