We frequently receive patients whose main reason for consultation is fear of illness. In some cases, the person believes that they suffer from an illness today, other times they are more worried about suffering from it in the future. In any case, the person suffers severe anxiety, worry and carries out a whole set of avoidance behaviors to relieve themselves. In current scientific literature, this phenomenon is known as health anxiety.
Historically, the term has been used hypochondria either hypochondriasis to describe people who, under normal health conditions, believed they were sick or greatly feared illness. Thus, for example, in the DSM-IV the central diagnostic criterion was “the worry and fear of suffering from, or the conviction of having, a serious illness based on the inadequate interpretation of bodily symptoms.”
Concern persists despite that the corresponding medical tests do not find any evidence of organic pathological processes, which has earned these people the nickname of “imaginary patients” and has led them to be frequently considered a nuisance by doctors and other health professionals. Some of these people also generate a certain social discomfort among their families and friends since, when they are sick, they usually require certain care and special treatment that others are not willing to grant because they consider them healthy people. And, finally, until a few decades ago, psychological interventions had been a failure in treating their concerns and fears, which was why they were seen as incurable and even untreatable by any tool of the health system. Thus, the term hypochondriac ended up acquiring a somewhat pejorative meaning in many environments, a stigma of someone who is not only emotionally disturbed, but also represents a burden on the health system and those close to him.
The consolidation of the cognitive behavioral paradigm during the 1980s, in line with the rise of neuroscience and pharmacological interventions, provided new and valuable treatment tools for this pathology. The effectiveness of the treatments grew considerably, reaching levels similar to those of anxiety disorders such as panic disorder or obsessive-compulsive disorder. In fact, both the general explanatory theoretical framework and the psychological and pharmacological intervention procedures do not differ much between these mentioned disorders, so the remission rates should not be very different either.
Research within the field developed strongly and disseminated towards the most specific aspects of the phenomenon, such as the role of avoidance behaviors, the relationship between the doctor and the patient and the impact that the Internet has had on this pathology. This last topic is of particular relevance when considering that avoidance and escape behaviors in hypochondria frequently take the form of “information seeking”, consequently, they can be easily executed by searching for information on the web.
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Hypochondria or hypochondriasis in the DSM-V no longer exists
Some authors consider that the ease of access to medical information to which we have been exposed in recent years has led to an increase in the psychological disorder in question, even creating a new study entity called cyberchondria. Although it is not a diagnosis in the full sense, cyberchondria describes a very characteristic set of behaviors, thoughts and emotions. Thus, those who suffer from cyberchondria carry out excessive searches for health information on the Internet, which, far from reassuring them, leads them to greater worry and anxiety that they try to alleviate with more searches, thus establishing a vicious circle typical of pathological anxiety. We insist, perhaps cyberchondria is not and will never be a formal diagnosis, but it surely constitutes a particularly important aspect of “health anxiety disorder,” as it presents itself in the age of information at the reach of a finger. .
The appearance of the DSM-V in 2013 has greatly changed the diagnostic nomenclature historically used in the field. Intending to echo the aforementioned fact that the word hypochondriac has acquired a pejorative meaning, he preferred to discard it; That is, hypochondria or hypochondriasis in the DSM-V no longer exists. Instead, the new version of the manual proposes a division of the old diagnosis into two new categories:
- He somatic symptom disorder characterized by the presence of one or more somatic symptoms that cause discomfort and result in excessive thoughts, feelings, and behaviors related to health. There is a high amount of anxiety about health or symptoms as well as too much time and/or energy devoted to them.
- He illness anxiety disorder whose central feature is the concern about suffering or contracting a serious illness in the absence of somatic symptoms. The picture is completed with high health anxiety and excessive health-related behaviors.
As can be easily deduced, the most critical element that differentiates the aforementioned disorders lies in the presence/absence of somatic symptoms, since the components of exaggerated anxiety and its related behaviors are present in both.
The DSM-V proposes that patients previously diagnosed with hypochondria will now be distributed between the two aforementioned diagnoses. Thus it is proposed (very arbitrarily for many) that, of those previously labeled as hypochondriacs, 75% will receive the new diagnosis of somatic symptom disorder and 25%, that of anxiety about the illness.
No one knows yet what the real long-term impact of the new terminology proposed by the DSM is, although a simple and quick reading of the literature easily suggests that the change does not receive the blessings of the main researchers and representative authors of the field. Rather, the new terms seem to have confused a diagnostic tradition that has been collecting information for many years, which must now be reinterpreted in light of the new vocabulary.
Health anxiety in cognitive behavioral treatment
Although we never doubt the usefulness of a diagnostic manual like the DSM, the behavioral tradition has repeatedly criticized its overuse and, particularly, the reification of psychopathological terms. This last criticism becomes especially important when nosological categories are redefined with few studies of construct validity, as perhaps happens with the two new proposals to replace hypochondria. Beyond this, no psychiatric diagnosis, whatever it may be, replaces the value of functional analysis in cognitive behavioral treatment, and we will have to address this during the ongoing evaluation we make of the patient who suffers from health anxiety.
Thus, and by virtue of the prevailing diagnostic confusion, the current field of the problem is conceptualized as health anxiety, an expression used to encompass a set of psychopathological phenomena characterized by fear, anxiety, anguish and excessive worry about issues related to one’s own health or that of loved ones. Such emotional reactions occur in different ways in people and in different types of situations and stimuli.
In this way, very frequently individuals will experience anxiety about their own bodily sensations; But there will be others who react with emotional discomfort to news of sick people or to mere exposure to medical information. High negative emotionality invariably leads to maladaptive attempts at relief, which will lead to greater discomfort in the long term; leaving the individual trapped in a vicious spiral of worry, anxiety and avoidance behaviors. The picture can be completed with fear of death, suffering or medical procedures.
The conceptualization of cognitive behavioral therapy regarding health anxiety is similar to that of any other anxiety disorder, in fact, for many it is simply an anxiety disorder. Let’s see it with an example:
Marta consults because according to her sayings “she lives worried about her health”, fears getting sick or already being sick and not knowing it. Although she recognizes that her fear is excessive and irrational she cannot help but think every day that she may have cancer or some other serious illness. In this way, minor and everyday physical sensations or discomforts, such as a headache or excessive itching, are interpreted by her as “signs of a brain tumor or skin cancer”. In order to calm down, Marta consults very frequently with doctors from different specialties and tries not to listen to the stories of other people who got sick because that quickly triggers her fear. In this way, she only listens to what the few doctors she trusts and her husband, whom she frequently consults about the normality of certain sensations, tell her. So, for example, she asks him: “Today my eyes stung a little, I was in the kitchen… what do you think? Could it be conjunctivitis or maybe the heat and fumes from what I was cooking?” To make sure of her, she asks the same thing several times. Marta suffers from a health anxiety disorder.
The problem behavior is constituted by the frequent, intense and disproportionate reaction of fear and anxiety, which on a cognitive level manifests itself with ideas such as “what if I have cancer?” The antecedents of such behaviors are normal physical sensations or discomforts that she overinterprets and catastrophizes; hearing stories of other people who got sick or simply hearing medical information. Reinsurance behaviors consist of excessively visiting some specific doctors and repeatedly asking the husband. This calms her momentarily but in the long term it maintains the problem.
For those engaged in cognitive behavioral therapy, the example narrated above is clearly understood as a brief beginning of a functional analysis, from which we will derive the treatment program. It is not clear whether Marta qualifies as having a “somatic symptom disorder” or an “illness anxiety disorder”; but, in truth, for the practical purposes of treatment this does not matter too much. What does matter is that the psychologist carries out the appropriate functional analysis and clinical formulation of the case and from there conducts the corresponding treatment, based on empirically based knowledge of psychology.
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