Illness Anxiety Disorder

Background

• Patients with illness anxiety disorder have a strong conviction that they have a serious medical illness, fear that they will develop one, or fear that a current illness is worse than it is, despite having no physical signs or symptoms or only mild ones.
• Diagnostic criteria by the Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5) includes no or very mild somatic symptoms; this differs from earlier DSM criteria, in which the analogous condition called hypochondriasis did not exclude characteristics of somatic symptom disorder, which is now a separate diagnosis.
• The actual prevalence is unclear; reported rates in the general population vary from 0.04% to 4.5%.
• Illness anxiety disorder has high comorbidity with other psychiatric disorders, such as generalized anxiety disorder, depression, and obsessive compulsive disorder.
• Illness anxiety disorder is usually chronic, requiring long-term therapeutic commitment from patients and therapists.

Evaluation

• Illness anxiety disorder generally involves serious concerns and fear over health, but these can manifest in different ways.
  • Patients who are "care-seeking" visit medical providers frequently for reassurance that they do not have a serious illness, while patients who are "care-avoiding" avoid seeing physicians because they are worried about confirming a feared diagnosis.
  • Some patients are worried that they have a serious illness, some are worried that they will develop a serious illness, and others have a heightened awareness of bodily sensations and are worried that the sensations indicate having or developing a serious illness.
  • Patients may display maladaptive behaviors such as repeated self-examinations, repeatedly seeking assurance from others, and frequently researching conditions and symptoms (often using Internet sources).
• Differential Diagnosis includes
  • the physical illness or related conditions the patient is concerned about
  • somatic symptom disorder
  • anxiety and other psychiatric disorders (some may be co-occurring)
  • body dysmorphic disorder and other conditions characterized by preoccupation with body
  • conversion disorder
  • fabrication of medical symptoms, such as with factitious disorder, malingering, and drug-seeking
• Diagnose with established criteria such as that by DSM-5, which distinguishes illness anxiety disorder from somatic symptom disorder by requiring a lack of serious somatic symptoms.
• Patients cannot be convinced that they do not have a serious illness even after negative test results and no physical signs observed by clinician, so avoid repeated diagnostic testing that is not clinically indicated.
• When conducting diagnostic testing that is clinically indicated, clearly communicate to patient reasons for test, what results would be considered abnormal, and what steps should be taken in case of positive, negative, or equivocal test.

Management

• When communicating with the patient:
  • Remember that the patient does not have the same level of medical insight and experience as healthcare providers.
  • Take patient's concerns seriously and respond with empathy.
  • Have empathy for previous frustrating experiences the patient may have had when seeking medical help.
• Clinicians seeing patients should actively communicate and consult with one another to provide consistent information to patient throughout treatment, and to avoid unnecessary tests and procedures. Patient's primary care provider should continue to be involved throughout treatment.
• Start counseling.
  • Cognitive behavioral therapy (CBT) has most evidence demonstrating efficacy.
  • Techniques that may be particularly useful include psychoeducation, attentional training, explanatory therapy, mindfulness-based CBT, and exposure therapy.
• Consider offering medications such as selective serotonin reuptake inhibitors in addition to counseling, especially for patients with severe symptoms and/or co-occurring depression or anxiety.