ILLNESS ANXIETY DISORDER (HYPOCHONDRIASIS)

ILLNESS ANXIETY DISORDER

Known as hypochondriasis

• Someone who exaggerates the slightest physical symptom

• Many people continually run to the doctor even though there is nothing really wrong with them

• Preoccupation with their health or appearance becomes so great that it dominates their lives

• Falls under somatic symptom disorders

• Physical symptoms are either not experienced at the present time or are very mild, but severe anxiety is focused on the possibility of having or developing a serious disease

  • If significant physical symptoms are present and cause distress, the diagnosis would instead be Somatic Symptom Disorder

• The main concern lies in the idea of being sick, NOT in the physical symptoms themselves

• The perceived threat feels so real that medical reassurance provides little or no relief

Somatic Symptom Disorder

 People have real physical symptoms and feel excessive anxiety and distress about them (majority)

PREVALENCE

• In the general population, about 1–5% may have symptoms (based on the old diagnosis of hypochondriasis, which is now split into SSD + Illness Anxiety Disorder)

• In primary care/doctor settings:

  • Around 6–7% show hypochondriasis

  • As high as 16% experience distressing somatic symptoms (close to SSD + IAD combined)

• Severe illness anxiety often starts later in life, since aging brings more health problems

DEMOGRAPHICS

• Often develops in adolescence

• More common among:

  • Women

  • Unmarried individuals

  • Lower socioeconomic groups

COMORBIDITY

• Often includes anxiety and mood disorders

• In psychiatric clinic patients, complaints can seem endless, sometimes including psychotic symptoms along with physical ones

• Suicide attempts are frequent, often as manipulative gestures rather than genuine lethal efforts

IMPACT

• Overuse or misuse of the healthcare system, with medical bills up to 9x  higher than the average patient

• About 19% of individuals with SSD are reported to be on disability

• Symptoms may come and go, but the disorder and “sick role” behavior are usually chronic and can last into old age

Koro

• (China, mostly males but can occur in females):

• A strong belief that the genitals (especially the penis in men) are shrinking or retracting into the abdomen

• Many fear that if the retraction continues, it will lead to death

• Often connected to feelings of guilt about frequent masturbation, dissatisfaction with sexual intercourse, or promiscuous activity

• Because sexuality is an important cultural value, these concerns trigger intense anxiety and can sometimes lead to panic attacks

Dhat

• (India)

  • A disorder centered on the fear of losing semen, which is viewed in Indian culture as a vital substance that preserves strength and health

  • Men with this condition worry that semen loss through nocturnal emissions, urination, or sexual activity is weakening their body

  • Commonly reported symptoms include dizziness, weakness, fatigue, and other low-energy feelings

Pakistani and Indian patients

• Many complain of burning sensations in the hands and feet

• Often linked to stress or emotional problems, but are interpreted as purely physical

Global Perspective

• For a long time, researchers believed that these “culture-bound syndromes” were mostly found in non-Western or developing countries

• However, newer studies show that somatization, or the tendency to express psychological distress through bodily symptoms, occurs worldwide

• The main difference is that the specific symptoms vary by culture, depending on which body functions or beliefs are emphasized

COGNITIVE AND PERCEPTUAL FACTORS

• Misinterpretation of normal physical sensations as signs of serious illness

• Disorder primarily involves distorted thinking and perception with strong emotional involvement

• Increased self-focus makes bodily sensations feel stronger than they actually are

• Anxiety grows when sensations are misinterpreted, producing more physical symptoms

• Individuals pay extra attention to illness-related cues, showing heightened sensitivity

BIOLOGICAL AND PSYCHOLOGICAL VULNERABILITIES

• Overreaction to stress, similar to patterns seen in anxiety disorders

• Tendency to view life events as unpredictable or uncontrollable, leading to constant vigilance

• Learned patterns from family where attention or concern is directed to specific physical conditions

ENVIRONMENTAL AND LIFE EVENTS

• Triggered by stressful life events such as trauma, serious illness, or death of a loved one

• Childhood exposure to illness in the family increases attention to physical health in adulthood

• Families may unintentionally reinforce that being sick brings attention or relief from responsibilities

• Adopting a “sick role” where illness gives social or practical benefits

PSYCHODYNAMIC APPROACHES

• Used to uncover unconscious conflicts through psychodynamic psychotherapy

• Effectiveness rarely reported and evidence is limited

COGNITIVE BEHAVIORAL THERAPY

• Most supported by research for both health anxiety and somatic symptom disorder

• Focuses on identifying and challenging misinterpretations of bodily sensations

• Teaches patients how attention can create or amplify symptoms

• Reduces reassurance-seeking behaviors

• Evidence from studies:

  • Barsky & Ahern (2005): 187 patients with hypochondriasis; six CBT sessions vs usual medical care. CBT reduced symptoms and improved quality of life, with effects lasting at follow-up

  • Allen et al. (2006): 40% of severe somatic symptom disorder patients improved with CBT, compared to 7% with standard care; improvements lasted at least a year

  • Weck et al. (2015): Exposure therapy alone (facing health fears without cognitive techniques) also greatly reduced symptoms, showing that confronting fears is effective.

EXPLANATORY/EDUCATIONAL THERAPY

• Explaining origin and nature of symptoms reduces fear and healthcare use

• Works best for milder forms of the disorder

• Provides reassurance in a sensitive, structured way

• Patients gain understanding of the relationship between stress and symptoms

• Evidence:

Fava et al. (2000): 20 patients with DSM-IV hypochondriasis; those who received explanatory therapy showed significant reduction in fear and beliefs about symptoms, maintained at 6-month follow-up.

MEDICATIONS

• Some benefit from antidepressants (SSRIs), especially if anxiety or depression co-occurs

• CBT often more effective than medication alone

• Evidence:

  • Greeven et al. (2007): CBT vs SSRI (paroxetine) vs placebo; CBT responders 45%, Paxil 30%, placebo 14%. CBT showed stronger improvement than medication alone.

BEHAVIORAL AND PRACTICAL STRATEGIES

• Reduce frequent medical visits through a gatekeeper physician

• Encourage healthy social interaction instead of relying on being sick for attention

• Promote part-time employment or normal daily activities when possible

PSYCHOLOGICAL FACTORS AFFECTING MEDICAL CONDITION

a related somatic symptom disorder

• The essential feature of this disorder is the presence of a diagnosed medical condition (e.g., asthma, diabetes, or severe pain) that is adversely affected by one or more psychological or behavioral factors

• Have a direct influence on the course or perhaps the treatment of the medical condition

• Examples:

  • Anxiety severe enough to clearly worsen asthmatic condition

  • Patient with diabetes who is in denial about the need to check insulin levels and intervene when necessary

This diagnosis would need to be distinguished from the development of stress or anxiety in response to having a severe medical condition that would more appropriately be diagnosed as an adjustment disorder.