Today we will continue our current theme of psychosomatic disorders as we discuss illness anxiety disorder.
Today's Content Level: Beginner, Intermediate
Illness anxiety disorder (IAD) is a psychosomatic condition characterized by excessive concern about having or developing a serious medical condition.
The key differences between illness anxiety and somatic symptom disorder is that illness anxiety is generated by fear rather than the presence of physical symptoms.
This diagnosis was introduced in the DSM-5 and patients were previously diagnosed with "hypochondriasis".
Diagnostic Criteria 2
Preoccupation with having or acquiring a serious illness.
Somatic symptoms are not present or, if present, are mild in intensity.
High level of anxiety about health.
Performs excessive health-related behaviors or exhibits maladaptive avoidance.
Duration of symptoms ≥ 6 months.
Not better explained by another mental disorder (somatic symptom disorder, generalized anxiety disorder, body dysmorphic disorder, etc.).
Specifiers: care-seeking type (high utilization of medical care) or care-avoidant type (medical care is rarely used).
Epidemiology is largely unknown due to limited studies since the disorder was first introduced in 2013 in the DSM-5.
Prevalence is estimated based on prevalence of the DSM-3 and DSM-4 diagnosis of hypochondriasis (now an obsolete diagnosis) for which about 25% of patients meet criteria for illness anxiety disorder.
Prevalence estimated to be about 0.75% in the medical outpatient environment and about 0.1% in the general population.
Thought to occur equally between men and women. It is the only somatic symptom-related disorder that does not likely have a higher frequency in women.
Average age of onset 20-30 years old. Symptoms typically worsen with age.
May be associated with fewer years of education, unemployment, and depressive disorders.
Clinical Pearls 4
People with illness anxiety disorder often seek initial care from their primary care provider as opposed to a mental health care provider.
A diagnosis is typically first speculated when, despite a normal physical examination, laboratory investigations, and repetitive assurances, the patients continue to have a severe disabling preoccupation and anxiety about an underlying serious medical condition.
Illness preoccupation must be present for at least 6 months, but the specific illness that is feared may change over that period of time.
Most patients with IAD belong to one of two types:
1) Care-seeking type. These patients have excessive health-related behaviors. Behaviors may include repeatedly checking his/her body for signs of illness, frequent utilization of the health care system, changing their doctors, or requesting multiple investigations and treatments.
2) Care-avoidant type. These patients avoid medical care. They have severe anxiety with the belief that the doctor or laboratory testing will reveal a life-threatening illness such as cancer.
Optional questionnaires: The Health Preoccupation Diagnostic Interview; The Health Anxiety Inventory; The Somatoform Disorders Symptom Checklist; The Illness Attitude Scale; The Whitely Index.
Prognosis: chronic but episodic as symptoms may wax and wane periodically. Can result in significant disability. Better prognostic factors include fewer somatic symptoms, shorter duration of illness, absence of childhood physical punishment, early referral for psychiatric evaluation.
Treatment approach is largely based on studies of patients with hypochondriasis and thus overlaps with treatment of somatic symptom disorder.
General approach: Team-based approach with primary care and behavioral health. There should be regularly scheduled visits to one primary care physician with a focus on reassurance, acknowledging health fears, education about coping, and limiting unnecessary tests/referrals. The main goal of treatment is to improve patients functional status and coping rather than elimination of symptoms. This is the most fundamental part of the successful management of IAD. It is a delicate balance of validating the patients' concerns regarding their health fears, yet providing reassurance and education about normal bodily functions
Psychotherapy: Cognitive behavioral therapy (CBT) is first-line treatment and involves cognitive restructuring of dysfunctional beliefs and modification of maladaptive behaviors. Other forms of therapy have been studied with some benefit including acceptance and commitment therapy (ACT), mindfulness-based cognitive therapy, relaxation training, problem-solving therapy, and behavioral stress management.
Pharmacotherapy: Comorbid anxiety and depressive disorders should be treated with selective serotonin reuptake inhibitors (SSRIs) or other appropriate psychotropic medications (see treatment of depression; treatment of anxiety). Some evidence suggests SSRIs may be effective in illness anxiety disorder even in the absence of comorbid psychiatric symptoms. Start low and go slow with any medication initiation given their sensitivity/concern about side effects.
Next lesson we will discuss somatic symptom disorder. If you want more learning resources then check out our recommended resources page.
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