Hypochondriasis

Essential (Required) Features:

• Persistent preoccupation or fear about the possibility of having one or more serious, progressive or life-threatening illnesses.
• The preoccupation is accompanied by either:
• Repetitive and excessive health-related behaviours, such as repeatedly checking of the body for evidence of illness, spending inordinate amounts of time searching for information about the feared illness, repeatedly seeking reassurance (e.g., arranging multiple medical consultations); or
• Maladaptive avoidance behaviour related to health (e.g., avoids medical appointments).
• The symptoms result in significant distress or significant impairment in personal, family, social, educational, occupational or other important areas of functioning. If functioning is maintained, it is only through significant additional effort.

Insight specifiers:

Individuals with Hypochondriasis vary in the degree of insight they have about the accuracy of the beliefs that underlie their health concerns. Although many can acknowledge that their thoughts or behaviours are untrue or excessive, some cannot, and the beliefs of a small minority of individuals with Hypochondriasis may at times appear to be delusional in the degree of conviction or fixity with which these beliefs are held (e.g., an individual is convinced that he has a terminal illness). Insight may vary substantially even over short periods of time, for example depending on the level of current anxiety or distress, and should be assessed with respect to a time period that is sufficient to allow for such fluctuation (e.g., a few days or a week). The degree of insight that an individual exhibits in the context of Hypochondriasis can be specified as follows:

6B23.0 Hypochondriasis with fair to good insight

• Much of the time, the individual is able to entertain the possibility that their disorder-specific beliefs may not be true and they are willing to accept an alternative explanation for their experience. This specifier level may still be applied if, at circumscribed times (e.g., when highly anxious), the individual demonstrates no insight.

6B23.1 Hypochondriasis with poor to absent insight

• Most or all of the time, the individual is convinced that the disorder-specific beliefs are true and they cannot accept an alternative explanation for their experience. The lack of insight exhibited by the individual does not vary markedly as a function of anxiety level.

6B23.Z Hypochondriasis, unspecified

Additional Clinical Features:

• Individuals with Hypochondriasis often make catastrophic misinterpretations of bodily signs or symptoms, including normal or commonplace sensations (e.g., worrying that a tension headache is indicative of a brain tumour).
• Individuals with Hypochondriasis typically have a high level of anxiety about health, are often hypervigilant of bodily sensations and symptoms, and may become easily alarmed about their personal health status, to the extent that the experience of anxiety, including panic attacks, may be a significant presenting feature. For this reason, Health Anxiety Disorder is included as an alternate name for the disorder.
• Individuals with Hypochondriasis may undergo repeated, unnecessary, medical examinations and diagnostic tests, with deterioration of the clinician-individual relationship, and frequent ‘doctor-shopping’. They may also spend excessive time searching health and medical sites on the internet.
• Conversely, individuals with Hypochondriasis may respond to their anxiety about their health by avoiding contact with reminders of health status, including medical check-ups, health facilities, and health-related information.
• Individuals with Hypochondriasis may become alarmed about their health when someone they know becomes sick, when they read or hear about illness, or in response to life stressors. The preoccupation is often a central topic of their conversation with others.

Boundary with Normality (Threshold):

• The preoccupation is not simply a reasonable concern related to a circumscribed situation (e.g., awaiting results of testing for a serious illness) and persists or reoccurs despite appropriate medical evaluation and reassurance.
• If a chronic or acute medical condition is present, or the individual is at high risk for developing a medical condition (e.g., due to high genetic risk, a recent exposure to a communicable disease), preoccupations related to such conditions are common and a high threshold should be used for a diagnosis of Hypochondriasis. The diagnosis of Hypochondriasis should only be made if the degree of preoccupation and repetitive health-related behaviours or avoidance are clearly excessive and disproportionate.
• Health-related anxiety is common among the elderly. New onset of health concerns in later-life may reflect normal age-related concerns or, if excessive and impairing, the presence of a Depressive Disorder rather than Hypochondriasis.

Course Features:

• Hypochondriasis (Health Anxiety Disorder) is generally considered to be a chronic and relapsing condition leading to significant impairment.
• Individuals with Hypochondriasis are much more likely to seek medical services for somatic rather than mental health reasons, which often contributes to health-related anxiety due to the waiting for diagnostic testing or the belief that their concerns are not being taken seriously.

Developmental Presentations

• Hypochondriasis (Health Anxiety Disorder) tends to have its onset in early to mid-adulthood. Identification is often delayed because patients seek multiple consultations with health providers focusing on having a serious physical illness.
• Hypochondriasis is thought to be rare in childhood and adolescence. However, fears and beliefs focusing on health may emerge in early childhood with significant levels of symptoms persisting throughout childhood, potentially contributing to diagnostic requirements being met in adulthood.
• Hypochondriasis is common among the elderly—though often under-diagnosed—with symptoms frequently focusing on memory loss. Clinicians may fail to identify Hypochondriasis due to the presence of comorbid medical conditions that emerge with aging and/or co-occurrence with depressive symptoms that overshadow hypochondriacal concerns. Preoccupations with bodily concerns increases with age such that determining the degree to which these concerns are manifestations of depressive symptoms, physical conditions, an accurate reflection of declining bodily functioning, or Hypochondriasis is challenging.
• Among younger children, differential diagnosis between Hypochondriasis and Obsessive-Compulsive Disorder is particularly challenging because health concerns can be prominent features of both disorders. Children may not be able to articulate the content of their fears or the focus of their apprehension making it is difficult to assess the difference between symptoms of Hypochondriasis and Obsessive-Compulsive Disorder.

Culture-Related Features:

• In Hypochondriasis (Health Anxiety Disorder), the focus of illness belief or conviction may be influenced by cultural beliefs about how the illness might have been acquired. For example, in some cultures, Hypochondriasis might arise as a result of perceived failure to follow prescribed cultural practices or rituals or as the effect of a curse, witchcraft or sorcery.

Sex- and/or Gender-Related Features:

• There are no known differences in prevalence rates between genders for Hypochondriasis.

Boundaries with Other Disorders and Conditions (Differential Diagnosis):

• Boundary with Body Dysmorphic Disorder: Body Dysmorphic Disorder is characterized by persistent preoccupation with perceived flaws or defects in the individual’s appearance, whereas in Hypochondriasis the preoccupation is about the possibility of having one or more serious, progressive or life-threatening illnesses.
• Boundary with other Obsessive-Compulsive or Related Disorders: Recurrent thoughts and repetitive behaviours occur in other Obsessive-Compulsive or Related Disorders but the foci of apprehension and form of repetitive behaviours are distinct for each diagnostic entity. In Obsessive-Compulsive Disorder, the intrusive thoughts and repetitive behaviours are not limited to concerns about health but rather encompass a variety of obsessions (e.g., of contamination, of causing harm) and compulsions (e.g., excessive washing, counting, checking) intended to neutralize these obsessions. In Body Dysmorphic Disorder, the preoccupation is with perceived flaws in appearance or physical feature(s), whereas in Olfactory Reference Disorder, individuals are preoccupied exclusively with emitting a perceived foul or offensive body odour. However, Obsessive-Compulsive or Related Disorder can co-occur, and multiple diagnoses from this grouping may be assigned if warranted.
• Boundary with Delusional Disorder and other Primary Psychotic Disorders: Some individuals with Hypochondriasis lack insight about the irrationality of their thoughts and behaviours to such an extent that convictions of having a medical illness may at times appear to be delusional in the degree of conviction or fixity with which these beliefs are held (see Insight specifiers, page __). If these beliefs are restricted to the fear or conviction of having a disease in an individual without a history of other delusions, that is, these beliefs occur entirely in the context of symptomatic episodes of Hypochondriasis and are fully consistent with the other clinical features of the disorder, Hypochondriasis should be diagnosed instead of Delusional Disorder. Somatic delusions characteristic of some presentations of Delusional Disorder tend to be less medically plausible (e.g., that an organ is rotting) and are generally not focused on the belief that one has a specific disease. Individuals with Hypochondriasis do not exhibit other features of psychosis (e.g., hallucinations or formal thought disorder).
• Boundary with Depressive Disorders: In Depressive Disorders, hypochondriacal preoccupations or somatic delusions can occur, but typically are an integral part of a range of preoccupations or delusions (e.g., related to guilt, nihilism, poverty, etc.) and occur alongside other depressive symptoms (e.g., loss of interest in pleasurable activities, suicidality, sleep disturbances, weight loss or gain, etc.).
• Boundary with Generalized Anxiety Disorder: Individuals with Generalized Anxiety Disorder may have worries about their health, but they also harbour a range of other worries focused on negative events that could occur in several different aspects of everyday life (e.g., work, finances, health, family), and unlike Hypochondriasis there is typically not a persistent preoccupation with illness that persists despite medical evaluation and reassurance.
• Boundary with Panic Disorder: Panic Disorder is characterized by recurrent, unexpected panic attacks. Individuals with Panic Disorder often worry that the somatic symptoms they experience during panic attacks are evidence of serious medical condition (e.g., a heart attack or a stroke). An additional diagnosis of Hypochondriasis should not be assigned on that basis. Conversely, if an individual with Hypochondriasis experiences panic attacks exclusively in response to preoccupation or fear about the possibility of having one or more serious, progressive or life-threatening illnesses, an additional diagnosis of Panic Disorder is not warranted. However, if both unexpected panic attacks and persistent preoccupation or fear about the possibility of having one or more serious, progressive or life-threatening illnesses are present and all other diagnostic requirements are met, both diagnoses may be assigned.
• Boundary with Bodily Distress Disorder: Bodily Distress Disorder is characterized by the presence of bodily symptoms that are distressing to the individual and to which excessive attention is directed, such as dwelling on the severity of the symptoms and repeatedly visiting health care providers. While some individuals with Hypochondriasis may experience bodily symptoms that cause distress and for which they may seek medical attention, their main concern in doing so is the fear that the symptoms are indicative of having a serious, progressive or life-threatening illness. In contrast, individuals with Bodily Distress Disorder are typically preoccupied with the bodily symptoms themselves and the impact they have on their lives, and while they may seek out health care providers who can determine the cause of their symptoms, they do so in order to get relief from the symptoms, not to disconfirm the belief that they have a serious medical illness.