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Illness Anxiety Disorder (formerly Hypochondriasis)

Background

Hypochondriasis, which is now known as illness anxiety disorder, and the other somatic symptom disorders (e.g., factitious disorder, conversion disorder) are among the most difficult and most complex psychiatric disorders to treat in the general medical setting. On the basis of many new developments in this field, the DMS-5 has revised diagnostic criteria to facilitate clinical care and research. While illness anxiety disorder is included in the category of “somatic symptom and related disorders” it continues to have much overlap with obsessive-compulsive disorder and related illness.

As with all psychiatric disorders, illness anxiety disorder demands creative, rich biopsychosocial treatment planning by a team that includes primary care physicians, subspecialists, and mental health professionals.

This article describes illness anxiety disorder, its diagnosis, and an overview of treatment approaches, with references for details beyond the scope of the article. Finally, the article reviews new developments in psychopharmacologic and psychotherapeutic treatments.

Case study

A 45-year-old white male engineer presents to a primary care clinic armed with multiple internet searches on the topic of cancer. He states that he “just knows” he has a GI cancer, “probably the colon or maybe the pancreas.” When asked how long this concern has bothered him he says “for years I have been concerned that I have cancer.” You ask about relevant symptoms and he is a bit vague, saying “I get some pain or pressure right here (he points to the left upper quadrant) but it is not there all the time.” Upon asking about prior workups he says “I have had ultrasounds and colonoscopies but they couldn’t find anything. I was initially relieved but a couple of weeks later started to think that they must have just missed something.”

When you ask about the patient’s goals for today’s visit he is emphatic. “I think what I really need is another colonoscopy and abdominal CT scan.” His examination is unrevealing. When you suggest a less invasive approach, he brings up error rates of the other evaluations and shows literature endorsing how abdominal CT is the criterion standard. He is anxious at baseline and increasingly irritable when you propose less invasive evaluation. He ends the encounter by stating that he will “find another doctor who sees my point and will get me what I need.”

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