Illness Anxiety Disorder

Illness anxiety disorder, formerly known as hypochondriasis, is a chronic condition characterized by a prolonged and exaggerated concern about one’s health and possible illness. Patients fear or are convinced that they have a disease and interpret minor or normal bodily symptoms as signs of a serious medical condition. Typically, concerns persist in spite of negative exam findings. To make the diagnosis, symptoms must be present for longer than 6 months. Treatment centers around psychotherapy, with a strong patient–physician relationship and regular visits.

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Epidemiology and Etiology

Epidemiology

  • Currently, epidemiological data are scarce, as the disorder was first described in the DSM-V. 
  • Estimated prevalence in outpatient setting: 0.75% 
  • Onset is usually in young adulthood and the prevalence rises with age. 
  • Likely no difference in prevalence among different genders and ethnicities

Etiology

  • The exact etiology is unknown. 
  • Those with illness anxiety disorder may want to assume the sick role as a way to be excused from regular obligations.
  • Fear of illness may be viewed as a form of punishment for the patient’s perceived wrongdoing.

Clinical Presentation and Diagnosis

Clinical presentation

  • Patients are highly concerned about having an illness, despite minor symptoms. 
  • They may frequently switch physicians, feeling that they are being mismanaged/misdiagnosed, and are not easily reassured by normal tests.
  • Patients may switch their belief of having 1 disease to another disease. 
  • They may be offended at and resistant to the idea of a psychiatric referral or diagnosis.

Diagnostic criteria

The DSM-V diagnostic criteria for illness anxiety disorders include the following:

  • The patient is preoccupied with getting a serious illness. 
  • The patient has no or only minimal somatic symptoms. 
  • The patient is highly anxious about their health and easily concerned about their (assumed) health issues. 
  • The patient obsessively checks their health status. 
  • The patient has been preoccupied for 6 or more months (the specific illness feared may change during this time period). 
  • Symptoms cannot be better explained by depression or another mental disorder.
Table: Features of illness anxiety disorder compared with important differential diagnoses
Willingness to undergo evaluationIntentional deceptive behaviorEvidence of external reward
Illness anxiety disorder+
Somatic symptom disorder+
Factitious disorder++
Malingering++

Management

  • 1st choice of treatment is psychotherapy, especially CBT → requires insight and compliance from the patient
  • Regularly scheduled visits with the same physician to address patient concerns and establish a rapport for patients to get the psychotherapy they need
  • Patients should be discouraged from seeking multiple specialist opinions and emergency department consultations.
  • Avoid ordering unnecessary procedures, tests, and pharmacotherapy. 
  • Comorbid depression and anxiety should be treated appropriately and may provide a potential window for a psychiatric referral. 

Differential Diagnosis

  • Somatic symptom disorder: a disorder in which patients present with multiple somatic complaints and excessive thoughts about the severity of their symptoms. Patients with somatic symptom disorder are unintentionally exaggerating their symptoms, whereas in illness anxiety disorder, patients are concerned primarily about having a terrible illness. 
  • Generalized anxiety disorder: an anxiety disorder presenting with persistent and excessive worry about everyday matters. Management includes psychotherapy and antidepressant medications such as selective serotonin reuptake inhibitors (SSRIs). Similar to illness anxiety disorder, patients may also be overly concerned about their health, but typically show extreme worry in multiple other domains.
  • Delusional disorder: can be diagnosed if a patient experiences 1 or more delusions for 1 month or more, without any other psychotic symptoms or behavioral changes and no decline in functioning abilities. Patient has strong, false beliefs despite being presented with arguments to challenge the beliefs. Compared with delusional disorder, patients with illness anxiety disorder are able to accept the possibility that they may not have the disease.

References

  1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.
  2. Weck F, Richtberg S, Neng JMB. (2014). Epidemiology of Hypochondriasis and Health Anxiety: Comparison of Different Diagnostic Criteria. Current Psychiatry Reviews. https://doi.org/10.2174/1573400509666131119004444
  3. Sadock BJ, Sadock VA, Ruiz P. (2014). Kaplan and Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11th ed.). Chapter 13, Psychosomatic medicine, pages 465-503. Philadelphia, PA: Lippincott Williams and Wilkins.
  4. French JH, Hameed S. Illness Anxiety Disorder. [Updated 2021 Feb 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK554399/

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