Patient will present as → a 25-year-old male graduate engineering student who is at your office for the fourth time in one week to be sure he does not have chlamydia. Despite having one sexual partner, he learned that there is an increase in the incidence of STDs on campus. He reports that he has only had sex once, but learned that chlamydia is hard to culture. He reports he may have dysuria intermittently, but is not sure. He has been evaluated at each visit, and physical and laboratory examinations have been entirely normal each time.
Key Points:
Minimal or absent physical symptoms, but persistent worry about health for ≥6 months (previously known as hypochondriasis)
- Patients are worried about having or developing a serious illness and
- This preoccupation is present for at least 6 months and
- Is not better explained by another mental disorder (e.g., obsessive-compulsive disorder and somatic symptom disorder)
DSM-5 Diagnostic Criteria
- Preoccupation with having or acquiring a serious illness.
- Somatic symptoms are not present or, if present, are only mild in intensity. If another medical condition is present or there is a high risk for developing a medical condition (e.g., strong family history is present), the preoccupation is clearly excessive or disproportionate.
- There is a high level of anxiety about health, and the individual is easily alarmed about personal health status.
- The individual performs excessive health-related behaviors (e.g., repeatedly checks his or her body for signs of illness) or exhibits maladaptive avoidance (e.g., avoids doctor appointments and hospitals).
- Illness preoccupation has been present for at least 6 months, but the specific illness that is feared may change over that period of time.
- The illness-related preoccupation is not better explained by another mental disorder, such as somatic symptom disorder, panic disorder, generalized anxiety disorder, body dysmorphic disorder, obsessive-compulsive disorder, or delusional disorder, somatic type.
Specify whether:
- Care-seeking type: Medical care, including physician visits or undergoing tests and procedures, is frequently used.
- Care-avoidant type: Medical care is rarely used.
The goal is to improve coping skills while never dismissing their fears -caregivers should closely follow their patients and develop a therapeutic alliance
- Group/insight-oriented therapy
- Regular appts with provider for reassurance
- Medications: (SSRIs) if concurrent/underlying anxiety or major depressive disorder
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Question 1 |
A 40-year-old woman presents with an 8-month history of an intense and debilitating fear that she has undiagnosed ovarian cancer. She has seen two gynecologists, both of whom performed comprehensive evaluations including pelvic exams and transvaginal ultrasounds, with normal results. Despite this, she remains convinced, stating "I just know something is wrong." Her fear is the central focus of her life, causing significant distress and leading to frequent reassurance seeking. To accurately distinguish a diagnosis of Illness Anxiety Disorder from Somatic Symptom Disorder in this patient, which of the following is the most crucial information for the clinician to elicit?
Whether the fear of illness is of delusional intensity Hint: If the belief were fixed, false, and of delusional intensity (i.e., the patient cannot acknowledge the possibility that they are wrong), the diagnosis would shift to a psychotic disorder, such as Delusional Disorder, Somatic Type. This differentiates IAD from psychosis, but not from SSD. | |
The presence and severity of her physical symptoms | |
Whether she engages in care-seeking or care-avoidant behaviors Hint: "Care-seeking" and "care-avoidant" are specifiers used to subtype Illness Anxiety Disorder itself. They do not help to distinguish IAD from Somatic Symptom Disorder, as patients with SSD can also exhibit both of these behavioral patterns. | |
The duration of her preoccupation with having cancer Hint: The DSM-5 duration criterion for both IAD and SSD is the same: the preoccupation and symptoms must be persistent for at least six months. Therefore, the duration does not help to differentiate between the two disorders. | |
The presence of comorbid generalized anxiety disorder Hint: Comorbidity with other anxiety and depressive disorders is high in both IAD and SSD. Therefore, identifying a comorbid condition does not help in making the differential diagnosis between them. |
Question 1 Explanation:
According to the DSM-5, the primary distinction between Illness Anxiety Disorder (IAD) and Somatic Symptom Disorder (SSD), the two main diagnoses that subsumed the older category of hypochondriasis, lies in the presence and prominence of physical symptoms. A diagnosis of IAD is made when somatic (physical) symptoms are minimal or nonexistent, and the patient's distress is centered on the idea or fear of having a serious illness. In contrast, a diagnosis of SSD requires the presence of one or more chronic, distressing somatic symptoms (e.g., pain, fatigue, GI distress) that are the focus of the patient's excessive thoughts, feelings, and behaviors. Therefore, to differentiate these two conditions, the clinician must specifically determine if the patient is primarily distressed by a persistent physical symptom (like severe pelvic pain) that she interprets as cancer (suggesting SSD), or if she has no significant physical symptoms but is simply terrified of the possibility of having cancer (suggesting IAD).
Question 2 |
A 35-year-old teacher diagnosed with illness anxiety disorder has been seeing you monthly for 3 months. Despite your reassurance and appropriate medical evaluations, she remains convinced she has multiple sclerosis due to occasional tingling sensations. She declines referral to psychiatry, stating "I have a real medical problem, not a mental issue." She has no comorbid psychiatric conditions and functions adequately at work. She expresses frustration that you "aren't taking her seriously" but continues attending appointments. What is the most appropriate next step in management?
Prescribe fluoxetine 20 mg daily and increase dose every 2 weeks Hint: Medication is third-line treatment; she has no comorbid conditions and isn't ready to accept psychiatric treatment | |
Order MRI brain and spine to definitively rule out multiple sclerosis Hint: Unnecessary testing reinforces illness anxiety and may lead to incidental findings causing more worry | |
Refer for cognitive-behavioral therapy despite her reluctance Hint: While CBT is first-line treatment, forced referral when patient isn't ready often results in non-engagement | |
Continue scheduled visits while acknowledging her health fears and avoiding unnecessary testing | |
Discharge her from your practice due to non-compliance with recommendations Hint: Abandoning the patient worsens outcomes; these patients need consistent, patient-centered care |
Question 2 Explanation:
The most appropriate approach follows general management principles for illness anxiety disorder in primary care. Regular scheduled visits (not contingent on new symptoms) help establish a therapeutic alliance while preventing unnecessary testing that can reinforce illness beliefs. Acknowledging her fears validates her experience without dismissing concerns. Since she's not ready for psychiatric referral and has no comorbid conditions requiring immediate medication, maintaining the relationship is crucial. The goal is improving coping with health fears rather than eliminating them. Over time, as trust builds, she may become more receptive to specific treatments like CBT. Premature pushing toward psychiatric treatment often damages the therapeutic relationship.
Question 3 |
A 28-year-old graduate student presents to the clinic requesting a full-body MRI scan. She reports experiencing intermittent mild headaches for 2 weeks and is convinced she has a brain tumor despite normal neurological examination and reassurance. Her mother died of ovarian cancer when the patient was 12 years old. Since then, her father has frequently checked his blood pressure and glucose levels, often discussing his health concerns with the family. The patient spends 3-4 hours daily researching symptoms online and has seen 4 different physicians in the past month. She acknowledges her concerns might be excessive but cannot stop worrying. According to the cognitive-behavioral model, which factor most likely contributed to the development of this patient's condition?
Genetic predisposition to anxiety disorders Hint: While anxiety disorders can have genetic components, family studies of hypochondriasis show no clear genetic pattern, and the patient's presentation is better explained by learned behaviors | |
Decreased plasma neurotrophin-3 levels Hint: Although found in some hypochondriasis patients, these are correlational findings without established causal relationships | |
Serotonin transporter gene polymorphisms Hint: No specific genetic markers have been identified for illness anxiety disorder | |
Pituitary gland volume abnormalities Hint: Small studies show smaller pituitary volumes in hypochondriasis, but it's unclear if this is cause or effect | |
Dysfunctional assumptions about health stemming from childhood experiences |
Question 3 Explanation:
This patient presents with classic features of illness anxiety disorder. The cognitive-behavioral model, which has the strongest empirical support, suggests that dysfunctional health beliefs often develop from early family experiences. The patient's exposure to serious parental illness (mother's cancer death) and abnormal illness behavior in her surviving parent (father's excessive health monitoring) created vulnerability for developing illness anxiety disorder. These childhood experiences lead to dysfunctional assumptions about illness prevalence, bodily symptoms, and disease course. The recent headaches triggered these assumptions, leading to catastrophic misinterpretation of benign symptoms. Her behavior demonstrates the classic cycle: bodily monitoring → misinterpretation → anxiety → reassurance seeking → temporary relief → continued monitoring.
There are 3 questions to complete.
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