Current Psychiatry Reviews - Volume 10, Issue 1, 2014

The DSM-5 revision of the health anxiety classification (i.e., hypochondriasis) highlights deficiencies in the present DSM taxonomy and the need to consider an alternative. Health anxiety is a clinical syndrome that has been and remains difficult to classify in the DSM system. We argue that the current DSM-5 proposal that splits this syndrome between two diagnoses, somatic symptom disorder (SSD) and illness anxiety disorder (IAD), has significant limitations. We anticipate that SSD will problematically increase comorbidity because criteria for this syndrome feature nonspecific symptoms that overlap with depressive and anxiety disorders. Further, the proposed IAD criteria are overly restrictive and not likely to capture the heterogeneous presentation of individuals with anxiety about their health. We propose an alternative organization that will increase the clinical utility and construct validity of many DSM-IV-TR, Axis I disorders, including health anxiety. This taxonomy, proposed by Goldberg, Krueger, Andrews and Hobbs, is based on the shared etiology of syndromes called emotional disorders. The emotional disorders include health anxiety, other somatoform, unipolar depressive, and anxiety disorders, all of which share the risk factor of negative emotionality/neuroticism (NE/N). We propose a research agenda to support this alternative taxonomy.

This review addresses the prevalence of hypochondriasis and less restrictive subtypes of hypochondriacal phenomena (abridged hypochondriasis and health anxiety). Altogether, 55 papers based on 47 independent samples reporting prevalence rates of hypochondriasis, abridged hypochondriasis, and health anxiety were taken into account. Investigations of the general population, general medical samples (e.g., primary care) and specific clinical samples (e.g., cancer patients) were included in the present review. In general populations a weighted prevalence of 0.40% was found for hypochondriasis (range 0.0-4.5%) and a weighted prevalence of 1.00% (0.6-2.0%) was found for abridged hypochondriasis. Health anxiety was frequently reported in general populations with a wide range (2.1-13.1%). In general medical samples a weighted prevalence rate of 2.95% (range 0.3-8.5%) was found for hypochondriasis. Abridged hypochondriasis was only reported in one study; however, the prevalence of abridged hypochondriasis was three times higher than the full diagnostic criteria of hypochondriasis. In specific clinical samples (e.g., cancer patients, psychiatric outpatients) hypochondriasis and health anxiety were frequently reported as well. Comparisons of persons with the full hypochondriasis diagnosis and abridged hypochondriasis show large similarities regarding psychopathological characteristics and clinical impairment, which underline the importance of a less restrictive definition of hypochondriasis considered in DSM-5. Findings regarding potential risk factors were very inconsistent and no clear risk factors could be identified. The high prevalence of hypochondriasis in medical settings should be addressed in the future with effective screening instruments in order to optimize treatment strategies for patients with hypochondriasis and persons with elevated health anxiety.

Hypochondriasis has common features with a number of other mental disorders, its boundaries are not always easy to draw and it occurs frequently with several psychiatric conditions. This review examines the relationships between hypochondriasis and other psychopathology in two ways. First, it discusses the differential diagnosis of hypochondriasis by identifying both the similarities and differences between hypochondriasis and organic diseases, psychotic disorders, depression, panic disorder, obsessive-compulsive disorder, generalized anxiety disorder, specific phobia of illness and somatization disorder. The greatest overlap seems to exist between hypochondriasis and panic disorder, but hypochondriasis can still be distinguished from it, as well as from other disorders. The diagnosis of hypochondriasis is not warranted in the presence of psychotic features, but it can be made alongside diagnoses of most other disorders, provided that hypochondriacal features are not better explained by them. In the second part, the article reviews studies of the cooccurrence of hypochondriasis and other disorders. The literature reveals some inconsistencies and discrepant findings, which is largely due to different settings in which studies have been conducted and various other methodological issues. Still, it appears that hypochondriasis is more likely to co-occur with depression, panic disorder and somatization disorder than with other psychiatric conditions, suggesting a closer relationship with them. The implications of these findings for the conceptualization of hypochondriasis, its diagnostic status and classification are briefly considered.

Hypochondriasis (HC) has presented physicians and researchers with nosological challenges since Freud’s era. Part of the difficulty lays in the significant overlap between the constructs of mental illness and personality disorders that already exists when it comes to understanding almost any psychological phenomena (i.e., state versus trait debate). Indeed, many of the symptoms of HC are similar to those of other mental illnesses such as anxiety, yet HC has also been associated with particular personality traits, cognitive styles, attitudes, and personality disorders. Likewise, there has been debate as to whether HC should be considered secondary to some other disorder or as a primary diagnosis in its own right. Finally, the etiology of HC is not well understood. Empirical literature suggests possible genetic components to HC, in addition to several potential environmental factors. In this article we review key theoretical works and empirical studies on the intersection of personality dysfunction and HC. In addition, we consider the role that trauma may play in the development of HC in certain individuals. Traumatic experiences are already widely linked to somatoform disorders. However, the characteristic features of hypochondriacal presentation (e.g., illness conviction, illness phobia, and failure to respond to reassurance from physicians) may be related to particular types of traumatic experiences which, when they occur in infancy and/or childhood, interfere with secure attachment and identity formation.

The present paper reviewed studies that examined the role of cognitive and perceptual variables in health anxiety and hypochondriasis that have been published since a 2007 meta-analysis of this literature. Specifically the current review examined the associations between hypochondriasis or health anxiety and (1) dysfunctional beliefs, (2) cognitive processes, (3) triggering stimuli, and (4) the perception of bodily sensations. Overall, the findings from the recent research were consistent with those that were included in the earlier meta-analysis, and were generally supportive of cognitivebehavioral approaches to understanding hypochondriasis and health anxiety. In recent years, there has been a shift in emphasis away from empirical studies of dysfunctional beliefs and toward greater attention to cognitive processes in health anxiety. So far, these cognitive process studies have not been especially systematic and have examined a variety of variables, including attentional biases toward potential threats, rumination, and intolerance of uncertainty. Such findings may help inform more comprehensive cognitive models of hypochondriasis and health anxiety. Conversely, attempts to integrate cognitive process variables into cognitive-behavioral models of health anxiety may help generate more systematic research.

Background: The hypochondriacal spectrum includes several clinical phenomena, such as disease phobia, thanatophobia and health anxiety. The major challenge for a dimensional tool is to capture the different features which sensitively differentiate the hypochondriacal syndrome from other clinical phenomena, such as somatization. This article provides a qualitative review of the instruments designed for the dimensional assessment of hypochondriacal fears and beliefs. Methods: Articles were retrieved by means of both computerized (Medline, PsycINFO) and manual searches. Results: In the 1960s, the Whiteley Index (WI) was the first instrument specifically built to measure the severity of hypochondriacal symptoms. In the 1980s, Kellner developed the nine Illness Attitude Scales (IAS), each of them concerns a specific cluster of attitudes, fears and beliefs. They were designed to reflect the clinimetric properties, in particular content validity and sensitivity to treatment-related changes. In the 1990s, the refinement of the cognitive-behavioral model of hypochondriasis was followed by an upsurge of questionnaires aimed at assessing the dimensions of hypochondriasis according to this model. However, most of these instruments need to be further validated and the amount of incremental information they yield remains to be established. In the last decade, the interest of the studies has been focused on the measurement of specific features of hypochondriasis, such as response to medical reassurance and obsessive-compulsive symptoms. Conclusions: Kellner’s IAS and Pilowsky’s WI are the most validated and widely used instruments. The clinimetric properties make the IAS the gold standard for the dimensional assessment of hypochondriacal fears and beliefs.

This paper presents a narrative review of psychological treatments for hypochondriasis and health anxiety. An extensive literature search encompassing publications in the English language yields over 40 case reports and systematic studies on mainly cognitive and behavioral interventions. After a brief introduction of the types of intervention, a summary of recent studies is given, and their methodological and clinical status are being discussed. It is concluded that there is a general evidence for psychological treatments (in particular cognitive-behavioral interventions) to be effective in reducing hypochondriacal symptoms. However, since most studies possess methodological flaws, their results should be interpreted with care.

Despite the high prevalence of hypochondriasis in primary care settings, there are relatively few pharmacotherapy trials in hypochondriasis. Ongoing controversy about nosology of hypochondriasis and lack of work demonstrating specific neurobiological alterations in hypochondriasis may contribute to this. There have been several open label trials of selective serotonin reuptake inhibitors (SSRIs) and serotonin-2A antagonist/reuptake inhibitors (SARIs) for the treatment of hypochondriasis, and more recently two randomized controlled trials (RCTs). Taken together, there is a small body of evidence to support the efficacy of SSRIs in the treatment of hypochondriasis. Further RCTs are needed to confirm efficacy, determine effectiveness of treatments in primary care settings, address influence of comorbidity and other potential predictors of outcome, and compare pharmacotherapy to psychotherapy.

Research suggests that a history of childhood anxiety correlates with and predicts adolescent depression. The present review synthesizes current knowledge of relations between childhood anxiety and adolescent depression, focusing on the possibility that primary anxiety in childhood may cause secondary depression in adolescents. Across existing studies, evidence strongly supports childhood anxiety as a risk factor for adolescent depression, and long-term follow-up studies of cognitive-behavioral childhood anxiety treatments may suggest a causal anxiety-depression link. However, mechanisms underlying this relationship remain unexplored. Future directions include careful assessment of comorbidity between anxiety and depressive disorders, longitudinal evaluations of anxiety and depression following interventions for childhood anxiety, and investigations of mediators and moderators of the anxiety-depression link. Finally, mechanisms by which the treatment of childhood anxiety might prevent depression in adolescents are proposed.