Illness anxiety disorder: Epidemiology, clinical presentation, assessment, and diagnosis
- James L Levenson, MD
James L Levenson, MD
- Professor of Psychiatry, Medicine, and Surgery
- Virginia Commonwealth University School of Medicine
Illness anxiety disorder is characterized by excessive concern about having or developing a serious, undiagnosed general medical disease . The patient’s distress comes primarily from an unfounded fear of having a disease rather than physical symptoms, and persists despite appropriate physical examination and laboratory testing that are negative. Physical symptoms are not present, or they are minimal and often represent a misperception of normal bodily sensations. Illness anxiety disorder is usually chronic. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, diagnosis of illness anxiety disorder conceptually overlaps with the prior Diagnostic and Statistical Manual, Fourth Edition, Text Revision, diagnosis of hypochondriasis [1,2].
This topic reviews the epidemiology, pathogenesis, clinical presentation, assessment, diagnosis, and differential diagnosis of illness anxiety disorder. Treatment and prognosis of illness anxiety disorder, and the clinical features, medical evaluation, and treatment of somatization are discussed elsewhere. (See "Illness anxiety disorder: Treatment and prognosis" and "Somatization: Epidemiology, pathogenesis, clinical features, medical evaluation, and diagnosis" and "Somatization: Treatment and prognosis".)
TERMINOLOGY AND DSM-5
Illness anxiety disorder is a diagnosis (table 1) that was introduced with publication of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) in 2013 . The clinical features and diagnostic criteria are discussed elsewhere in this topic. (See 'Clinical presentation' below and 'Diagnosis' below.)
Illness anxiety disorder was derived in part from the diagnosis of hypochondriasis, which was eliminated from DSM-5. In DSM-5, patients previously diagnosed with hypochondriasis are nearly always diagnosed with either somatic symptom disorder (if physical complaints are prominent) or illness anxiety disorder (if physical complaints are minimal or nonexistent). Although relatively few studies of illness anxiety disorder have been published, there is a larger literature on the symptom of health anxiety, defined as persistent unrealistic worry or conviction about having an illness. The spectrum of health anxiety ranges from none to severe, with the severe end representing a clinical endpoint (such as illness anxiety disorder or hypochondriasis) [3-5].
In the previous edition of the Diagnostic and Statistical Manual (Fourth Edition, Text Revision; DSM-IV-TR), the term hypochondriasis (table 2) described patients who misinterpreted one or more bodily symptoms and believed that they had a serious disease or were preoccupied with fear of a disease, despite appropriate medical evaluation and reassurance . Both the DSM-IV-TR diagnosis of hypochondriasis and the DSM-5 diagnosis of illness anxiety disorder include patients who believe that they have a serious disease or are preoccupied with fear of a disease, despite a normal physical examination, negative tests, and reassurance [1,2].
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association, Arlington 2013.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, American Psychiatric Association, Washington DC 2000.
- Olatunji BO, Kauffman BY, Meltzer S, et al. Cognitive-behavioral therapy for hypochondriasis/health anxiety: a meta-analysis of treatment outcome and moderators. Behav Res Ther 2014; 58:65.
- Longley SL, Broman-Fulks JJ, Calamari JE, et al. A taxometric study of hypochondriasis symptoms. Behav Ther 2010; 41:505.
- Ferguson E. A taxometric analysis of health anxiety. Psychol Med 2009; 39:277.
- Bailer J, Kerstner T, Witthöft M, et al. Health anxiety and hypochondriasis in the light of DSM-5. Anxiety Stress Coping 2016; 29:219.
- World Health Organization. International Classification of Diseases (ICD). ICD-10: Version 2015. Hypochondriacal Disorder. http://www.who.int/classifications/icd/en/ (Accessed on September 18, 2015).
- Weck F, Richtberg S, Neng JM. Epidemiology of hypochondriasis and health anxiety: comparison of different diagnostic criteria. Curr Psychiatry Rev 2014; 10:14.
- Noyes R, Stuart S, Watson DB, Langbehn DR. Distinguishing between hypochondriasis and somatization disorder: a review of the existing literature. Psychother Psychosom 2006; 75:270.
- Sunderland M, Newby JM, Andrews G. Health anxiety in Australia: prevalence, comorbidity, disability and service use. Br J Psychiatry 2013; 202:56.
- Creed F, Barsky A. A systematic review of the epidemiology of somatisation disorder and hypochondriasis. J Psychosom Res 2004; 56:391.
- The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. http://www.who.int/classifications/icd/en/bluebook.pdf (Accessed on April 25, 2011).
- Abramowitz JS, Braddock AE. Hypochondriasis: conceptualization, treatment, and relationship to obsessive-compulsive disorder. Psychiatr Clin North Am 2006; 29:503.
- Abbey SE, Wulsin L, Levenson JL. Somatization and somatoform disorders. In: The American Psychiatric Publishing Textbook of Psychosomatic Medicine: Psychiatric Care of the Medically Ill, American Psychiatric Publishing, Inc., Washington, DC 2011. p.261.
- Marcus DK, Gurley JR, Marchi MM, Bauer C. Cognitive and perceptual variables in hypochondriasis and health anxiety: a systematic review. Clin Psychol Rev 2007; 27:127.
- Barsky AJ, Ahern DK, Bailey ED, et al. Hypochondriacal patients' appraisal of health and physical risks. Am J Psychiatry 2001; 158:783.
- Barsky AJ, Coeytaux RR, Sarnie MK, Cleary PD. Hypochondriacal patients' beliefs about good health. Am J Psychiatry 1993; 150:1085.
- Bass C, Murphy M. Somatoform and personality disorders: syndromal comorbidity and overlapping developmental pathways. J Psychosom Res 1995; 39:403.
- Gilleland J, Suveg C, Jacob ML, Thomassin K. Understanding the medically unexplained: emotional and familial influences on children's somatic functioning. Child Care Health Dev 2009; 35:383.
- Olatunji BO, Etzel EN, Tomarken AJ, et al. The effects of safety behaviors on health anxiety: an experimental investigation. Behav Res Ther 2011; 49:719.
- Noyes R Jr, Holt CS, Happel RL, et al. A family study of hypochondriasis. J Nerv Ment Dis 1997; 185:223.
- Brondino N, Lanati N, Barale F, et al. Decreased NT-3 plasma levels and platelet serotonin content in patients with hypochondriasis. J Psychosom Res 2008; 65:435.
- Atmaca M, Yildirim H, Sec S, Kayali A. Pituitary volumes in hypochondriac patients. Prog Neuropsychopharmacol Biol Psychiatry 2010; 34:344.
- Witthöft M, Mier D, Ofer J, et al. Neuronal and behavioral correlates of health anxiety: results of an illness-related emotional Stroop task. Neuropsychobiology 2013; 67:93.
- Barsky AJ. Clinical practice. The patient with hypochondriasis. N Engl J Med 2001; 345:1395.
- Sadock BJ, Sadock VA, Ruiz P. Illness anxiety disorder. In: Kaplan & Sadock's Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry, Eleventh Edition, Wolters Kluwer, Philadelphia 2015. p.471.
- Noyes R Jr, Longley SL, Langbehn DR, et al. Hypochondriacal symptoms associated with a less therapeutic physician-patient relationship. Psychiatry 2010; 73:57.
- Barsky AJ, Wyshak G, Klerman GL. Hypochondriasis. An evaluation of the DSM-III criteria in medical outpatients. Arch Gen Psychiatry 1986; 43:493.
- Gureje O, Ustün TB, Simon GE. The syndrome of hypochondriasis: a cross-national study in primary care. Psychol Med 1997; 27:1001.
- Sakai R, Nestoriuc Y, Nolido NV, Barsky AJ. The prevalence of personality disorders in hypochondriasis. J Clin Psychiatry 2010; 71:41.
- Barsky AJ, Wyshak G, Klerman GL. Psychiatric comorbidity in DSM-III-R hypochondriasis. Arch Gen Psychiatry 1992; 49:101.
- Noyes R Jr, Kathol RG, Fisher MM, et al. Psychiatric comorbidity among patients with hypochondriasis. Gen Hosp Psychiatry 1994; 16:78.
- Eilenberg T, Frostholm L, Schröder A, et al. Long-term consequences of severe health anxiety on sick leave in treated and untreated patients: Analysis alongside a randomised controlled trial. J Anxiety Disord 2015; 32:95.
- Fink P, Ørnbøl E, Christensen KS. The outcome of health anxiety in primary care. A two-year follow-up study on health care costs and self-rated health. PLoS One 2010; 5:e9873.
- Mykletun A, Heradstveit O, Eriksen K, et al. Health anxiety and disability pension award: The HUSK Study. Psychosom Med 2009; 71:353.
- olde Hartman TC, Borghuis MS, Lucassen PL, et al. Medically unexplained symptoms, somatisation disorder and hypochondriasis: course and prognosis. A systematic review. J Psychosom Res 2009; 66:363.
- Schweitzer PJ, Zafar U, Pavlicova M, Fallon BA. Long-term follow-up of hypochondriasis after selective serotonin reuptake inhibitor treatment. J Clin Psychopharmacol 2011; 31:365.
- Dimsdale JE, Dantzer R. A biological substrate for somatoform disorders: importance of pathophysiology. Psychosom Med 2007; 69:850.
- Axelsson E, Andersson E, Ljótsson B, et al. The health preoccupation diagnostic interview: inter-rater reliability of a structured interview for diagnostic assessment of DSM-5 somatic symptom disorder and illness anxiety disorder. Cogn Behav Ther 2016; 45:259.
- Silverman JJ, Galanter M, Jackson-Triche M, et al. The American Psychiatric Association Practice Guidelines for the Psychiatric Evaluation of Adults. Am J Psychiatry 2015; 172:798.
- APA Work Group on Psychiatric Evaluation. The American Psychiatric Association Practice Guidelines for the Psychiatric Evaluation of Adults, Third Edition. http://psychiatryonline.org/guidelines (Accessed on September 22, 2015).
- Lee S, Ng KL, Ma YL, et al. A general population study of the Chinese Whiteley-7 index in Hong Kong. J Psychosom Res 2011; 71:387.
- Fink P, Ewald H, Jensen J, et al. Screening for somatization and hypochondriasis in primary care and neurological in-patients: a seven-item scale for hypochondriasis and somatization. J Psychosom Res 1999; 46:261.
- Salkovskis PM, Rimes KA, Warwick HM, Clark DM. The Health Anxiety Inventory: development and validation of scales for the measurement of health anxiety and hypochondriasis. Psychol Med 2002; 32:843.
- Alberts NM, Hadjistavropoulos HD, Jones SL, Sharpe D. The Short Health Anxiety Inventory: a systematic review and meta-analysis. J Anxiety Disord 2013; 27:68.
- Kellner R, Abbott P, Winslow WW, Pathak D. Fears, beliefs, and attitudes in DSM-III hypochondriasis. J Nerv Ment Dis 1987; 175:20.
- Kellner R, Fava GA, Lisansky J, et al. Hypochondriacal fears and beliefs in DSM-III melancholia. Changes with amitriptyline. J Affect Disord 1986; 10:21.
- Lee S, Creed FH, Ma YL, Leung CM. Somatic symptom burden and health anxiety in the population and their correlates. J Psychosom Res 2015; 78:71.
- TERMINOLOGY AND DSM-5
- Genetics and biological correlates
- CLINICAL PRESENTATION
- Comorbid psychopathology
- Course of illness
- When to suspect the disorder
- DIFFERENTIAL DIAGNOSIS
- General medical disorders
- Psychiatric disorders