Illness Anxiety Disorder (Hypochondriasis)

What is illness anxiety disorder?

Illness anxiety disorder (IAD), also known as health anxiety, hypochondria, and hypochondriasis, is a psychiatric disorder characterized by a preoccupation with having or developing a medical condition, which causes excessive anxiety and concern, impacting daily life and functioning ^[1].

Illness anxiety disorder is a diagnosis in the Diagnostic and Statistical Manual of Mental Disorders, 5^th Edition, (DSM-5) ^[2], and is a revised version of the diagnosis, hypochondriasis, which was included in the DSM-IV ^[3] and had a more specific set of diagnostic criteria. IAD is considered a more reliable diagnosis, due to the change in criteria, making it easier to diagnose and treat ^[4].

People with IAD experience persistent concern about their health, believing that they have or will develop a serious medical condition, regardless of medical tests and reassurance ^[5]. IAD can be specified as one of two types ^[6]:

• Care-seeking type: regularly visiting the emergency room or doctor for checks and reassurance
• Care-avoidant type: avoiding medical checks due to fearing a diagnosis of a serious condition

IAD typically begins in early adulthood and worsens with time if left untreated.

Symptoms of illness anxiety disorder

Symptoms of illness anxiety disorder may vary from person to person, but typically include ^[1][7]:

• Intense focus on bodily sensations, such as normal aches and pains, tightness, or headaches
• Misinterpreting normal or new sensations as a symptom of a serious condition, such as believing that a new pain is caused by cancer
• Persistent fear of having or developing a serious medical condition, which impacts quality of life and functioning
• Regularly visiting the doctor with new or vague symptoms
• Seeking multiple medical opinions, making appointments with several physicians
• Avoiding medical tests, due to the fear of being diagnosed with a serious condition
• Questioning or disbelieving reassurance from a physician, doubting their abilities and believing they missed or ignored a present illness
• No or little presence of physical symptoms
• Regularly checking the body for lumps, lesions, or other signs of physical conditions
• Preoccupation with the idea of illness and death
• If there is an increased risk of genetic illness, there is a disproportionate level of concern and preoccupation with the thought of developing this condition
• Requiring regular reassurance from family and friends about physical symptoms
• Compulsive checking of information on the internet or in the media about medical conditions
• Worsening mental health, including increasing anxiety and new or worsening depression

Causes of illness anxiety disorder

The cause of illness anxiety disorder is not known, but research suggests that there are several contributing factors to the development of the condition, including:

• Family anxieties: Studies suggest that having grown up in a family that was preoccupied with cleanliness, health, and avoiding illness, who regularly discussed these concerns, increases the likelihood of developing the condition later in life ^[1][8].
• Childhood exposure to illness: Having had a serious illness in childhood or witnessing a parent or sibling with a serious illness has been found to increase the chance of illness anxiety disorder ^[6][8].
• Childhood abuse: It has been found that there is a greater prevalence of health anxiety amongst those who experienced any kind of abuse in childhood, with more severe abuse leading to more severe anxieties ^[9].
• Other anxiety disorders: Research suggests that people with other anxiety disorders, such as generalized anxiety disorder, are at an increased risk of developing illness anxiety disorder ^[1][10].
• Regular research: People who regularly look up medical conditions online and spend a lot of time reading about specific conditions may be more likely to develop IAD ^[1][11].
• Covid-19: Since the COVID-19 pandemic, there has been found to be an increase in anxiety disorders across the world, including health anxiety, suggesting that consistent news reports of the disease and the requirements in place to prevent contracting the disease may have increased health concerns ^[12].

Diagnosing illness anxiety disorder

It may take some time to receive a diagnosis of illness anxiety disorder, as it can be difficult to differentiate from other conditions.

Commonly, people with this condition will regularly attend appointments with their doctor, who may notice after several appointments that there is a high level of health anxiety present despite no diagnosable illness, thus prompting a referral to a specialist or a consideration of an IAD diagnosis ^[7].

To diagnose IAD, criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders ^[2] will be used, which includes:

• Excessive concerns about being or becoming ill, without a presence of physical symptoms and despite tests and reassurance
• Symptoms that are present for at least 6 months
• Symptoms that are not due to another mental health condition, such as obsessive-compulsive disorder (OCD), generalized anxiety disorder, or body dysmorphic disorder

Several questions will be asked to ascertain the presenting symptoms and severity of the condition, how long it has been present, what impact it has on quality of life, and what has been done to check for illnesses. A medical questionnaire may be used to gather this information, such as The Health Preoccupation Diagnostic Interview ^[1].

Treatment for illness anxiety disorder

Illness anxiety disorder requires a multidisciplinary approach to treatment, involving interventions from medical professionals and mental health professionals, as well as the potential use of medication. Care must be provided on a collaborative basis, to allow for proper monitoring of improvements or changes in physical and mental wellbeing ^[1][6].

Research suggests that without a psychological approach to treatment, no amount of medical testing or reassurance will alleviate the symptoms of IAD, as this may actually contribute to reinforcing reassurance-seeking behaviors, without managing the underlying anxieties, thus potentially worsening the condition ^[6].

As such, the most effective treatment of illness anxiety disorder will involve a combination of:

• One medical physician to be responsible for ongoing monitoring of physical health, providing opportunities for testing and checking new health complaints, but not overutilizing testing or reassurance. As such, visits to ER or multiple physicians will be reduced, by building a trusting therapeutic relationship in which physical health can be managed ^[1][13].
• Psychological intervention usually in the form of cognitive behavioral therapy (CBT), in which beliefs and behaviors can be challenged and altered, normal bodily functions and sensations can be accepted and understood, and anxieties and emotions can be explored, with helpful coping techniques put in place ^[5][11].

There will be open communication between the professionals involved, using empathetic and validating language, thus creating strong therapeutic relationships while avoiding the reinforcement of unhelpful compulsive behaviors.

Other interventions that may be useful for treatment include:

• Medication: Antidepressant medications known as selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine and citalopram, and serotonin-norepinephrine reuptake inhibitors (SNRIs), such as venlafaxine and duloxetine, can be used in the treatment of IAD, to help manage and reduce anxieties ^[5].
• Family therapy: Family therapy can be a useful tool in managing IAD, as it can provide a better understanding and acceptance of the condition, while providing information on how best to support a loved one with the condition and what language or actions may be considered unhelpful ^[6].

Self-care for illness anxiety disorder

If you have illness anxiety disorder, you can manage your symptoms by ^[7]:

• Learning more: By understanding more about IAD and about normal bodily functions and sensations, you can reduce your health anxieties and better manage the symptoms of your condition.
• Monitoring your symptoms: You can monitor your symptoms by keeping a diary, in which you can record your feelings about your health and any behaviors you engage in, such as checking your body for changes and asking family, friends, or doctors for reassurance. This can help you to recognize triggers and better understand your symptoms.
• Setting goals: By recording your daily emotions and behaviors, you can use this information to set goals for yourself, such as gradually reducing unhelpful behaviors and increasing positive actions.
• Being busy: Keeping yourself busy and active can help to distract from health anxieties, as well as contribute to improvements in physical and mental health.
• Relaxation exercises: Using relaxation exercises such as meditation, breathing exercises, and yoga can help to reduce anxieties and promote mindfulness and healthy behaviors.

Frequently asked questions about hypochondria

How common is illness anxiety disorder?

Various studies suggest that illness anxiety disorder affects between 2% and 13% of the general population, depending on the specific criteria used for diagnosis and the changes made in the DSM-5 ^[6][14]. It is believed to affect males and females equally and tends to emerge in early adulthood ^[1].

How does illness anxiety disorder impact daily life?

Illness anxiety disorder can have a negative impact on daily functioning and quality of life, including ^[1][13]:

• Relationships: Interpersonal relationships can be impacted by IAD, as it can cause social withdrawal due to a fear of contracting an illness in social situations, thus contributing to a reduction in social interactions, leading to isolation and worsening mental wellbeing.
• Finances: Paying for regular health check-ups, medical testing, and medications can put a strain on finances if these actions are recurrent and prolonged, adding to stress with financial concerns.
• Functioning: IAD can contribute to impairments in academic or professional functioning, as a preoccupation with health can impair concentration, and taking days away from work due to feared illness can reduce performance and financial income. Similarly, day-to-day functioning may be impaired by inactivity caused by a belief of being unwell.
• Mental health: Prolonged health concerns can contribute to worsening mental health, including high levels of stress and a development or worsening of anxiety and depression.
• Sleep: Anxiety often contributes to sleep disturbances, which in turn can increase stress and anxiety, as well as impairing the immune system, thus worsening the symptoms of IAD, as well as contributing to impairments in functioning due to fatigue.

What is the outlook for people with illness anxiety disorder?

Illness anxiety disorder is a chronic condition, which means that it can persist indefinitely, and it typically worsens over time. If left untreated, or if treatment does not produce required results due to very severe symptoms, IAD may continue to worsen with age ^[1].

However, with early intervention and appropriate treatment, such as psychotherapy, medications, and positive professional relationships, a significant reduction in symptoms is possible ^[11]. As it is a chronic condition, ongoing treatment may be required to reach and maintain recovery ^[6].