Hypochondria is a well-known term related to having fears of being diagnosed with a serious disease, often due to a misinterpretation of bodily symptoms. Although hypochondria used to be a diagnosable mental health condition, the most recent Diagnostic and Statistical Manual of Mental Disorders (DSM-5) reinterpreted this disorder into two classifications: (1) somatic symptom disorder and (2) illness anxiety disorder.
Somatic Symptom Disorder vs. Illness Anxiety Disorder
In general, somatic symptom disorder is used when the individual is experiencing actual physical symptoms; however, they are exacerbating the severity of these sensations and experience significant anxiety as a result. For example, this might occur if an individual has chronic headaches, yet believes these headaches are indicative of a brain tumor (despite having a negative MRI). As a result of this belief, this person spends considerable time and energy worrying about this symptom and attending multiple different medical appointments.
Illness anxiety disorder is a related condition, yet has some differences. In this disorder, an individual is overly preoccupied with being diagnosed with a serious disease or health condition. In this case, the individual generally does not experience physical symptoms or has very minor symptoms/sensations. As a result of this fear, people experience significant worry, attend multiple medical appointments, avoid health risks, and engage in many checking behaviors (i.e., web searches, body checks). Consider an individual with a family history of cancer. In order to meet criteria for illness anxiety disorder, this individual would spend considerable time worrying about a potential cancer diagnosis. Additionally, they might attend multiple appointments and experience minimal relief when given negative results. In this scenario, this fear would also significantly impair one’s functioning and may negatively impact their ability to work, maintain relationships, and have a daily routine.
Research suggests that of individuals who would have previously met diagnostic criteria for hypochondria, approximately 75% meet criteria for somatic symptom disorder, while 25% would be classified as illness anxiety disorder. Although both of these diagnoses cause functional impairment, an individual with somatic symptom disorder tends to experience more severe health anxiety and depression. Additionally, people with somatic symptom disorder have higher rates of panic disorder and agoraphobia, when compared to illness anxiety disorder.
Unsurprisingly, individuals with these concerns are more likely to attend appointments with primary care physicians or medical specialists, compared to psychologists or psychiatrists. It is important to mention that these conditions do not include individuals who simply have unexplained physical symptoms – in order to meet diagnostic criteria, the person must also experience significant symptoms of anxiety and resulting functional impairment.
Although some screening instruments have been created (e.g., Patient Health Questionnaire – 15, Somatic Symptoms Scale – 8), individuals with these concerns are generally diagnosed via an in-depth clinical interview, alongside other comprehensive medical exams. It has been suggested that screening instruments can lead to false positives; therefore, they should be followed-up with a clinical interview prior to diagnosis.
For somatic symptom disorder, diagnosis can take a considerable amount of time. Given that these individuals do experience physical symptoms, diagnosis often first requires extensive physical and medical examination.
Importance of Empathy
Individuals with these conditions can often feel invalidated, as they may consistently hear that the medical exams do not show evidence of their symptoms/concerns. Although this message is often meant to provide reassurance, this can actually lead the individual to mistrust their provider or feel as though their concerns are minimized – this is particularly true when individuals are experiencing physical symptoms. In these cases, it is incredibly important for providers to first validate one’s experience of these symptoms.
Individuals with these concerns should be educated on the role of anxiety/stress in generating and exacerbating physical symptoms. For example, consider an individual who experiences chronic headaches. Let’s assume that this individual believes there is something significantly wrong with their neurological functioning. The presence of this belief, as well as the associated symptoms of anxiety, can significantly increase one’s stress, which can lead one to develop a headache and experience impairments in cognitive functioning (e.g., concentration and memory). Alternatively, when experiencing a headache, this person may be particularly focused on this bodily sensation. When this occurs, the individual typically experiences anxious thoughts and emotions, which actually exacerbate symptoms of the headache.
When working with this patient, it is important that they are told their pain/symptoms are real. They are experiencing headaches and cognitive impairment. Additionally, it is important to communicate that it makes sense that these symptoms lead to anxiety – these experiences can be quite troubling. Once this validation and empathy has been provided, it is important to then discuss the role of anxiety/stress.
Treatment for these conditions generally begin with one’s primary care physician, since these individuals usually present to medically-focused providers. For this phase of treatment, it is encouraged that individuals attend regular visits and maintain care with the same provider(s), as opposed to meeting with multiple providers. Additionally, this phase of treatment is focused on diagnostic testing and improving one’s functioning. Once the potential medical concerns have been ruled out, the next step is usually to pursue psychotherapy.
Cognitive-behavioral therapy (CBT) is considered to be the most effective therapy. Research on CBT in this population has demonstrated improvements in illness-related thoughts and behaviors, anxiety, and depression. In general, therapy will focus on providing education, introducing coping strategies, and challenging illness-related beliefs (while validating one’s physical experiences). Fortunately, individuals generally begin seeing improvements within one month of beginning therapy.
The introduction of relaxation and coping skills can be quite powerful. Practicing these skills, particularly in moments of stress, often reinforces the relationship between stress/anxiety and symptom worsening. For example, consider the previous individual who experiences chronic headaches. Let’s assume that this individual begins to experience a headache. Instead of being overly focused on these sensations, he or she begins to practice relaxation strategies. As a result, he or she experiences less anxiety, as well as a reduction in physical symptoms. This experience can be very influential, as it helps individuals feel empowered and experience more control over their physical symptoms.
Medication has also been studied; however, some studies have shown less improvement when compared to CBT. Additionally, this population may be particularly fearful of medication and the potential side effects. Nonetheless, antidepressants have emerged as a potential second or third line treatment for this population.
In summary, individuals with significant fears related to their physical health may meet criteria for Illness Anxiety Disorder or Somatic Symptom Disorder. Although diagnosis of this concern can be somewhat prolonged, particularly when one is experiencing physical symptoms, treatment, especially CBT, seems to be quite promising.