Illness anxiety disorder: Treatment and prognosis
- James L Levenson, MD
James L Levenson, MD
- Professor of Psychiatry, Medicine, and Surgery
- Virginia Commonwealth University School of Medicine
Medical and psychiatric care of illness anxiety disorder combines general strategies for patient management with specific therapeutic interventions. However, some patients do not respond and have a poor prognosis.
This topic reviews the treatment and prognosis of illness anxiety disorder. The epidemiology, clinical presentation, assessment, and diagnosis of illness anxiety disorder are discussed separately, as are the clinical features, medical evaluation, and treatment of somatization. (See "Illness anxiety disorder: Epidemiology, clinical presentation, assessment, and diagnosis" 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 separately. (See "Illness anxiety disorder: Epidemiology, clinical presentation, assessment, and diagnosis".)
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) [2-4].
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 [1,5].
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association, Arlington 2013.
- 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.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, American Psychiatric Association, Washington DC 2000.
- 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).
- 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.
- Barsky AJ, Ahern DK. Cognitive behavior therapy for hypochondriasis: a randomized controlled trial. JAMA 2004; 291:1464.
- Scher LM, Knudsen P, Leamon M. Somatic symptom and related disorders. In: The American Psychiatric Publishing Textbook of Psychiatry, Sixth Edition, Hales RE, Yudofsky SC, Roberts LW. (Eds), American Psychiatric Publishing, Washington, DC 2014. p.537.
- Gerstenblith TA, Stern TA. Primary care and consultation-liaison interventions for somatic symptom and related disorders. In: Gabbard's Treatments of Psychiatric Disorders, Fifth Edition, Gabbard GO. (Ed), American Psychiatric Publishing, Washington, DC 2014. p.571.
- Wulsin L. Intensive interventions for somatic symptom disorders. In: Gabbard's Treatments of Psychiatric Disorders, Fifth Edition, Gabbard GO. (Ed), American Psychiatric Publishing, Washington, DC 2014. p.591.
- Abramowitz JS, Braddock AE. Hypochondriasis: conceptualization, treatment, and relationship to obsessive-compulsive disorder. Psychiatr Clin North Am 2006; 29:503.
- Page LA, Wessely S. Medically unexplained symptoms: exacerbating factors in the doctor-patient encounter. J R Soc Med 2003; 96:223.
- Barsky AJ. Clinical practice. The patient with hypochondriasis. N Engl J Med 2001; 345:1395.
- Noyes R Jr, Longley SL, Langbehn DR, et al. Hypochondriacal symptoms associated with a less therapeutic physician-patient relationship. Psychiatry 2010; 73:57.
- Hoedeman R, Blankenstein AH, van der Feltz-Cornelis CM, et al. Consultation letters for medically unexplained physical symptoms in primary care. Cochrane Database Syst Rev 2010; :CD006524.
- Kroenke K. Efficacy of treatment for somatoform disorders: a review of randomized controlled trials. Psychosom Med 2007; 69:881.
- Thomson AB, Page LA. Psychotherapies for hypochondriasis. Cochrane Database Syst Rev 2007; :CD006520.
- Greeven A, van Balkom AJ, Visser S, et al. Cognitive behavior therapy and paroxetine in the treatment of hypochondriasis: a randomized controlled trial. Am J Psychiatry 2007; 164:91.
- Walker J, Vincent N, Furer P, et al. Treatment preference in hypochondriasis. J Behav Ther Exp Psychiatry 1999; 30:251.
- Williams C, House A. Cognitive behaviour therapy for health anxiety. Lancet 2014; 383:190.
- Tyrer P, Cooper S, Salkovskis P, et al. Clinical and cost-effectiveness of cognitive behaviour therapy for health anxiety in medical patients: a multicentre randomised controlled trial. Lancet 2014; 383:219.
- Weck F, Neng JM, Richtberg S, et al. Cognitive therapy versus exposure therapy for hypochondriasis (health anxiety): A randomized controlled trial. J Consult Clin Psychol 2015; 83:665.
- Hedman E, Axelsson E, Andersson E, et al. Exposure-based cognitive-behavioural therapy via the internet and as bibliotherapy for somatic symptom disorder and illness anxiety disorder: randomised controlled trial. Br J Psychiatry 2016; 209:407.
- Hedman E, Axelsson E, Görling A, et al. Internet-delivered exposure-based cognitive-behavioural therapy and behavioural stress management for severe health anxiety: randomised controlled trial. Br J Psychiatry 2014; 205:307.
- Clark DM, Salkovskis PM, Hackmann A, et al. Two psychological treatments for hypochondriasis. A randomised controlled trial. Br J Psychiatry 1998; 173:218.
- Bourgault-Fagnou MD, Hadjistavropoulos HD. A randomized trial of two forms of cognitive behaviour therapy for an older adult population with subclinical health anxiety. Cogn Behav Ther 2013; 42:31.
- Visser S, Bouman TK. The treatment of hypochondriasis: exposure plus response prevention vs cognitive therapy. Behav Res Ther 2001; 39:423.
- Hedman E, Andersson G, Andersson E, et al. Internet-based cognitive-behavioural therapy for severe health anxiety: randomised controlled trial. Br J Psychiatry 2011; 198:230.
- Barsky AJ, Geringer E, Wool CA. A cognitive-educational treatment for hypochondriasis. Gen Hosp Psychiatry 1988; 10:322.
- Sørensen P, Birket-Smith M, Wattar U, et al. A randomized clinical trial of cognitive behavioural therapy versus short-term psychodynamic psychotherapy versus no intervention for patients with hypochondriasis. Psychol Med 2011; 41:431.
- Buwalda FM, Bouman TK, van Duijn MA. Psychoeducation for hypochondriasis: a comparison of a cognitive-behavioural approach and a problem-solving approach. Behav Res Ther 2007; 45:887.
- Weck F, Gropalis M, Hiller W, Bleichhardt G. Effectiveness of cognitive-behavioral group therapy for patients with hypochondriasis (health anxiety). J Anxiety Disord 2015; 30:1.
- Weck F, Richtberg S, Jakob M, et al. Therapist competence and therapeutic alliance are important in the treatment of health anxiety (hypochondriasis). Psychiatry Res 2015; 228:53.
- McManus F, Surawy C, Muse K, et al. A randomized clinical trial of mindfulness-based cognitive therapy versus unrestricted services for health anxiety (hypochondriasis). J Consult Clin Psychol 2012; 80:817.
- Eilenberg T, Fink P, Jensen JS, et al. Acceptance and commitment group therapy (ACT-G) for health anxiety: a randomized controlled trial. Psychol Med 2016; 46:103.
- Fallon BA, Petkova E, Skritskaya N, et al. A double-masked, placebo-controlled study of fluoxetine for hypochondriasis. J Clin Psychopharmacol 2008; 28:638.
- Greeven A, van Balkom AJ, van der Leeden R, et al. Cognitive behavioral therapy versus paroxetine in the treatment of hypochondriasis: an 18-month naturalistic follow-up. J Behav Ther Exp Psychiatry 2009; 40:487.
- Oosterbaan DB, van Balkom AJ, van Boeijen CA, et al. An open study of paroxetine in hypochondriasis. Prog Neuropsychopharmacol Biol Psychiatry 2001; 25:1023.
- Barsky AJ, Ahern DK, Bauer MR, et al. A randomized trial of treatments for high-utilizing somatizing patients. J Gen Intern Med 2013; 28:1396.
- Rolfe A, Burton C. Reassurance after diagnostic testing with a low pretest probability of serious disease: systematic review and meta-analysis. JAMA Intern Med 2013; 173:407.
- Petrie KJ, Müller JT, Schirmbeck F, et al. Effect of providing information about normal test results on patients' reassurance: randomised controlled trial. BMJ 2007; 334:352.
- Greeven A, van Balkom AJ, Spinhoven P. Personality predicts time to remission and clinical status in hypochondriasis during a 6-year follow-up. J Nerv Ment Dis 2014; 202:402.