Illness anxiety disorder, formerly known as hypochondriasis, is characterized by a preoccupation with having or acquiring a serious, undiagnosed medical illness.[1]
Signs and symptoms
According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR), somatic symptom disorders all share a common feature: the prominence of somatic symptoms associated with significant distress and impairment.[1]
The core feature of somatic symptom disorder is the presence of one or more somatic symptoms that are distressing or result in significant disruption of daily life.
The core feature of illness anxiety disorder is a preoccupation with having or acquiring a serious, undiagnosed medical illness.
Diagnosis
DSM-5-TR criteria[1] for illness anxiety disorder are:
A. Preoccupation with having or acquiring a serious illness
B. Somatic symptoms are not present or, if present, are only mild in intensity
C. There is a high level of anxiety about health, and the individual is easily alarmed about personal health status
D. The individual performs excessive health-related behaviors (eg, repeatedly checking their body for signs of illness) or exhibits maladaptive avoidance (eg, avoids doctor appointments and hospitals)
E. Illness preoccupation has been present for at least 6 months, but the specific illness that is feared may change over that period of time
F. The illness-related preoccupation is not better explained by another mental disorder
Management
Randomized controlled trials now suggest that cognitive-behavioral therapy (CBT) is efficacious in the treatment of illness anxiety disorder[2, 3, 4, 5, 6] and preferred by patients over medications.[7, 8]
Cognitive and exposure therapy also seems to be promising for illness anxiety disorder.[9, 10] Mindfulness-based cognitive therapy also appears to be effective when added to usual care.[11, 12]
Illness anxiety disorder, formerly known as hypochondriasis, and the other somatic symptom disorders (eg, factitious disorder, conversion disorder) are among the most difficult and most complex psychiatric disorders to treat in the general medical setting. On the basis of many new developments in this field, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DMS-5)[13] revised diagnostic criteria to better facilitate clinical care and research. While illness anxiety disorder is now included in the category of "somatic symptom and related disorders" it continues to have much overlap with obsessive-compulsive disorder and other related illnesses.[1]
As with all psychiatric disorders, illness anxiety disorder demands creative, rich biopsychosocial treatment planning by a multidisciplinary team that includes primary care physicians, subspecialists, and mental health professionals.
This article describes illness anxiety disorder, its diagnosis, and an overview of treatment approaches, with references for details beyond the scope of the article. Finally, the article reviews new developments in psychopharmacologic and psychotherapeutic treatments.
Case study
A 45-year-old white male engineer presents to a primary care clinic armed with multiple internet searches on the topic of cancer. He states that he “just knows” he has a GI cancer, "probably the colon or maybe the pancreas." When asked how long this concern has bothered him, he says "for years I have been concerned that I have cancer." You ask about relevant symptoms and he is a bit vague, saying "I get some pain or pressure right here (he points to the left upper quadrant) but it is not there all the time." Upon asking about prior workups or diagnostic studies, he says “I have had ultrasounds and colonoscopies, but they couldn't find anything. I was initially relieved but a couple of weeks later started to think that they must have just missed something.”
When you ask about the patient's goals for today’s visit, he is emphatic. "I think what I really need is another colonoscopy and an abdominal CT scan." His examination is unrevealing. When you suggest a less invasive approach, he brings up error rates of the other evaluations and shows literature endorsing how abdominal CT is the criterion standard. He is anxious at baseline and increasingly irritable when you propose less invasive evaluation. He ends the encounter by stating that he will “find another doctor who sees my point and will get me what I need.”
Neurochemical deficits associated with illness anxiety disorder appear similar to those of mood and anxiety disorders. For example, Hollander et al posited an "obsessive-compulsive spectrum" to include hypochondriasis, obsessive-compulsive disorder (OCD), body dysmorphic disorder (BDD), anorexia nervosa, and Tourette syndrome, all of which were believed to have similarities in responsiveness to serotonin reuptake inhibitors and to demonstrate "hyperactivity" in areas of the frontal lobes.[14] Another article highlights the effectiveness of fluoxetine, a serotonin reuptake inhibitor and a mainstay in the treatment of OCD, as effective in the treatment of hypochondriasis although this is considered second-line treatment after psychotherapy, or offlabel use.[15, 16, 17, 18]
While the formulation of obsessive-compulsive (OC) spectrum disorders was adopted by the DSM-5, this new clustering does not include illness anxiety disorder. It does include: OCD, BDD, hoarding disorder, trichotillomania, excoriation disorder, and other related disorders that are substance induced or due to another medical condition. In addition, encountering a patient with more than one of the anxiety spectrum disorders comorbid with illness anxiety disorder is not unusual. Findings of neurochemical deficits in patients with illness anxiety disorder are only preliminary, but such deficits may explain why symptoms overlap, why the disorders are commonly comorbid,[19] and why effective treatments for OC spectrum disorders are also effective for illness anxiety disorder (eg, selective serotonin reuptake inhibitors [SSRIs]).
In a study of biological markers, subjects who met DSM-IV-TR diagnostic criteria for hypochondriasis had decreased plasma neurotrophin 3 (NT-3) levels and platelet serotonin (5-HT) levels, compared to healthy control subjects. NT-3 is a marker of neuronal function and platelet 5-HT is a surrogate marker for serotonergic activity.[20] In another study, patients with somatization disorder were found to have significantly lower plasma levels of brain-derived neurotrophic factor (BDNF), which has been associated with underlying pathophysiology in conditions including depression and schizophrenia.[21]
Based on the previously defined "hypochondriasis," the DSM estimates that the community 1–2-year prevalence is 1.3–10% in high-income countries such as the United States and Germany, while the 6-month to 1-year prevalence in medical outpatients is 3–8%. Some degree of preoccupation with disease is apparently common because 10–20% of people who are healthy and 45% of people without a major psychiatric disorder have intermittent unfounded worries about illness.[22, 23] In a study of specialty clinics, nearly one-fifth of patients endorsed illness anxiety.[1]
Most people who would have been identified as having hypochondriasis under the DSM-IV criteria are now categorized with somatic symptom disorder. However, in one-third of cases, the diagnosis is instead illness anxiety disorder.[1]
International/cultural effects
Efforts have been made to quantify international rates of illness anxiety disorder and other somatic symptom disorders. Those rates are heavily influenced by the diagnostic criteria involved (ie, somatization disorder versus abridged somatization disorder) and how studies are conducted. Within the United States, researchers have also worked to define how culture and ethnicity interact to determine "idioms" of distress and also how these factors influence the physician-patient relationship. This research has included the formulation of patterns of presentations that can be classified as "culture bound syndromes." A selective literature review recommends that culture be considered in idiopathic somatic symptom presentations, but also that caution be taken to not be overly generalizing about ethnicity.
Mortality/morbidity
Illness anxiety disorder is usually episodic, with symptoms that last from months to years and equally long quiescent periods. Although formal outcome studies have not been conducted, one third of patients with illness anxiety disorder are believed to eventually improve significantly. A good prognosis appears to be associated with high socioeconomic status, treatment-responsive anxiety or depression, the absence of a personality disorder, and the absence of a related nonpsychiatric medical condition. The number of somatic symptoms at baseline may also influence the course of the condition, leading to worse outcomes.[24] Most children are believed to recover by adolescence or early adulthood, but empiric studies have not been carried out.
Epidemiological studies are few, but patients with illness anxiety disorder appear to have no significant differences in age or gender than patients without this disorder although a German study noted slightly greater prevalence in patients of female gender and older age.[25] There have been several studies that have found patients with illness anxiety disorder to have decreased educational and income levels and higher rates of childhood illness and abuse.[22] These individuals use medical care at high rates, making frequent visits to the emergency department, the doctor, and other health care providers and undergoing frequent physical examinations, laboratory testing, and other costly, invasive, and potentially dangerous procedures.[26, 27]
Cognitive, social learning, and psychodynamic theories imply that patients have significant psychosocial disturbances in terms of relationships, vocations, and other endeavors. Exacerbations may occur with psychological stressors and in patients with comorbid psychiatric conditions.
These high-use patterns differ dramatically from those of nonsomatizing patients and remain true even when comorbid medical conditions and sociodemographic differences are accounted for.[28] The medically unexplained complaint is often a symptom of illness anxiety[29] and may well be a presentation of associated abnormal illness behavior.[30]
Patients with illness anxiety disorder have a high rate of psychiatric comorbidity.[31] In one general medical outpatient clinic, 88% of patients with hypochondriasis had one or more concurrent psychiatric disorders, the most common being generalized anxiety disorder (71%), dysthymic disorder (45.2%), major depression (42.9%), somatization disorder (21.4%), and panic disorder (16.7%). These patients are 3 times more likely to have a personality disorder than the general population.[31] Personality disorders prevalent in this population include paranoid, avoidant, and obsessive-compulsive.[32] Substance abuse or dependence is also a serious comorbid condition, particularly use of benzodiazepines, though epidemiological studies have not assessed the exact frequency of this problem. Health anxiety is regarded as a risk factor for non-medical use of prescription drugs.[33]
Sex- and age-related demographics
Illness anxiety disorder appears to occur equally in men and women.[34]
The disorder can begin at any age, but the most common age of onset is early adulthood. The disorder is thought to be rare in children.[1]
Illness anxiety disorder is a common disorder in primary care settings.
The differential diagnosis includes other somatoform, depressive, anxiety (eg, generalized anxiety disorder, OCD), and psychotic disorders.
Biopsychosocial treatment is required to manage this complex disorder, and further research is required to better understand its pathophysiology and interface with other psychiatric conditions. Recognizing the biological similarities between these seemingly disparate disorders may be a useful starting point to begin a more systematic study of novel treatments for hypochondriasis.[35, 36]
A systematic review of six studies on hypochondriasis indicated that 30%–50% of patients achieve recovery.[37, 24]
A good prognosis appears to be associated with high socioeconomic status, treatment-responsive anxiety or depression, the absence of a personality disorder, and the absence of a related nonpsychiatric medical condition.
Most children recover by adolescence or early adulthood.
There is a dearth of long-term follow-up studies examining outcomes of patients with hypochondriasis. In a prospective study that examined 58 patients with hypochondriasis who had participated in selective serotonin reuptake inhibitor (SSRI) treatment for 4–16 years (mean 8.6 ± 4.5 y), 40% continued to meet the diagnosis of hypochondriasis. Predictors of continued diagnosis of hypochondriasis include longer duration of hypochondriasis prior to treatment, history of childhood physical punishment, and lower use of SSRI during the treatment period. A large portion of patients with hypochondriasis who received SSRI treatment were able to achieve remission.[38, 39]
The long-term prognosis of patients with hypochondriasis is understudied due to the heterogeneity of the disorder. A Swedish study comparing 4129 patients with hypochondriasis compared to 41,290 demographically matched individuals without hypochondriasis found the former to have increased risk of death from both natural and unnatural causes, especially suicide.[27]
Educational approaches provide accurate information, allowing the patient to realize somatic symptoms are exceedingly common, with only a small proportion caused by actual disease and most symptoms being compatible with physical health.
Accurate information about the relationship of a threatening stimulus and its somatic consequences can influence the severity of autonomic responses, subjective distress, and behavior.
Maladaptive iatrogenic beliefs must be countered. Providing a small amount of information at a time and repeating it is best.
For mild and short-lived symptoms, the primary medical provider can provide detailed education (symptoms, course, monitoring, diagnosis, and treatment) about the medical condition about which the patient is concerned.
Education should additionally focus on the role of anxiety and how anxiety could increase autonomic activity or arousal and, thereby, cause the body to misattribute certain physical sensations and symptoms.
For more persistent and chronic hypochondriasis, especially in situations where the patient has already failed treatment with multiple providers, education needs be delivered in small “doses,” when the time is right, and after the establishment of a firm patient-provider relationship.
The tailoring of education delivery as applied to mild versus severe symptoms has not been systematically studied.
Since hypochondriasis may be precipitated by psychosocial stress, family support is likely to be additionally helpful. However, the role of family education requires further investigation.
Even in the absence of formal research into family education for hypochondriasis, several practical pointers are recommended:
The patient needs to give permission to involve family members in diagnosis and treatment planning decisions.
Family members need to be told that the physician will not keep secrets from the patient; ie, anything family members tell the physician about the patient will be shared, with direct attribution, to the patient.
Family members need to understand that the distress the patient feels is real even if the conviction about illness is false or cannot be substantiated.
Family members should not enable overuse of medical services by reinforcing patients’ requests for excessive interventions.
Family members should be encouraged to support the outpatient chronic disease model for hypochondriasis as described above.
Family members should be educated on the common psychiatric comorbidity of hypochondriasis and help the patient self-monitor for mood and anxiety symptoms and seek help for these separately.
Family or couple’s therapy should be considered in patients where family and marital discord is a major source of conflict that may be contributing to psychological distress. Alternatively, family therapy should be considered in patients whose symptoms have caused major distress to family dynamics that seem to further perpetuate current symptoms.
Hypochondriasis was removed as a diagnosis from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) in 2013.[13] Instead, approximately 75% of individuals previously diagnosed with hypochondriasis are subsumed under the diagnosis of somatic symptom disorder. The remaining 25% have high health anxiety in the absence of somatic symptoms and are classified as having illness anxiety disorder. Both somatic symptom disorder and illness anxiety disorder are classified in the DSM-5-TR under Somatic Symptom and Related Disorders.[1] The disorders in this class include somatic symptom disorder, illness anxiety disorder, functional neurological symptom disorder (conversion disorder), and factitious disorder.
The health preoccupation diagnostic interview has been determined to have sufficient inter-rater reliability for somatic symptoms disorder and illness anxiety disorder (kappa of 0.85; n=104).[40] According to the DSM-5-TR, somatic symptom disorders all share a common feature: the prominence of somatic symptoms associated with significant distress and impairment.[1]
The core feature of somatic symptom disorder is the presence of one or more somatic symptoms that are distressing or result in significant disruption of daily life. Additionally, any present physical signs/symptoms are physiological in nature.
The core feature of illness anxiety disorder is a preoccupation with having or acquiring a serious, undiagnosed medical illness.
Diagnostic criteria (DSM-5-TR)
The DSM-5-TR criteria for illness anxiety disorder are as follows:[1]
The individual is preoccupied with having or acquiring a serious illness.
Somatic symptoms are not present or, if present, are only mild in intensity. If another medical condition is present or there is a high risk for developing a medical condition (eg, strong family history is present), the preoccupation is clearly excessive or disproportionate.
The individual has a high level of anxiety about health, and is easily alarmed about personal health status.
The individual performs excessive health-related behaviors or exhibits maladaptive avoidance.
The individual has been preoccupied with illness for at least 6 months.
The individual's preoccupation is not better explained by another mental disorder.
The absence of physical findings, particularly after serial examinations, supports the diagnosis of illness anxiety disorder. However, the patient must receive a physical examination to make the psychiatric intervention possible. A mental status examination complements the physical examination.
General appearance, behavior, and speech
See the list below:
Modestly or well groomed, not grossly disheveled
Cooperative with the examiner, yet ill at ease and not easily reassured
Possible signs of anxiety, including moist hands, perspiring forehead, strained/tremulous voice, and wide eyes and intense eye contact
Psychomotor status
See the list below:
Restlessness
Frequent shifts in posture
Mild-to-moderate agitation
Slowed (if sleeping poorly)
Mood and affect
Mood is the pervasive and sustained emotion that colors the patient's perception of the world, and affect is what the examiner observes.
Anxious or worried, depressed mood
Restricted, shallow, fearful, or anxious affect, with restricted fluctuations and limited depth
Thought process
See the list below:
Spontaneous speaking with occasional abrupt changes in topic
Circumstantial, scattered at times
Responds to questions but may divert to next worry or revert to an already expressed concern despite reassurance to the contrary
No latency unless also depressed
No thought blocking or looseness of associations
Concrete focus of thought, but with capacity to abstract in a number of areas when encouraged or tested
May appear distractible and yet can concentrate independently and with encouragement
Thought content
See the list below:
Preoccupation with being ill
Anxious themes concerning what in the body is wrong, how it is wrong, and how it is experienced
May have feelings of despair and/or hopelessness, although these are not usually of significant depth unless little relief has come from seeing multiple providers and/or the patient concurrently depressed
Catastrophizing tendencies (focused on dire consequences of various symptoms and obtaining more diagnostic testing)
Uninterested in revealing other aspects of daily functioning or general lifestyle topics at length
Inflexibility regarding bodily concerns, but only rarely to the point of a delusion (ie, fixed, false belief), and if so, limited to somatic complaints rather than grandiose or persecutory complaints
No perceptual disturbances (eg, hallucinations)
No suicidal ideation, unless concurrently depressed
No homicidal ideation
Cognitive function
See the list below:
Attentive
Oriented fully to time, place, and person
Rare difficulties with concentration, memory, and other faculties, but functions in the normative range with refocusing and encouragement
May have some deficits if concurrently depressed; these also tend to be overcome in response to encouragement
Interestingly, may have selective attention (eg, the patient is distressed by an ongoing bodily complaint but not by a newly sprained ankle)
Insight
See the list below:
Able to recognize bodily sensations
Lacking full understanding of underlying psychological concerns and how they underpin development and maintenance of bodily complaints; tends to see the "trees" rather than the "forest"
Some awareness of own feelings about people and events, but not always with the ability to translate that into action, sustained change in mood, or lessening of preoccupations
Judgment
See the list below:
Capable of social greetings and other behaviors
Persistence in discussing and evaluating continuing preoccupations (due to limited insight)
Developmental and other predisposing factors consistently indicate the importance of parental attitudes toward disease, previous experience with physical disease, and culturally acquired attitudes relevant to the etiology of the disorder.[41] Overall, however, few demographic and clinical differences have been found between patients with illness anxiety disorder and the general population. Certain special populations, such as medical students, may exhibit heightened anxiety or concern in regards to contracting an illness that they see (ie, “medical student syndrome”).[42] There are some findings that risk factors for illness anxiety disorder include a lower educational level, lower income, and a history of childhood illness or abuse.[22]
A cognitive model of illness anxiety disorder suggests that patients misinterpret bodily symptoms by augmenting and amplifying their somatic sensations. Patients also appear to have lower-than-usual thresholds for, and tolerance of, physical discomfort. For example, what most people normally perceive as abdominal pressure, patients with illness anxiety experience as abdominal pain. When they do sustain an injury (eg, ankle sprain), it is experienced with significant anxiety and is taken as confirmation of their worry about being ill. This may be due to a tendency among patients with illness anxiety to exaggerate their assessment of vulnerability to disease and their appraisal of the risk of serious illness.[28]
The social learning theory frames illness anxiety disorder as a request for admission to the sick role made by a person facing seemingly insurmountable and insolvable problems. This role may allow them to avoid noxious obligations, postpone unwelcome challenges, and be relieved from duties and obligations.[43]
The psychodynamic theory implies that aggressive and hostile wishes toward others are transferred via repression and displacement into physical complaints. The somatic symptoms serve to "undo" guilt felt about the anger and serve as a punishment for being "bad."
Neurochemical deficits with illness anxiety disorder and some other somatoform disorders (eg, body dysmorphic disorder [BDD]) appear similar to those of depressive and anxiety disorders. For example, in 1992, Hollander et al. posited an obsessive-compulsive spectrum that includes OCD, BDD, anorexia nervosa, Tourette syndrome, and impulse control disorders (eg, trichotillomania, pathological gambling).[14] Although only preliminary data have been reported on these neurochemical deficits, such deficits may explain why symptoms overlap, why the disorders are commonly comorbid, and why treatments may parallel one another (eg, SSRIs). Additionally, P-wave dispersion (the difference between the maximum and minimum P-wave duration on the electrocardiograph) has been found to be significantly higher in patients with panic disorder and in patients with illness anxiety, compared with healthy control subjects. The elevated P-wave dispersion may be an indicator of cardiac autonomic dysfunction in anxiety disorders.[44]
Patients who are hypochondriacal may be significant consumers of medical care, undergoing repetitive doctor visits, physical examinations, laboratory testing, and other costly, invasive, and/or potentially dangerous procedures.
Physician concerns regarding workups for somatic complaints also may preclude diagnosis of common comorbid disorders (eg, depression) that are quite treatable.
Screening tools for illness anxiety disorder include the following:
The Health Anxiety Inventory (HAI) (long version; short version of 14 items, 5 min) reliably distinguishes patients with hypochondriasis from patients with anxiety disorders or healthy controls.[57]
The Illness Attitude Scale (29 items, 15 min, English only) is used for detection and to assess severity.[68]
The Whitely Index of Hypochondriasis (14 items, 5 min, >14 languages) is used for detection, for rating severity, and for measuring change per interventions.[69]
The Somatoform Disorders Symptom Checklist (65 yes-or-no items, 20 min, > 5 languages) screens for hypochondriasis, somatization disorder, body dysmorphic disorder (BDD), and other conditions.[70]
Continue successful long-term trials of medications for patients with illness anxiety disorder.
For patients with comorbid disorders, consider maintenance of those trials because these disorders can initiate and/or exacerbate hypochondriacal symptoms.
Close collaboration among all treating providers to prevent investigative duplication
Physician concerns and influence
The most powerful therapeutic tool is the physician and their team's attention, concern, interest, careful listening, and nonjudgmental stance, which can potentially break a pathological cycle of maladaptive interactions between the patient and movement from physician to physician (see the image below).[71]
View Image
Pathological cycle of bodily concern and anxiety in hypochondriasis.
One difficulty with which physicians struggle is related to countertransference (ie, physicians' own emotional reactions to the patient). Typically, physicians feel angry, hopeless, and/or helpless because their assessments and interventions are not effective and efforts at reassuring the patient are usually met with resistance and even escalation of physical symptoms. These feelings may lead physicians to reject or withdraw from patients with illness anxiety disorder.
Psychiatric inpatient care
As with the other somatoform disorders, inpatient psychiatric hospitalization for the somatoform disorder itself is rarely necessary. As these patients are at risk for concurrent mood, anxiety, and personality disorders, a psychiatric admission may be necessary to manage episodic decompensation of the comorbid psychiatric conditions or suicidal ideation.
If the patient experiences suicidal ideation or makes a suicide act based on comorbid depression or personality disorder or develops uncontrollable anxiety, then an inpatient psychiatric hospitalization may be indicated. In such a case, an illness anxiety disorder diagnosis may be established in the context of an inpatient admission.
Formal psychometric testing may be of help.
The hypochondriacal patterns of behavior can be addressed in ward therapy interventions.
When patients are discharged following recovery of behavioral stability, the treatment model described below may be implemented.
General medical inpatient care
Patients with illness anxiety disorder should be admitted to general medicine and surgery services based on the actual medical and surgical acuity, and not solely to facilitate costly and unnecessary workup.
Due to the enigmatic nature of various physical symptoms, occasionally patients with illness anxiety disorder are admitted to the general medical-surgical hospital for an extensive work-up.
When illness anxiety disorder is suspected in a medical or surgical inpatient, a psychosomatic medicine consultation should be performed to elucidate the diagnosis and address psychiatric comorbidity.
If clinically recommended by the psychosomatic medicine consultant, psychotropic medication interventions can be started.
As in the outpatient care model, patients should not be exposed to high-risk invasive procedures.
Numerous other strategies appear to benefit patients with illness anxiety disorder or hypochondriasis (see the image below). These strategies may prevent potentially serious complications, including the effects of unnecessary diagnostic and therapeutic procedures.
View Image
Factors that maintain anxiety in patients with hypochondriasis.
Establish one primary care physician as the patient's main physician and maintain consistent followup.
Review the patient's medical history to build a therapeutic alliance and rule out medical disorders.
Premature reassurance, prescription of psychotropic medications, and referral for mental health services may suggest to the patient that he or she is not being taken seriously. Therefore, while such treatments may be indicated at some time (in the future), prematurely offering a diagnosis or psychiatric treatment may, in fact, impair the establishment of a trusting patient-physician relationship.
Empathetically acknowledge the patient's pain and suffering.
Couple reassurance statements of normal findings with statements that that the patient will not be abandoned. For example, “Mr. Smith, it appears that you are still having concern about having a “several medical disorder” despite all the workup, which, so far, has not showed any abnormal finding. I will continue to work with you to maximize you overall well-being and health.”
Reassure the patient that evaluation will be ongoing.
Understand the “the fear” of having an unknown medical disorder as a form of emotional communication.
Search for underlying medical and psychiatric disorders potentially amenable to treatment.
Seek consultation or refer the patient to a colleague if establishing a therapeutic alliance proves difficult.
Allow for time-limited structured discussions about somatic concerns.
Spend sufficient time on health care maintenance issues such as diet, experience, smoking cessation, and cancer detection.
Treat any comorbid psychiatric disorders concurrently.
Be aware of emotional reactions toward the patient (ie, anger, hopelessness, helplessness) and seek frequent informal consultation when possible.
Focus on care of the patient with illness anxiety disorder, not exclusively on “a cure” for the disorder.
Psychotherapy
Several authors have suggested a cognitive-educational approach to understand the development of the severe anxiety associated with illness anxiety disorder and the factors that maintain the long-term anxiety.[72] Randomized controlled trials now suggest that cognitive-behavioral therapy (CBT) is efficacious in the treatment of illness anxiety disorder[2, 3, 4, 5, 6] and may be the recommended treatment for patients with this disorder. Bibliotherapy, using CBT principles, may also be useful.
In a meta-analysis of outcomes using CBT for illness anxiety disorder, higher pre-treatment severity and great number of CBT sessions is associated with higher effect size.[73]
Cognitive and exposure therapy also seems promising for illness anxiety disorder.[9, 10] Mindfulness-based cognitive therapy also appears to be effective when added to usual care.[11, 12] Acceptance and commitment group therapy (ACT-G) has also been demonstrated to show effectiveness for treating severe health anxiety in a randomized controlled trial of 126 patients.[74]
In clinical settings, both the availability of CBT and treatment adherence of patients with illness anxiety disorder to psychotherapy in general are major barriers to successful outcomes. It is possible that case management and integrated primary care and psychiatry programs may be especially suitable for patients with illness anxiety disorder and somatic symptom disorder. However, prospective treatment studies are urgently needed in this area.
Patients with illness anxiety disorder should eat 3 meals per day to feel as healthy as possible. They should avoid substances that adversely affect mood, exacerbate anxiety symptoms, or reduce the quality of sleep (eg, caffeine, alcohol, nicotine).
Exercise increases psychological wellbeing. Patients who are hypochondriacal may be reluctant to follow this advice, but many patients greatly increase their physical activity as treatment progresses. Exercise helps to improve mood, reduce tension, and improve sleep in patients with associated depression, anxiety, or both.
Pharmacotherapy is used as an adjunct to psychotherapy and educational treatments, or when these treatments are refractory. The goals of pharmacotherapy are to reduce comorbid symptoms and disorders (eg, depression), to prevent complications, and, in a few circumstances, to reduce hypochondriacal symptoms. Each medication has advantages and disadvantages.[75]
There are no medications approved specifically for the treatment of hypochondriasis, somatic symptom disorder, or illness anxiety disorder. Medications are usually started to treat the comorbid depression or anxiety disorder.
A meta-analysis of 13 randomized controlled trials, with three including SSRIs, found SSRIs to be effective in acute treatment of hypochondriasis, especially when intervention occurred at younger age.[76]
Clinical Context:
Selectively inhibits presynaptic serotonin reuptake, minimal or no effect on reuptake of norepinephrine, and clinically insignificant inhibition of reuptake of dopamine.
Clinical Context:
Selectively inhibits presynaptic serotonin reuptake, norepinephrine (at doses of approximately 150 mg PO qam), and dopamine (at doses of approximately 150-225 mg qam).
Clinical Context:
Potent selective inhibitor of neuronal serotonin reuptake. Does not bind significantly to alpha-adrenergic, histamine, or cholinergic receptors and, thus, has fewer adverse effects than TCAs.
Clinical Context:
Selective serotonin reuptake inhibitor (SSRI) and S-enantiomer of citalopram. Used for the treatment of depression. Mechanism of action is thought to be potentiation of serotonergic activity in CNS resulting from inhibition of CNS neuronal reuptake of serotonin. Onset of depression relief may be obtained after 1-2 wk, which is sooner than other antidepressants.
These are typically used for depression or anxiety comorbid with hypochondriasis, although in some cases they alleviate hypochondriacal symptoms in the absence of another disorder. They are indicated for use in adults with depression, anxiety (eg, panic disorder, OCD, social phobia, generalized anxiety, posttraumatic stress disorders), and bulimia nervosa disorders.
Clinical Context:
Has membrane-stabilizing activity and decreases automaticity of contractions. May block beta-adrenoreceptors in the central nervous system. As it is a lipophilic compound, may readily enter the blood–brain barrier.
Compete with beta-adrenergic agonists for available beta-receptor sites. Propranolol inhibits beta-1 receptors (located mainly in cardiac muscle) and beta-2 receptors (located mainly in bronchial and vascular musculature), inhibiting chronotropic, inotropic, and vasodilatory responses to beta-adrenergic stimulation.
Clinical Context:
For management of panic attacks. Binds receptors at several sites within CNS, including limbic system and reticular formation. Effects may be mediated through GABA receptor system.
Indicated for treatment of anxiety disorders and panic attacks, with or without agoraphobia, which are commonly comorbid with hypochondriasis. Use with caution because patients with hypochondriasis may have increased risk of substance abuse or dependence. Also use with caution in geriatric patients due to increased risk of confusion as well as falls and fractures.[77]
Clinical Context:
Indicated for Tourette syndrome for suppression of motor and phonic tics. Off-label use for psychosis, hypochondriacal delusions and parasitosis, and Huntington chorea.
Clinical Context:
Binds to dopamine D2 receptor with 20-times lower affinity than for serotonin receptor. Improves negative symptoms of psychoses and reduces incidence of EPS. Indicated for treatment of psychotic disorders, including schizophrenia and bipolar disorder mania; also used for sleep.
Clinical Context:
Binds to dopamine D2 and serotonin receptors. Improves negative symptoms of psychoses and reduces incidence of EPS. Indicated for treatment of psychotic disorders, including schizophrenia and bipolar disorder mania; also used for sleep
Have been shown to reduce morbidity associated with illness anxiety disorder, particularly in presence of comorbid anxiety or hypochondriacal worries that mimic obsessions or delusions. Because of potential for serious long-term adverse effects (eg, extrapyramidal symptoms such as tardive dyskinesia), consultation with psychiatrist recommended to evaluate need for antipsychotic medication. Insufficient data to list other antipsychotics, although they have been used in patients with hypochondriasis.
Jaskaran Singh Dhillon, MD, Post-Graduate Research Assistant, Department of Psychiatry, Ochsner Medical Center
Disclosure: Nothing to disclose.
Coauthor(s)
Glen L Xiong, MD, Associate Clinical Professor, Department of Psychiatry and Behavioral Sciences, Department of Internal Medicine, University of California, Davis, School of Medicine; Medical Director, Sacramento County Mental Health Treatment Center
Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: SafelyYou, Blue Cross Blue Shield<br/>book co-editor for: Wolter Kluwer, American Psychiatric Publishing Inc.
Specialty Editors
Francisco Talavera, PharmD, PhD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Received salary from Medscape for employment. for: Medscape.
Chief Editor
David Bienenfeld, MD, Professor, Departments of Psychiatry and Geriatric Medicine, Wright State University, Boonshoft School of Medicine
Disclosure: Nothing to disclose.
Additional Contributors
Debra Kahn, MD, Associate Clinical Professor, Director of Psychosomatic Medicine Service, Director of Psychosomatic Fellowship, Director of Transplant Psychiatry, Department of Psychiatry and Behavioral Sciences, University of California, Davis, School of Medicine
Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Otsuka Pharmaceutical Development & Commercialization, Inc.
Donald M Hilty, MD, MBA, Associate Chief of Staff, Mental Health, Northern California VA Healthcare System; Professor of Psychiatry, Department of Psychiatry and Behavioral Sciences, University of California, Davis, School of Medicine
Disclosure: Nothing to disclose.
James A Bourgeois, OD, MD, Professor of Clinical Psychiatry, Medical Director of Emergency Psychiatry, Department of Psychiatry and Behavioral Sciences, University of California, Davis Medical Center, University of California, Davis, School of Medicine
Disclosure: Nothing to disclose.
Peter M Yellowlees, MD, MBBS, Professor of Psychiatry, Director of Health Informatics Program, University of California, Davis, School of Medicine
Disclosure: Received consulting fee from Medscape for independent contractor.
Acknowledgements
The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors Shayna L Marks, BA, MA; Dandan Liu, BA; and Celia Chang, MD to the development and writing of this article.
References
Somatic Symptom and Related Disorders. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision. Washington, DC: American Psychiatric Association; 2022.
American Psychiatric Association. Somatic Symptom and Related Disorders. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington, DC: American Psychiatric Association; 2013. 310-318.
Fallon BA, Petkova E, Skritskaya N, et al. A double-masked, placebo-controlled study of fluoxetine for hypochondiasis. J Clin Psychopharmcol. December 2008. 6:638-45.
Starcevic V. Boundaries and overlap between hypochondriasis and other disorders: Differential diagnosis and patterns of co-occurrence. Curr Psychiatry Rev. 2014. 10 (1):24-33.
Xiong GL, Bougeois JA, Chang CH, Liu D, Hilty DM. Hypochondriasis: common presentations and treatment strategies in primary care and specialty settings. Therapy. 2007. (4):3:323-38.
){kind=link}
){kind=link}