Illness Anxiety Disorder DSM-5 300.7 (F45.21)

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DSM Category: Somatic Symptom and Related Disorders

Introduction

IAD (Illness Anxiety Disorder) is a DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, fifth edition) formerly known as somatoform disorder, and prior to that, hypochondriasis (American Psychiatric Association, 2013. IAD is a disorder involving excessive concern with one’s health in the absence of objective, verifiable evidence of a health condition (American Psychiatric Association, 2013). Persons with IAD experience what has been called Health anxiety and Body vigilance (Mayo Foundation for Medical Education and Research, 2014). The etymology of the word Hypochondria is Hypokhondria, or under the cartilage [the breastplate], referring to the ancient Greek belief that the thoracic viscera were the source of melancholy, or sadness and worry. Hypochondria was used to mean illness without a specific cause (1839), depression, or melancholy without a real cause (1660) (Harper, 2014).

Symptoms of Illness Anxiety Disorder

According to the DSM-5, the symptoms of IAD include:

1) Preoccupation with the idea that one has or will get a serious illness.

2) Lack of somatic symptoms, or mild somatic symptoms, such as diaphoresis or slight tachycardia.

3) If there is a verifiable medical condition present, e.g., a benign cyst, or the patient is in a high –risk category for developing a medical condition, e.g., heart disease, but there are no current indicators of heart disease- the patient’s anxiety or concern is out of proportion to the objective reality.

4) The patient is hyper-vigilant about their health, and is prone to feeling distressed about their health, changes in their health, or ambiguous symptoms.

5) The patient will frequently monitor themselves for sign of illness, such as checking their blood pressure or temperature several times a day.

6) The patient will avoid medical care or evaluation due to anxiety about what they imagine will be found.

7) This anxiety and preoccupation will have persisted at least six months, although the source of anxiety may shift- e.g., fear of diabetes will be superseded by fear of cancer.

8) The anxiety and preoccupation with illness is not better accounted for by another mental disorder, including somatic symptom disorder, panic disorder, GAD (Generalized Anxiety Disorder), OCD (Obsessive Compulsive Disorder), or a psychotic episode with somatic delusions.

The clinician can add specifiers to the diagnosis:

  • Care-seeking type: The patient will frequently seek medical care, presenting with health concerns and complaints, and undergoing diagnostic procedures.
  • Care-avoidant type: The patients will have anxiety about presenting themselves for diagnosis and avoid medical care (American Psychiatric Association, 2013).

Other components of the clinical presentation of IAD can include:

  • Frequent, dramatic statements regarding one’s health.
  • Self-pity.
  • Exaggeration of the impact of actual disorders.
  • Dramatic response and preoccupation with minor injuries.
  • Claiming to have unverifiable disorders, or a disorder persisting for an implausible length of time.
  • Lack of response to reassurance from medical providers.

A thorough medical work up, sometimes exhaustive testing, and consultation with specialists will fail to yield any objective evidence of serious medical problems. The basis of the patient’s distress is anxiety about a misinterpretation of a physical symptom or sign. If there is a verifiable condition, it tends to be minor, easily treated, benign, and self-limiting, the result of normal function, or WNL (Within Normal Limits) uncomfortable sensations that do not indicated illness.

The patient may not only have anxiety about health and disease in themselves, but also in people around them. They may react strongly to news of medical conditions such as the 2014 Ebola epidemic in West Africa. They may project their health-related anxiety on to family members, over-reacting to minor illness or injuries in children. IAD can lead people to limit their lifestyle and activities, and they may adopt an imagined disease as their primary identity. People with IAD may thrive on attention and sympathy. They tend to discuss and complain about their health excessively, causing discomfort in others, eventually causing others to avoid them, resulting in social constriction or isolation. The ironic risk it that if the person with IAD truly becomes ill, people around them may not respond, or they may be isolated to the extent that they have no one to respond to them. They may have difficulty accepting the diagnosis of a psychological disorder, as they are convinced there is something medically wrong with them, and they may feel their concerns are being discounted. It is noted that people with hypochondriasis (using the DSM-IV nomenclature in use at the publication time of the source) may have rigidly held beliefs and convictions about health that are not supported by science (Starcevic, 2013).

The IAD individual may research the disease(s) they imagine they have, sometimes inducing what is commonly been referred to as med student syndrome. This is the erroneous belief that one has a medical condition, based on incomplete knowledge, as they may not have the context to understand the conditions they are studying. An example of this is the current trend of Gluten-free foods. Celiac disease, or gluten-intolerance is a genuine, verifiable medical condition, but many will self-diagnose, and then adopt a restricted diet based on the belief they have this disorder. Misattribution of apparent benefits may emerge partly due to a placebo effect.

IAD individuals tend to over utilize health care services, have extensive medical care, invasive diagnostic procedures, and sometimes-unneeded elective surgeries. They may crave the attention and care they get. Being the center of attention of a team of highly trained and skilled individuals can be rewarding (Drug.com., 2014). They may have multiple providers, can frustrate care providers, who may not be thorough as they are accustomed to groundless complaints from the patient. Iatrogenic disease can result from complications due to invasive diagnostic and testing procedures.

Risk Factors for Illness Anxiety Disorder

The DSM-5 does not specify risk factors for IAD (American Psychiatric Association, 2013). Having a first order relative with IAD can lead to IAD through observational learning (Cleveland Clinic, 2014). A personal or family history of serious or chronic illness or an experience with the medical profession that diminished one’s faith, trust, or confidence in physicians can lead to IAD.

Onset of Illness Anxiety Disorder

According to the DSM-5, IAD often begins in early to middle adulthood, and is lifelong.

IAD may be set off by a major stressor, or serious but eventually benign threat to the individual’s health. Child abuse or serious illness in childhood can precipitate IAD in an adult (American Psychiatric Association, 2013).

Differential Diagnosis in Illness Anxiety Disorder

The DSM-5 describes the following rule-out’s for the clinician to consider:

  • Other legitimate medical conditions: One can really be sick, and still have IAD. The non-medical provider must have the collaboration of a medical team to rule out legitimate conditions. IAD indicates that the response to an actual illness is out of proportion to the severity of the illness.
  • Adjustment disorders.
  • Health-related anxiety is a non-pathological response to a serious illness.
  • Somatic symptom disorder is the appropriate diagnosis when there are significant somatic symptoms. In contrast, individuals with IAD have minimal or absent somatic symptoms, but there primary concern is that they have an illness.
  • Anxiety disorders- including GAD: The anxiety will stem from multiple sources, which could include their health, but health will not be the primary focus. Individuals with panic disorder may be hypersensitive to respiratory or cardiac symptoms that may be benign.
  • Body dysmorphic disorder- The individual will be focused on an imagined flaw in their appearance.
  • Major depressive disorder- People who are depressed can have somatic symptoms- e.g., headaches, stomach aches, muscle and joint pain, and a reduced tolerance for discomfort, and the possibility of mood congruent delusions- e.g.,-“ I’m rotting, I’m dead”. The preoccupation will be limited to the acute depressive episode (American Psychiatric Association, 2013).

Other considerations for differential diagnosis include:

  • Munchausen’s syndrome: Deliberate induction of a medical disorder for secondary psychological gains- e.g., attention from medical staff.
  • Malingering- the possibility that the patient is feigning illness for secondary gains must be considered.
  • Drug seeking- Patients present themselves at ER’s and PCP’s (Primary Care Physicians) offices seeking opiates or benzodiazepines to sustain their addiction. This is also known as “doc shopping”, in which an opiate or benzodiazepine addict will visit numerous physicians or ER’s, complaining of non-verifiable conditions to obtain drugs. This is distinct from IAD, in that the motive is to obtain abusable drugs, and they do no not believe they have an illness that requires medication. However, opiate addicts are specifically hypersensitive to signals from their bodies that are reminiscent of withdrawal symptoms, such as lacrimation or rhinitis.

Comorbidity in Illness Anxiety Disorder

Approximately two-thirds of individuals with IAD are likely to have at least one other comorbid form of psychopathology.

  • Somatic symptom disorder: This disorder involves some degree of physical symptoms, which have a psychological basis (American Psychiatric Association, 2013).
  • OCD can either be co-morbid with IAD, or, it IAD may be a form of OCD. Some individuals with IAD experience intrusive images, including diagnosis of a terminal illness, suffering with it, dying, and the aftermath of their death for their family (Cleveland Clinic, 2014). OCD has neurobiological commonalities with hypochondriasis, (van den Heuve, Mataix-Cols, Zwitser, Cath, van der Werf, Groenewegen, van Balkom, and Veltman, 2011) and it could be speculated that hypochondriasis, or IAD under the DSM-5 nomenclature, is better understood as a type of OCD content.
  • GAD (General Anxiety Disorder): The content of anxiety can include, but will not be limited to health concerns. This is a rule-out as well as a potential comorbidity.
  • PTSD (Post-traumatic Stress Disorder): Trauma content can center on physical concerns- e.g., someone with a recent MI (Myocardial Infarction) may overreact to innocuous and ambiguous chest discomfort.
  • Psychosis: Somatic delusions will have a bizarre content, and no basis in reality- e.g. “ someone took out my spine”
  • BPD (Borderline Personality Disorder): Dramatic complaints about physical symptoms or minor injuries, or fabrication or even induction of a disorder (Munchausen’s Syndrome) can occur as part of the Borderline presentation.
  • Histrionic Personality Disorder: Part of the dramatic presentation can include greatly exaggerated or frequent complaints of medical problems, or an overly emotional response to a minor injury.
  • Orthorexia: Exclusion of certain foods without sufficient objective evidence or formal diagnosis- e.g., gluten intolerance.
  • Exacerbation of serious medical conditions due to avoidance of medical care, or such frequent presentation for medical care that providers do not take legitimate complaints seriously.

Treatment of Illness Anxiety Disorder

The DSM-5 does not specify Treatment options for IAD ( American Psychiatric Association, 2013). MCBT (Mindful Cognitive Behavioral Therapy, or REBT (Rational Emotive Behavioral Therapy) may be useful to learn to respond appropriately to benign or ambiguous signals from one’s body (Williams, McManus, Muse, and Williams, 2011). SSRI’s (Selective Serotonin Re-uptake Inhibitors) can be useful to manage IAD, as previously noted, there is an OCD component to the disorder, or it may be a form of OCD (Drug.com., 2014).

Prognosis of Illness Anxiety Disorder

The DSM-5 does not specify the prognosis of IAD ( American Psychiatric Association, 2013). A review of the literature indicated that IAD can endure and persist for life, but it is amenable to treatment.

References

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders. (5th Edition). Washington, DC.

Cleveland Clinic (2014). Hypochondriasis. Cleveland Clinic. Retrieved November 8, 2014 from http://my.clevelandclinic.org/services/neurological_institute/center-for-behavorial-health/disease-conditions/hic-hypochondriasis

Drug.com. (2014). Hypochondriasis Harvard Health topics. Retrieved November 8, 2014 from http://www.drugs.com/health-guide/hypochondriasis.html

Harper, D. (2014). Hypochondria. Online Etymology Dictionary. Retrieved November 8, 2014 from http://www.etymonline.com/index.php?term=hypochondria

Mayo Foundation for Medical Education and Research. (2014). For Medical Professionals. DSM-5 redefines hypochondriasis. Mayo Foundation for Medical Education and Research. Retrieved November 8, 2014 from http://www.mayoclinic.org/medical-professionals/clinical-updates/psychiatry-psychology/diagnostic-statistical-manual-mental-disorders-redefines-hypochondriasis

O. A. van den Heuve, D. Mataix-Cols, G. Zwitser, D. C. Cath, Y. D. van der Werf,

H. J. Groenewegen, A. J. L. M. van Balkom, and D. J. Veltman. (2011). Common limbic and frontal-striatal disturbances in patients with obsessive-compulsive disorder, panic disorder and hypochondriasis. Psychological Medicine. 2399–2410. doi: 10.1017/S0033291711000535.

Starcevic, V. (2013). Editorials: Hypochondriasis and health anxiety: conceptual challenges The British Journal of Psychiatry. 202: 7-8 doi: 10.1192/bjp.bp.112.115402.

Williams, M.J., McManus, F. Muse, K., Williams, J.G.M.G. (2011). Mindfulness-based cognitive therapy for severe health anxiety (hypochondriasis): An interpretative phenomenological analysis of patients’ experiences. British Journal of Clinical Psychology. 1-19. DOI:10.1111/j.2044-8260.2010.02000.x


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