Somatoform disorder include different entities. One of complex and difficult to treat ailment among the somatoform disorder is illness anxiety disorder, formerly known as hypochondriasis. My power point presentation is an attempt to simplify the mystery of this common psychiatric diagnosis. (Dr Satyajeet Singh, MD, Neuropsychiatrist, Aiims Patna)

1. Illness
Anxiety
Disorder
D r S a t y a j e e t S i n g h , M D
N e u r o p sy c h i a t r i st ,
A i i m s Pa t n a

2. 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."

3. Case study
 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.”

4. Case study
 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."
 Since his past examination
were unrevealing, you will like
suggest a less invasive
approach, he brings up error
rates of the other evaluations
& shows literature endorsing
how abdominal CT is the
criterion standard

5. Case study
 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.”
No offence, If you are not getting my point, I will like to seek
an yet another opinion

6. Background
 Hypochondriasis, which is now
known as illness anxiety
disorder, are among the most
difficult & most complex psychiatric
disorders to treat in the general
medical setting
 On the basis of many new
developments, the DMS 5 has
revised diagnostic criteria to
facilitate clinical care & research
 While illness anxiety disorder is
included in the category of
"somatoform disorder”, it continues
to have much overlap with
obsessive-compulsive disorder

7. Background
 As with all psychiatric disorders,
illness anxiety disorder demands
creative, rich bio-psycho-social
treatment planning by a team that
includes primary care physicians, sub-
specialists & mental health
professionals
 In this class, our aim is to describe
illness anxiety disorder, its diagnosis,
and an overview of treatment
approaches
 Finally, we will reviews new
developments in psycho-
pharmacologic and psycho-
therapeutic treatments

8. Epidemiology – Frequency
 Based on the previously defined
"hypochondriasis," the DSM
estimates that the community 1-2
year prevalence is 1.3-10%, while
the 6-month to 1-year prevalence in
medical outpatients is 3-8%
 Some degree of preoccupation with
disease is apparently common,
because 10-20% of people who are
healthy and 45% of people without a
major psychiatric disorder have
intermittent unfounded worries
about illness

9. Epidemiology – International/cultural effects
 Rates of illness anxiety disorders are
heavily influenced by the diagnostic
criteria involved & how studies are
conducted
 Researchers have also worked to define
how culture & ethnicity interact to
determine "idioms" of distress

10. Epidemiology – Mortality/Morbidity
 Illness anxiety disorder is usually episodic, with symptoms that last from months to years and
equally long quiescent periods
 One third of patients with illness anxiety disorder are believed to eventually improve significantly
 A good prognosis appears to be associated with
1. High socioeconomic status
2. Treatment-responsive anxiety or depression
3. Absence of a personality disorder
4. Absence of a related non-psychiatric medical condition
 Most children are believed to recover by adolescence or early adulthood, but empiric studies
have not been carried out

11. Epidemiology – Mortality/Morbidity
 Patients with illness anxiety disorder appear to
have no differences in age or gender than patients
without this disorder
 There have been several studies that have found
patients with illness anxiety disorder to have
decreased educational and income levels
 These individuals use medical care at high rates,
making frequent visits to the emergency
department, the doctor, and other health care
providers and undergoing frequent physical
examinations, laboratory testing, and other
costly, invasive, and potentially dangerous
procedures
Doctor, I sustained head injury
at the age of three, now I am 30
but I think my heaviness of
head for last four year is due to
that past event of head trauma.
Also I think you should prescribe
CT scan brain as it is being
conducted free of cost here at
AIIMS Patna

12. Epidemiology – Mortality/Morbidity
 Cognitive, social learning, and
psychodynamic theories imply
that patients have significant
psychosocial disturbances in
terms of relationships,
vocations, and other
endeavours
 Exacerbations may occur with
psychological stressors and in
patients with comorbid
psychiatric conditions

13. Epidemiology – Mortality/Morbidity
 Patients with illness anxiety disorder have a high
rate of psychiatric co-morbidity
 The most common being
1. Generalized anxiety disorder (71%),
2. Dysthymic disorder (45.2%),
3. Major depression (42.9%)
4. Panic disorder (16.7%)
5. Personality disorder
6. Substance abuse or dependence
 Long-term prognosis of patients with
hypochondriasis is understudied due to the
heterogeneity of the disorder. However, higher
severity at baseline is likely associated with
worse outcome

14. Epidemiology
 Sex – Illness and
anxiety disorder
appears to occur
equally in men and
women.
 Age –
Hypochondriasis can
begin at any age, but
the most common
age of onset is early
adulthood.

15. Clinical Presentation – DSM V – IAD
 The DSM-5 criteria for illness anxiety disorder are as follows:
1. The individual is preoccupied with having or acquiring a serious illness.
2. 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 (eg, strong family
history is present), the preoccupation is clearly excessive or disproportionate.
3. The individual has a high level of anxiety about health, and is easily alarmed about personal
health status.
4. The individual performs excessive health-related behaviours or exhibits maladaptive
avoidance.
5. The individual has been preoccupied with illness for at least 6 months.
6. The individual's preoccupation is not better explained by another mental disorder

16. Clinical Presentation – MSE– IAD
 General appearance, behaviour, and speech
 Modestly or well groomed, not grossly disheveled
 Cooperative with the examiner, yet ill at ease and
not easily reassured
 Possible signs of anxiety, including moist hands,
perspiring forehead, strained/tremulous voice,
and wide eyes and intense eye contact
 Psychomotor status
 Restlessness
 Frequent shifts in posture
 Mild-to-moderate agitation

17. Clinical Presentation – MSE– IAD
 Mood and affect
 Anxious or worried, depressed mood
 Restricted, shallow, fearful, or anxious affect,
with restricted fluctuations and limited depth
 Thought process
 Responds to questions but may divert to next
worry or revert to an already expressed
concern despite reassurance to the contrary

18. Clinical Presentation – MSE– IAD
 Thought content
 Preoccupation with being ill
 Anxious themes concerning
what in the body is wrong,
how it is wrong, and how it is
experienced
 Feelings of despair and/or
hopelessness
 Catastrophizing tendencies
(focused on dire consequences
of various symptoms and
obtaining more diagnostic
testing)

19. Clinical Presentation – MSE– IAD
 Cognitive function
 Attentive; Oriented fully to time,
place, and person; No difficulties
with concentration, memory, and
other faculties
 Interestingly, may have selective
attention (eg, the patient is
distressed by an ongoing bodily
complaint but not by a newly
sprained ankle)

20. Clinical Presentation – MSE– IAD
 Insight
 Able to recognize bodily sensations
 Lack full understanding of underlying
psychological concerns
 They tends to see the "trees" rather than the
"forest"
 Judgment
 Capable of social greetings and other
behaviors
 Persistence in discussing and evaluating
continuing preoccupations (due to limited
insight)

21. Cause – IAD
 Neurochemical deficits – Recent
studies indicate an "obsessive-
compulsive spectrum" to
include hypochondriasis, obsessive-
compulsive disorder (OCD), body
dysmorphic disorder (BDD), anorexia
nervosa, and Tourette syndrome, all
of which were believed to have
similarities in
1. Responsiveness to serotonin
reuptake inhibitors
2. Demonstrate "hyperactivity" in
areas of the frontal lobes

22. NEUROTROPHIN 3
NT - 3
Cause – IAD
 In a study of biological markers,
decreased plasma
neurotrophin 3 (NT-3) levels
and platelet serotonin (5-HT)
levels, compared to healthy
control subjects
 NT-3 is a marker of neuronal
function and platelet 5-HT is a
surrogate marker for
serotonergic activity. PLATELET
SEROTONIN
5-HT

23. Cause – IAD
 Cognitive theory –
 Patients misinterpret bodily
symptoms by augmenting &
amplifying their somatic sensations
 Patients also appear to have lower-
than-usual thresholds for, and
tolerance of, physical discomfort
 For example, what most people
normally perceive as abdominal
pressure, patients with illness
anxiety experience as abdominal
pain

24. Cause – IAD
 Social learning theory –
 Proposes illness anxiety disorder
as a request for admission to the
sick role made by a person facing
seemingly insurmountable and
insolvable problems
 This role may allow them to
avoid noxious obligations,
postpone unwelcome
challenges, and be relieved from
duties and obligations

25. Cause – IAD
 Psychodynamic theory –
 Implies that aggressive and
hostile wishes toward others are
transferred via repression and
displacement into physical
complaints
 The somatic symptoms serve to
"undo" guilt felt about the anger
and serve as a punishment for
being "bad."

26. Differential Diagnosis – IAD
1. Physical & neurological illness
2. Anxiety Disorders
3. Body Dysmorphic Disorder
4. Conversion Disorders
5. Delusional Disorder
6. Depression
7. Personality Disorders
8. Schizophrenia
9. Somatic Symptom Disorders

27. Treatment & Management – IAD
 Establish a firm therapeutic alliance with the
patient.
 Educate the patient regarding the
manifestations of hypochondriasis.
 Offer consistent reassurance.
 Optimize the patient's ability to cope with the
symptoms, rather than trying to eliminate the
symptoms
 Avoid performing high-risk, low-yield invasive
procedures
 Close collaboration among all clinician to
prevent investigative duplication

28. Treatment & Management – IAD
 Exercise increases
psychological well-
being
 Patients are mostly
reluctant to follow
this advice
 Exercise helps to
improve mood,
reduce tension, and
improve sleep in
patients with
associated
depression, anxiety,
or both

29. Treatment & Management – IAD
 RCT indicates that
cognitive-behavioral
therapy (CBT) is
efficacious in the
treatment of
hypochondriasis
 In clinical settings, both
the availability of CBT
and treatment
adherence of patients
with hypochondriasis to
psychotherapy in general
are major barriers to
successful outcomes
1. Identify &
challenge illness
related
misinterpretation
of bodily
sensation
2. Show the patient
how the symptom
can be created by
sensate focusing
3. Reassurance &
education
regarding the
source of
symptom & its
potential for harm

30. Treatment & Management – IAD
 Pharmacotherapy
is used as an
adjunct to
psychotherapy and
educational
treatments.
 There are no
medications
approved
specifically for the
treatment of
hypochondriasis

31. Treatment & Management – IAD
 SSRI – These are typically used for depression or
anxiety comorbid with hypochondriasis, although in
some cases they alleviate hypochondriacal symptoms
 Beta-adrenergic receptor-blocking agents – Are used
to relieves symptom of autonomic arousal
 Benzodiazepines – Indicated for treatment of anxiety
disorders and panic attacks, with or without
agoraphobia, which are commonly comorbid with
hypochondriasis. Use with caution because patients
with hypochondriasis may have increased risk of
substance abuse or dependence
 Antipsychotic – Have been shown to reduce morbidity
associated with this disorder, particularly in presence
of comorbid anxiety or hypochondriacal worries that
mimic obsessions or delusions