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HYPOCHONDRIASIS
AND HEALTH ANXIETY
A GUIDE FOR
CLINICIANS
Edited by
Vladan Starcevic, MD, PhD, FRANZCP
Associate Professor of Psychiatry
Sydney Medical School—Nepean
University of Sydney
and
Russell Noyes Jr., MD
Emeritus Professor of Psychiatry
Carver College of Medicine
University of Iowa
1
1
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Library of Congress Cataloging-in-Publication Data
Hypochondriasis and health anxiety: a guide for clinicians / edited by Vladan Starcevic and
Russell Noyes Jr.
p. ; cm.
Includes bibliographical references.
ISBN 978–0–19–999686–5 (alk. paper)
I. Starcevic, Vladan, editor of compilation. II. Noyes, Russell, Jr., editor of compilation.
[DNLM: 1. Hypochondriasis. WM 178]
RC552.H8
616.85′25—dc23
2013045530
This material is not intended to be, and should not be considered, a substitute for medical or
other professional advice. Treatment for the conditions described in this material is highly
dependent on the individual circumstances. And, while this material is designed to offer accurate
information with respect to the subject matter covered and to be current as of the time it was
written, research and knowledge about medical and health issues is constantly evolving and dose
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the use and/or application of any of the contents of this material
9 8 7 6 5 4 3 2 1
Printed in the United States of America
on acid-free paper
Contents
vii Contributors
1 1. Introduction and Key Issues
Vladan Starcevic and Russell Noyes Jr.
8 2. Clinical Manifestations of Hypochondriasis and Related
Conditions
Laura Sirri and Giovanni A. Fava
28 3. Diagnosis and Classification of Hypochondriasis
Justine Nienke Pannekoek and Dan J. Stein
39 4. Relationships with Other Psychopathology and Differential
Diagnosis of Hypochondriasis
Vladan Starcevic
65 5. Assessment of Hypochondriasis and Health Anxiety
Susan L. Longley, Katherine Meyers, Rachel Maxwell, and Letizia Boin
85 6. Epidemiological and Economic Aspects of Hypochondriasis and
Health Anxiety
Karl Looper and Philip Dickinson
113 7. Course and Outcome of Hypochondriasis and Health Anxiety
Russell Noyes Jr.
128 8. Management and Physician–Patient Relationship
in Hypochondriasis
Russell Noyes Jr.
149 9. Cognitive and Behavioral Models and Cognitive-Behavioral and Related
Therapies for Health Anxiety and Hypochondriasis
Theo K. Bouman
199 10. Interpersonal Psychotherapy for Hypochondriasis and Related
Disorders: An Attachment-Based Approach
Scott Stuart
222 11. Psychodynamic Models and Therapeutic Approaches
Contents vi to Hypochondriasis
Don R. Lipsitt
241 12. Pharmacological Treatment and Neurobiology of Hypochondriasis,
Illness Anxiety, and Somatic Symptoms
Kelli Jane Kerr Harding and Brian A. Fallon
259 Index
Contributors
Letizia Boin, BA Kelli Jane Kerr Harding, MD
Department of Psychology Assistant Professor of Clinical
Eastern Illinois University Psychiatry
Charleston, IL, USA New York State Psychiatric Institute
Columbia University Medical
Theo K. Bouman, PhD
Center,
Professor of Clinical Psychology
New York, NY, USA
and Postmaster Institute PPO
University of Groningen Don R. Lipsitt, MD
Groningen, The Netherlands Clinical Professor of Psychiatry
Philip Dickinson, BSc, MSc Harvard Medical School
Department of Neurology and Boston, MA, USA; and
Neurosurgery, Cambridge Health Alliance
Faculty of Medicine Cambridge, MA, USA
McGill University Susan L. Longley, PhD
Montreal, Québec, Canada Assistant Professor of
Brian A. Fallon, MD, MPH, MEd Psychology
Professor of Psychiatry Eastern Illinois University
New York State Psychiatric Institute Charleston, IL, USA
Columbia University Medical Center
Karl Looper, MD, MSc,
New York, NY, USA
FRCPC(C)
Giovanni A. Fava, MD Associate Professor and Director of
Professor of Clinical Psychology Postgraduate Education
University of Bologna Department of Psychiatry
Bologna, Italy; and McGill University; and
Clinical Professor of Psychiatry Department of Psychiatry
State University of New York at Buffalo Jewish General Hospital
Buffalo, NY, USA Montreal, Québec, Canada
Rachel Maxwell, BA Laura Sirri, PhD
viii
Contributors Department of Psychology Department of Psychology
Eastern Illinois University University of Bologna
Charleston, IL, USA Bologna, Italy
Katherine Meyers, MA Vladan Starcevic, MD, PhD, FRANZCP
Department of Psychology Associate Professor of Psychiatry
Illinois Institute of Technology Sydney Medical School—Nepean
Chicago, IL, USA University of Sydney
Sydney, NSW, Australia
Russell Noyes Jr., MD
Emeritus Professor of Psychiatry Dan J. Stein, MD
Carver College of Medicine Professor and Chair
University of Iowa Department of Psychiatry
Iowa City, IA, USA University of Cape Town
Cape Town, South Africa
Justine Nienke Pannekoek, MSc
Department of Psychiatry Scott Stuart, MD
Leiden University Medical Center Professor of Psychiatry and
Leiden, The Netherlands; and Psychology
Department of Psychiatry Carver College of Medicine
University of Cape Town University of Iowa
Cape Town, South Africa Iowa City, IA, USA
Hypochondriasis
and Health Anxiety
1 Introduction and
Key Issues
Vladan Starcevic and Russell Noyes Jr.
It may be a truism to state that hypochondriasis is a puzzle, but at the very minimum
it remains a challenge. That this is occurring despite its very long history is a testa-
ment to the resilience of this disturbance. It is also a reason to approach the notion of
hypochondriasis with respect, regardless of the obsolete nature of the term. Whether
referring to an “imaginary illness,” a delusional belief as part of a more severe mental
illness, or anything in between, hypochondriasis has been the subject of serious con-
sideration even if its sufferers have not always been taken seriously. Terminological
fads come and go and constructs are deconstructed and reconstructed, yet the
underlying issues and dilemmas have not disappeared. This is very much the hall-
mark of hypochondriasis and the main raison d’être for this book.
In this introduction, our intention is twofold. First, we will briefly discuss the
topic of the book and the reasons for writing it at this particular time. Second, our
aim is to introduce the content of the book as it reflects the main issues associated
with hypochondriasis.
WHAT IS IN THE TITLE?
The book carries the terms “hypochondriasis” and “health anxiety” in its title because
this is how its subject has been referred to until now. A growing dissatisfaction with
the term and the concept of hypochondriasis has led to its elimination from the
recently published fifth edition of the Diagnostic and Statistical Manual of Mental
Disorders (DSM-5; American Psychiatric Association, 2013) and replacement with
two disorders: somatic symptom disorder and illness anxiety disorder. Most clini-
cians have yet to become familiar with the new disorders, and this is why these
terms do not appear in the title. In contrast, hypochondriasis and health anxiety
2
Hypochondriasis and Health Anxiety are instantly recognizable concepts, regardless of personal attitudes and preference.
The term “hypochondriasis” is used in this book to refer to the diagnostic concept
based on criteria found in the main diagnostic and classification systems (Diagnostic
and Statistical Manual of the American Psychiatric Association and International
Classification of Diseases of the World Health Organization). Unlike “hypochondria-
sis,” “health anxiety” has never been an official diagnosis and its definitions vary.
Therefore, “health anxiety” is defined in the book whenever this term is used.
Our view is that health anxiety for the most part denotes one aspect of hypo-
chondriasis—the affective one. The concept also encompasses associated behaviors
such as avoidance and reassurance seeking. From this perspective, hypochondriasis
is a broader concept, which subsumes health anxiety and a cognitive component
that is referred to as “disease suspicion,” “disease belief,” or “disease conviction.”
Hypochondriasis usually, though not necessarily, suggests a more severe condi-
tion than health anxiety; but the precise nature of their relationship remains to be
elucidated.
WHY A BOOK ON HYPOCHONDRIASIS AND HEALTH
ANXIETY NOW?
Another book on hypochondriasis and health anxiety is timely for a number of rea-
sons. The first pertains to the aforementioned changes in the psychiatric nomencla-
ture. This type of situation often produces confusion and further complicates matters
that are already complex and controversial. Not surprisingly, opinion is already
divided about somatic symptom disorder and illness anxiety disorder. While some
have welcomed the new terminology (Dimsdale et al., 2013), others have criticized
it, especially somatic symptom disorder (Frances, 2013). Our goal in this book is to
bring more clarity to this domain of psychopathology. We intend to do this by criti-
cally examining the relevant concepts and by pointing to their advantages and dis-
advantages. This might guide future research and help with conceptual refinement.
There are indications that health anxiety and hypochondriasis are frequently
encountered in clinical practice. The number of people with health anxiety who con-
sult the Internet for their concerns (“silent hypochondriacs” or “cyberchondriacs”) is
unknown but likely to be high. Ours is a health-conscious era in which healthy life-
styles are promoted and mass media used to spread warnings about dangers to our
health. This creates favorable conditions for an epidemic of health anxiety for which
health care professionals and services seem ill prepared. Therefore, there is a need to
better understand health anxiety and hypochondriasis, especially in this technologi-
cal age. Better recognition and understanding of the “modern” hypochondriasis is
another goal of this book.
While there is much information on hypochondriasis and health anxiety, most
of it is scattered in specialized journals or publications that examine this domain of
psychopathology from a single perspective. In contrast, our book aims to present
3
multiple theoretical models and treatment approaches and bring together diverse
Introduction and Key Issues
but clinically useful information under a single cover. We have been open to mul-
tiple perspectives, and our book provides a missing but overarching, integrative
approach to hypochondriasis and health anxiety. Thus, we have included not only
the cognitive and behavioral theories and therapies for which there is most support
and evidence of efficacy but also the interpersonal model and therapy as well as psy-
chodynamic theoretical and treatment approaches and pharmacotherapy perspec-
tives. We believe that this will allow clinicians to integrate knowledge and improve
their skills so that their patients ultimately benefit.
Much is unknown about hypochondriasis and health anxiety, and we need to
be aware of our limitations when facing patients with this predicament. At the
same time, we should use all our resources as we try to understand, support, and
help them. This calls for a book that has a pragmatic orientation and that translates
evidence-based knowledge and clinical wisdom into practical recommendations,
suggestions, and opinion. Such recommendations and suggestions may be found
throughout the book along with numerous case illustrations. We hope that our book
will be practical, accessible, and a resource for all clinicians who encounter and
provide care for people with hypochondriasis and health anxiety. Although these
are primarily general practitioners and mental health professionals, other clinicians
may also find the book relevant for their practice.
ISSUES ADDRESSED BY THE BOOK
Conceptual Issues
What is hypochondriasis? This simple question has been surprisingly difficult to
answer, and our book will not make yet another attempt to provide a definite answer.
Instead, we will look at the structure of the concept of hypochondriasis and revisit
its components.
Hypochondriasis can be conceptualized broadly—an approach espoused by the
DSM-IV (American Psychiatric Association, 1994)—or more narrowly. The advan-
tage of a broad definition is that it is all-inclusive, with the following five compo-
nents: (1) a preoccupation with somatic symptoms and/or disease, (2) a fear of
disease, (3) the idea that one already has a serious disease (disease belief or convic-
tion), (4) a misinterpretation of somatic symptoms, and (5) persistence of preoc-
cupation despite medical evaluation and reassurance. With such a broad diagnostic
concept, but restrictive in the sense that all of its components have to be present
to make the diagnosis, it is not surprising that hypochondriasis has been found
infrequently in community samples. Therefore, the true prevalence of hypochon-
driasis may have been underestimated by the way it has been conceptualized. This
has apparently been one of the reasons behind attempts to simplify the concept of
hypochondriasis, to make its diagnostic criteria less restrictive and the diagnosis
4
Hypochondriasis and Health Anxiety easier to establish.
But “splitting” broader concepts is never easy. The elimination of the term “hypo-
chondriasis” from the DSM-5 was driven by its antiquated and misleading etymol-
ogy and perception of its pejorative or stigmatizing connotations. However, in the
process of its conceptual shrinking, the concept of hypochondriasis was lost along
with the term. In other words, the diminution of hypochondriasis did not lead to
another definition of hypochondriasis but to “something else.”
The “splitting” of hypochondriasis has been difficult because of the uncertainty as
to how best to do it. Traditionally, the two key components of hypochondriasis have
been disease fears and disease beliefs, and hypochondriasis could have been divided
into a type with predominant disease fears and a type with predominant disease
beliefs. This did not happen, perhaps because disease fears and disease beliefs often
co-occur and any division along these lines might have seemed artificial. Instead,
in the DSM-5 hypochondriasis was somewhat arbitrarily divided on the basis of
the presence or absence of somatic symptoms. This has resulted in the creation of a
relatively circumscribed diagnostic category of illness anxiety disorder (with few or
no somatic symptoms) and a much broader category of somatic symptom disorder
(characterized by the presence of at least one “distressing” or “disruptive” somatic
symptom). Paradoxically, the latter appears more heterogeneous than hypochon-
driasis as it is has been created to replace as many as four DSM-IV diagnostic enti-
ties: hypochondriasis with somatic symptoms, somatization disorder, pain disorder,
and undifferentiated somatoform disorder. Somatic symptom disorder is also likely
to encompass a variety of “medically unexplained symptoms” that were not classified
among the DSM-IV somatoform disorders. With such heterogeneity, one wonders
about the utility of this diagnosis for communication, research, and management.
While illness anxiety disorder and somatic symptom disorder appear more “neu-
tral,” that is, less stigmatizing and perhaps more acceptable to patients, only time will
tell whether or not the negative connotations accompanying hypochondriasis will
be transferred to the new diagnostic terms. History suggests that the stigma does
not disappear just as a result of the change in terminology. The overall approach
needs to change as well so that patients with hypochondriasis are not routinely met
with an “all in your head” attitude. In addition, it is difficult to be convinced that the
new terms will bridge more successfully the conceptual gap between the mind and
the body.
These diagnostic conundrums are likely to dominate the field in the coming
years, with one of the key tasks for research being a careful weighing of the advan-
tages and disadvantages of the new terms and concepts. It is already clear that there
is one disadvantage of the conceptual shake-up and that is the loss of continuity
with the previous literature. Consequently, all our knowledge about hypochondria-
sis (and, to a lesser extent, health anxiety) will have to be “translated” into a language
of the new diagnostic categories endorsed by the DSM-5. As the book demonstrates,
