Correspondence

Hypochondriasis

N Engl J Med 2002; 346:783-784March 7, 2002

Article

To the Editor:

Dr. Barsky's Clinical Practice review of hypochondriasis (Nov. 8 issue)1 omits a common and important feature of the symptom complex in many patients: anxiety-induced hyperventilation. The symptoms mentioned in the review — intermittent paresthesias, belching, atypical chest pain, chronic headache, dizziness, and tinnitus — are the typical manifestations of hyperventilation.2 Unfortunately, most physicians ascribe these symptoms to organic causes and subject patients to multiple, unnecessary, and often expensive diagnostic studies. Even more unfortunately, these studies have false positive rates as high as 30 percent, as has been demonstrated with regard to exercise stress tests in women with atypical chest pain.3 The vicious cycle often leads to multiple, unnecessary, and frequently expensive therapies.

Fortunately, if anxiety-induced hyperventilation is considered and the symptom complex can be reproduced by voluntary overbreathing, the syndrome can be recognized easily. Even more fortunately, relief can be provided once the patient understands the mechanism responsible for his or her symptoms. Prevention and immediate relief of symptoms may be attained by rebreathing into a paper sack, and longer-term relief may be attained through cognitive behavioral therapy that includes the use of controlled breathing exercises.4

Some patients many need one of the 10 drugs listed in Barsky's Table 2 for further relief. But rather than rushing into pharmacotherapy, practitioners should consider a process, hyperventilation, that is probably involved in the symptoms of many psychosomatic syndromes. Conditions associated with hyperventilation certainly include chronic fatigue, fibromyalgia, and panic attacks, and very likely also include the Gulf War syndrome and chronic Lyme disease, in addition to other common psychosomatic conditions.5 Various factors may be responsible for the initial anxiety, but hyperventilation marks a common path from anxiety to disabling symptoms.

Norman M. Kaplan, M.D.
University of Texas Southwestern Medical Center, Dallas, TX 75390-8899
norman.kaplan@utsouthwestern.edu

5 References

1. 1

   Barsky AJ. The patient with hypochondriasis. N Engl J Med 2001;345:1395-1399
   Full Text | Web of Science | Medline

2. 2

   Kaplan NM. Anxiety-induced hyperventilation: a common cause of symptoms in patients with hypertension. Arch Intern Med 1997;157:945-948
   CrossRef | Web of Science | Medline

3. 3

   Fleet RP, Dupuis G, Marchand A, Burelle D, Arsenault A, Beitman BD. Panic disorder in emergency department chest pain patients: prevalence, comorbidity, suicidal ideation, and physician recognition. Am J Med 1996;101:371-380
   CrossRef | Web of Science | Medline

4. 4

   Barlow DH, Gorman JM, Shear MK, Woods SW. Cognitive-behavioral therapy, imipramine, or their combination for panic disorder: a randomized controlled trial. JAMA 2000;283:2529-2536[Erratum, JAMA 2000;284:2450, 2597.]
   CrossRef | Web of Science | Medline

5. 5

   Wessely S, Nimnuan C, Sharpe M. Functional somatic syndromes: one or many? Lancet 1999;354:936-939
   CrossRef | Web of Science | Medline

Author/Editor Response

Dr. Barsky replies:

To the Editor: Anxiety-induced hyperventilation is a prominent feature of panic attacks and panic disorder, and the prevalence of diagnosable panic disorder is high among patients with hypochondriasis.1,2 The prominence of cardiorespiratory symptoms in panic disorder may make this condition particularly difficult to distinguish from acute cardiac or pulmonary disease. Dr. Kaplan is correct in pointing out that once panic anxiety has been diagnosed, several effective therapeutic approaches are available, of which pharmacotherapy is only one. If the patient is having infrequent, uncomplicated panic attacks with limited symptoms, I agree that behavioral techniques, such as rebreathing and relaxation training, are both indicated and effective. If the panic attacks are more frequent and involve other symptoms and if the patient meets the diagnostic criteria for panic disorder, cognitive behavioral therapy is an effective alternative to pharmacotherapy.

Arthur J. Barsky, M.D.
Brigham and Women's Hospital, Boston, MA 02115
abarsky@partners.org

2 References

1. 1

   Barsky AJ, Wyshak G, Klerman GL. Psychiatric comorbidity in DSM-III-R hypochondriasis. Arch Gen Psychiatry 1992;49:101-108
   Web of Science | Medline

2. 2

   Noyes R Jr, Kathol RG, Fisher MM, Phillips BM, Suelzer MT, Woodman CL. Psychiatric comorbidity among patients with hypochondriasis. Gen Hosp Psychiatry 1994;16:78-87
   CrossRef | Web of Science | Medline

Citing Articles (1)

Citing Articles

1. 1

   Natascia Brondino, Niccolò Lanati, Francesco Barale, Valentina Martinelli, Pierluigi Politi, Diego Geroldi, Enzo Emanuele. (2008) Decreased NT-3 plasma levels and platelet serotonin content in patients with hypochondriasis. Journal of Psychosomatic Research 65:5, 435-439
   CrossRef