A 23-year-old woman comes to the office for a checkup. She reports that a family friend was diagnosed with multiple sclerosis 6 months ago. Since then, the patient has become increasingly preoccupied with the thought that she may have a neurologic illness. She spoke with her sister, who briefly reassured her, but has since been unable to get the thought out of her head and stays up at night researching symptoms on the internet. The patient double-checks food labels for preservatives and washes produce multiple times to remove pesticides because she read this could be linked with neurologic conditions. She has noticed that her eyes get tired and that she has cramping in her fingers when she spends long hours writing on the computer. She worries that this may be an early sign of multiple sclerosis and that she will not be able to support herself as a freelance journalist if she cannot write. The patient has no psychiatric history but acknowledges that she is a "worrier." Family history is significant for schizophrenia in a paternal uncle and anxiety in her mother. Physical examination, including neurologic evaluation, is normal. Which of the following is the most likely diagnosis in this patient?

Question

A 23-year-old woman comes to the office for a checkup.  She reports that a family friend was diagnosed with multiple sclerosis 6 months ago.  Since then, the patient has become increasingly preoccupied with the thought that she may have a neurologic illness.  She spoke with her sister, who briefly reassured her, but has since been unable to get the thought out of her head and stays up at night researching symptoms on the internet.  The patient double-checks food labels for preservatives and washes produce multiple times to remove pesticides because she read this could be linked with neurologic conditions.  She has noticed that her eyes get tired and that she has cramping in her fingers when she spends long hours writing on the computer.  She worries that this may be an early sign of multiple sclerosis and that she will not be able to support herself as a freelance journalist if she cannot write.  The patient has no psychiatric history but acknowledges that she is a "worrier."  Family history is significant for schizophrenia in a paternal uncle and anxiety in her mother.  Physical examination, including neurologic evaluation, is normal.  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

11ec25c8_d7cd_fa69_bc81_13c33222e2f2_MD0003_00 This patient's excessive concern about having multiple sclerosis despite the absence of prominent somatic symptoms is consistent with illness anxiety disorder (IAD) (previously known as hypochondriasis). Patients with IAD are preoccupied with the unfounded fear of having a serious, undiagnosed illness and are rarely reassured by negative findings on physical examination or laboratory testing. Their fears of illness often become a central feature of their lives, leading to high health care utilization, repeated self-checking for signs of illness, and catastrophic interpretations of minor, nonspecific physical sensations (eg, thinking that eye fatigue and cramping after prolonged muscle use could signify a serious disease). The treatment of IAD consists of scheduling regular visits, limiting diagnostic tests and referrals, and focusing on coping and functional improvement. (Choice A) Conversion disorder is characterized by neurologic symptoms and loss of function that are inconsistent with known disease. Examples include weakness or paralysis in anatomically inexplicable distributions and nonepileptic seizures, unlike in this patient who has vague, nonspecific symptoms. (Choice B) Patients with delusional disorder, somatic type, have false, fixed beliefs about the body. In contrast, patients with IAD are not delusional and can acknowledge the possibility that they do not have the disease, such as this patient who was briefly reassured by her sister. (Choice C) Patients with generalized anxiety disorder may have illness anxiety but also worry excessively about multiple everyday issues (eg, relationships, work, finances). This patient's anxiety appears to be restricted to fears of having a serious illness and its implications. (Choice E) Although this patient has intrusive thoughts and checking behaviors (eg, seeking reassurance, checking labels, washing foods), these revolve around her preoccupation with disease. She lacks the compulsive behaviors involving other concerns that characterize obsessive-compulsive disorder (eg, checking locks, counting, excessive handwashing). IAD is diagnosed when the predominant concerns are restricted to health and disease. (Choice F) Patients with somatic symptom disorder have prominent somatic symptoms (eg, pain, gastrointestinal distress, sexual dysfunction). In contrast, those with IAD are preoccupied with the idea of being sick and have minimal or no somatic symptoms, as seen in this patient who has mild, nonspecific symptoms. Educational objective: Illness anxiety disorder is characterized by excessive concern about having a serious, undiagnosed disease despite minimal or no somatic symptoms. References: DSM-5 illness anxiety disorder and somatic symptom disorder: comorbidity, correlates, and overlap with DSM-IV hypochondriasis. (http://www.ncbi.nlm.nih.gov/pubmed/28867421) Attribution of somatic symptoms in hypochondriasis. (http://www.ncbi.nlm.nih.gov/pubmed/24123559)

A 23-Year-Old Woman Comes to the Office for a Checkup