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Hypochondriasis/Illness Anxiety Disorder

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Bethany Shikatani (nee Gee)

Matilda Nowakowski

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St. Joseph's Healthcare Hamilton

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Martin M Antony
Ryerson University
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Illness Anxiety Disorder/

Hypochondriasis
Bethany Shikatani (ne Gee), Matilda E.
Nowakowski, and Martin M. Antony
Ryerson University, Canada

Illness anxiety disorder is defined as a preoccupation with fears of having or acquiring a

serious illness based on the misinterpretation
of bodily symptoms. DSM-5 classifies this disorder under the somatic symptoms and related
disorders category. In order to meet criteria
for a diagnosis of illness anxiety disorder, the
following additional criteria must be met:
1. Somatic symptoms are not present or are of
only mild intensity.
2. The patient has high anxiety about his or her
health.
3. The patient engages in excessive healthrelated behaviors or avoidance.
4. The duration must be a minimum of 6
months.
The specifier care-seeking type or careavoidant type is used to indicate the level of
medical care use.
Illness anxiety disorder was not included as
a distinct diagnostic category until the publication of DSM-II, and it was then labeled
hypochondriacal neurosis. It had similar criteria to illness anxiety disorder as the latter is
defined in the current DSM, and it was listed
under the neuroses category. In DSM-III,
DSM-III-R, DSM-IV, and DSM-IV-TR, the
name was changed to hypochondriasis, and it
was included under the category of somatoform disorders.
Illness anxiety disorder has a 1- to 2-year
prevalence of 1.3% to 10% in the general population (American Psychiatric Association,
2013). It commonly develops in early adulthood, tends to be chronic, and occurs equally in

men and women (Creed & Barsky, 2004). From

a cognitive behavioral perspective, illness anxiety disorder is believed to stem from dysfunctional beliefs about health and illness, which
lead to the misinterpretation of the meaning
of benign bodily symptoms. These beliefs may
stem from early learning experiences, may
be precipitated by stressors or disease-related
information, and are often perpetuated by
maladaptive coping behaviors such as seeking
reassurance from doctors or close others and
frequent checking for signs of illness (Taylor &
Asmundson, 2004). Genetic factors have also
been found to play a small role in illness anxiety
disorder, and they account for a 1037% variance in scores on health anxiety measures (Taylor, Thordarson, Jang, & Asmundson, 2006).
Cultural factors may play a role in the presentation and interpretation of bodily symptoms.
For example, as compared to individuals in
Western cultures, individuals of Asian backgrounds more frequently react to stress with
physical complaints (Sue & Sue, 1999), and
individuals of certain African backgrounds
tend to express different somatic complaints
such as numbness, tingling, and hot flashes
(Ohaeri & Odejide, 1994).

Assessment
It is important to conduct a comprehensive
assessment that includes detailed information about the clients presenting problems,
including baseline levels of symptoms related
to health anxiety and comorbid difficulties.
As well, it is necessary to review information
related to the clients current and past physical
health, including prior medical examinations,
tests, and treatments received, to rule out the
presence of a general medical condition.
Self-Report Measures
Self-report measures of illness anxiety disorder should be used in conjunction with
diagnostic interviews; and they are also useful

The Encyclopedia of Clinical Psychology, First Edition. Edited by Robin L. Cautin and Scott O. Lilienfeld.
2015 John Wiley & Sons, Inc. Published 2015 by John Wiley & Sons, Inc.
DOI: 10.1002/9781118625392.wbecp295

2 ILLNESS ANXIETY DISORDER/HYPOCHONDRIASIS

for monitoring treatment progress. Relevant
self-report measures include the Illness Attitudes Scales (IAS; Kellner, 1986), the Whiteley
Index (WI; Pilowsky, 1967), and the Short
Health Anxiety Inventory (SHAI; Salkovskis,
Rimes, Warwick, & Clark, 2002), among many
others.
Clinical Interviews
Assessment of the clients difficulties related
to health anxiety can be conducted using a
structured interview, such as the Structured
Clinical Interview for DSM-5 Disorders (First,
Williams, Karg, & Spitzer, 2014), the Structured
Diagnostic Interview for Hypochondriasis
(SDIH; Barsky et al., 1992), or the Health Anxiety Interview (Taylor & Asmundson, 2004).
Further assessment can be conducted using
less standardized methods, such as asking
specific questions related to health anxiety.
Case Conceptualization
To develop a comprehensive case conceptualization, clinicians should obtain information
from a wide range of sources (e.g., interviews,
self-report scales, and monitoring diaries).
It is important to consider comorbid diagnoses, cultural factors, accommodation by
family members or others, level of insight, and
motivation for treatment. This information
can be used to develop hypotheses about the
predisposing, precipitating, perpetuating, and
protective factors related to the clients health
anxiety. The therapist and client should then
decide collaboratively how to approach treatment, including which areas to target first and
on which techniques to focus.

Treatment
A number of empirically supported treatments
have been developed for illness anxiety disorder. We provide a brief summary of these
treatments here. The reader is encouraged to
refer to recently published books for more
detailed information (e.g., Furer, Walker, &
Stein, 2007; Owens & Antony, 2011; Taylor &
Asmundson, 2004).

Psychoeducation
Based on a cognitive behavioral model, psychoeducation helps clients understand the
factors involved in the development and maintenance of illness anxiety disorder and to
identify strategies for addressing symptoms.
In contrast to reassurance seeking (a common
behavior among those with heightened health
anxiety), which repeatedly provides clients
with the same information (e.g., that they are
healthy), psychoeducation aims to provide
clients with new information (e.g., a better
understanding of why their anxiety persists
despite reassurance that they are healthy).
Behavioral Stress Management
Many harmless but unpleasant physical symptoms can arise from high stress levels (e.g.,
heart palpitations and muscle pain). Therefore,
behavioral stress management teaches clients
stress management skills (e.g., relaxation training, time management, organization skills,
and effective problem solving) and encourages
them to engage in regular pleasurable activities.
By decreasing stress levels and increasing quality of life, individuals can reduce or eliminate
many of the physical symptoms that trigger
illness anxiety disorder.
Exposure and Response Prevention
Exposure and response prevention (ERP) is
based on the premise that individuals with
illness anxiety disorder either completely avoid
stimuli associated with feared illnesses or
engage in safety behaviors, such as reassurance seeking and checking, when exposed
to feared stimuli. Although these behaviors
decrease feelings of anxiety in the short term,
they are assumed to maintain anxiety in the
long term. Therefore, ERP focuses on helping
clients to gradually face their feared physical
symptoms and stimuli without engaging in
safety behaviors. Exposures can be conducted
in a number of formats, including in vivo or
situational (e.g., exposure to medical clinics),
in imagination (e.g., imagining that they have a
feared illness), and interoceptive formats (e.g.,

ILLNESS ANXIETY DISORDER/HYPOCHONDRIASIS

practicing exercises that bring on feared physical sensations, such as increased heart rate and
dizziness). With repeated exposure practices,
clients experience a decrease in their anxiety
levels and learn that their feared consequences
are unlikely to occur.
Cognitive Behavioral Therapy
CBT is a multicomponent treatment for
illness anxiety disorder. It includes psychoeducation and exposure, as well as cognitive
restructuring and behavioral experiments.
Cognitive restructuring involves identifying
and modifying clients catastrophic thoughts,
interpretations, and beliefs about their bodily
sensations. It also focuses on helping clients
accept and tolerate the uncertainty of illness
and death. Behavioral experiments are used
to test the new beliefs established through
cognitive restructuring. For instance, a client
may test a new belief that reassurance seeking
does not decrease the chances of developing
a serious illness by decreasing reassurance
seeking and observing the outcome.
Pharmacotherapy
Although only a few studies have examined
pharmacological treatments for illness anxiety disorder, findings suggest that selective
serotonin reuptake inhibitors (e.g., fluoxetine,
fluvoxamine, and paroxetine) are effective in
symptom reduction (Taylor, Asmundson, &
Coons, 2005).

Effectiveness of Treatments
A meta-analysis examining the effectiveness of
psychotherapy for treating illness anxiety disorder found that cognitive therapy, behavioral
therapy, CBT, and behavioral stress management led to significant symptom improvement
as compared to waitlist control groups; however, psychoeducation alone did not. CBT
also resulted in significant improvements in
general functioning and physical symptoms,
whereas cognitive therapy resulted in significant decreases in secondary anxiety and
depression (Thomson & Page, 2007). Another
meta-analysis found CBT to be superior to

other forms of psychological treatments for

illness anxiety disorder, demonstrating large
effect sizes. Pharmacological treatments such
as fluoxetine, fluvoxamine, paroxetine, and
nefazodone were also found to lead to large
effect sizes, with fluoxetine demonstrating the
greatest effects. Psychoeducation was found
to be effective for mild cases of illness anxiety
disorder (Taylor et al., 2005).
SEE ALSO: Body Dysmorphic Disorder; ExposureBased Therapies; Somatic Symptom and Related Disorders/Somatoform Disorders

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