The Astonishing Hell of Health Anxiety and Hypochondriasis

Health Anxiety?

We’ve all probably felt ill or fallen to a cold or flu in our life at some point. If we get sick, we’ll probably be inconvenienced and upset, and maybe we’d pick up a behind the counter med or get a doctors appointment. At its worse, we’ll probably go to a doctor, get a prescribed medication, take off work and allow ourselves to get better. Generally speaking, we’ll be fine, but someone struggling with a health anxiety disorder may think and feel a little differently about it. It’s not just a cold or flu, it’s anything; any mild irritation, sign, or symptom will turn into something far worse. If you’re struggling with a somatoform disorder (hypochondriasis or conversion disorder), OCD or generalized anxiety, you’re going to have an entire mess on your hands, figuratively speaking.

OCD is also very well known to be a contributing factor to symptoms of pain and misconstrued anxiety. Those struggling with certain kinds of OCD can struggle with pain without cause; this can cause further paranoia and concern. Not only doe OCD cause pain, it causes further distress in reaction to the pain.

Dealing with health anxiety — no matter the cause — you’re going to be going through a hell only few can understand. Health anxiety disorders are few and far between, and so aren’t there sufferers: the struggle is certainly real. If you want to avoid getting the disorder, you’re generally in luck, but stressors, even later in life, can cause this. Nature and nurture do have a role in this as well, but a major stress event can cause this, even if you don’t have a history of mental illness, family or upbringing. The best thing you can do is be mentally strong — being vigilant in not allowing stress to have control.

Body dsymorphic disorder is another mental disorder that used to be considered a somatoform disorder. Body dysmorphia is classified as an OCD related illness. People struggling with BDD are preoccupied with a perceived defect in their appearance to the point of obsession.

With Covid-19 literally floating around, it doesn’t help most people anyway, but imagine the pain of someone with health anxiety. Those struggling with disorders such as the ones listed below, a pandemic will give them an excuse to stay inside. If they can’t, the stress caused can contribute to even more problems, considering a lock-down doesn’t necessarily make anything better. The anxiety that comes with this cannot be controlled, considering how pervasive it can become. A coronavirus or not, the struggles seem all too familiar to those struggling with a mental disorder such as these. With all of this, I’m going to describe below the several different disorders related to health anxiety.

Depression can also play a role in pain without a cause.

A somatic symptom disorder, formerly known as a somatoform disorder, is any mental disorder that manifests as physical symptoms that suggest illness or injury, but cannot be explained fully by a general medical condition or by the direct effect of a substance, and are not attributable to another mental disorder (e.g., panic disorders). Somatic symptom disorders, as a group, are included in a number of diagnostic schemes of mental illness, including the Diagnostic and Statistical Manual of Mental Disorders.

Somatic symptom disorder has been a controversial diagnosis, since it was historically based primarily on negative criteria – that is, the absence of a medical explanation for the presenting physical complaints. Consequently, any person suffering from a poorly understood illness can potentially fulfill the criteria for this psychiatric diagnosis, even if they exhibit no psychiatric symptoms in the conventional sense. In 2013–14, there were several widely publicized cases of individuals being involuntarily admitted to psychiatric wards on the basis of this diagnosis alone. This has raised concerns about the consequences of potential misuse of this diagnostic category. (Health Anxiety)

In people who have been diagnosed with a somatic symptom disorder, medical test results are either normal or do not explain the person’s symptoms, and history and physical examination do not indicate the presence of a known medical condition that could cause them, though the DSM-5 cautions that this alone is not sufficient for diagnosis. The patient must also be excessively worried about their symptoms, and this worry must be judged to be out of proportion to the severity of the physical complaints themselves. A diagnosis of somatic symptom disorder requires that the subject have recurring somatic complaints for at least six months.

There is anecdotal evidence that it is common for serious illnesses or deaths of family members or friends to trigger hypochondria in certain individuals. Similarly, when approaching the age of a parent’s premature death from disease, many otherwise healthy, happy individuals fall prey to hypochondria. These individuals believe they are suffering from the same disease that caused their parent’s death, sometimes causing panic attacks with corresponding symptoms. (Health Anxiety)

Approximately 20 randomized controlled trials and numerous observational studies indicate that cognitive behavioral therapy (CBT) is an effective treatment for hypochondriasis. Typically, about two-thirds of patients respond to treatment, and about 50% of patients achieve remission, i.e., no longer suffer from hypochondriasis after treatment. CBT for hypochondriasis and health anxiety may be offered in various formats, including as face-to-face individual or group therapy, via telephone, or as guided self-help with information conveyed via a self-help book or online treatment platform. Effects are typically sustained over time. (Health Anxiety)

Symptoms are sometimes similar to those of other illnesses and may last for years. Usually, the symptoms begin appearing during adolescence, and patients are diagnosed before the age of 30 years. Symptoms may occur across cultures and gender. Other common symptoms include anxiety and depression. However, since anxiety and depression are also very common in persons with confirmed medical illnesses, it remains unproven whether such symptoms are a consequence of the physical impairment or a cause.

The genetic contribution to hypochondriasis is probably moderate, with heritability estimates around 10-37%. Non-shared environmental factors (i.e., experiences that differ between twins in the same family) explain most of the variance in key components of the condition such as the fear of illness and disease conviction. In contrast, the contribution of shared environmental factors (i.e., experiences shared by twins in the same family) to hypochondriasis is approximately zero. (Health Anxiety)

Somatic symptom disorders are not the result of conscious malingering (fabricating or exaggerating symptoms for secondary motives) or facticious disorders (deliberately producing, feigning, or exaggerating symptoms). Somatic symptom disorder is difficult to diagnose and treat. Some advocates of the diagnosis believe this is because proper diagnosis and treatment requires psychiatrists to work with neurologists on patients with this disorder.

Other people are so afraid of any reminder of illness that they will avoid medical professionals for a seemingly minor problem, sometimes to the point of becoming neglectful of their health when a serious condition may exist and go undiagnosed. Yet others live in despair and depression, certain that they have a life-threatening disease and no physician can help them. Some consider the disease as a punishment for past misdeeds. (Health Anxiety)

Hypochondriasis or hypochondria is a condition in which a person is excessively and unduly worried about having a serious illness. An old concept, the meaning of hypochondria has repeatedly changed. It has been claimed that this debilitating condition results from an inaccurate perception of the condition of body or mind despite the absence of an actual medical diagnosis. An individual with hypochondriasis is known as a hypochondriac. Hypochondriacs become unduly alarmed about any physical or psychological symptoms they detect no matter how minor the symptom may be, and are convinced that they have, or are about to be diagnosed with, a serious illness.

Hypochondriasis is categorized as a somatic amplification disorder—a disorder of “perception and cognition” — that involves a hyper-vigilance of situation of the body or mind and a tendency to react to the initial perceptions in a negative manner that is further debilitating. Hypochondriasis manifests in many ways. Some people have numerous intrusive thoughts and physical sensations that push them to check with family, friends, and physicians. For example, a person who has a minor cough may think that they have tuberculosis. Sounds produced by organs in the body, such as those made by the intestines, might be seen as a sign of a very serious illness to patients dealing with hypochondriasis.

Oftentimes, hypochondria persists even after a physician has evaluated a person. A doctor may have reassured them that their concerns about symptoms do not have an underlying medical basis. If there is a medical illness, their concerns are far in excess of what is appropriate for the level of disease. It is also referred to hypochondriaism which is the act of being in an hypochondriatic state: acute hypochondriaism. Many hypochondriacs focus on a particular symptom as the catalyst of their worrying, such as gastro-intestinal problems, palpitations, or muscle fatigue. To qualify for the diagnosis of hypochondria the symptoms must have been experienced for at least 6 months.

Hypochondriasis is often accompanied by other psychological disorders. Bipolar disorder, clinical depression, obsessive-compulsive disorder (OCD), phobias, and somatization disorder are the most common accompanying conditions in people with hypochondriasis, as well as a generalized anxiety disorder diagnosis at some point in their life.

Hypochondria is often characterized by fears that minor bodily or mental symptoms may indicate a serious illness, constant self-examination and self-diagnosis, and a preoccupation with one’s body. Many individuals with hypochondriasis express doubt and disbelief in the doctors’ diagnosis, and report that doctors’ reassurance about an absence of a serious medical condition is unconvincing, or short-lasting. Additionally, many hypochondriacs experience elevated blood pressure, stress, and anxiety in the presence of doctors or while occupying a medical facility, a condition known as “white coat syndrome.”

Other people are so afraid of any reminder of illness that they will avoid medical professionals for a seemingly minor problem, sometimes to the point of becoming neglectful of their health when a serious condition may exist and go undiagnosed. Yet others live in despair and depression, certain that they have a life-threatening disease and no physician can help them. Some consider the disease as a punishment for past misdeeds.

Many hypochondriacs require constant reassurance, either from doctors, family, or friends, and the disorder can become a debilitating challenge for the individual with hypochondriasis, as well as their family and friends. Some hypochondriacal individuals completely avoid any reminder of illness, whereas others frequently visit medical facilities, sometimes obsessively. Some sufferers may never speak about it. The DSM-IV-TR defined this disorder, “Hypochondriasis”, as a somatoform disorder and one study has shown it to affect about 3% of the visitors to primary care settings. The 2013 DSM-5 replaced the diagnosis of hypochondriasis with the diagnoses of somatic symptom disorder (75%) and illness anxiety disorder (25%).

Many people with hypochondriasis experience a cycle of intrusive thoughts followed by compulsive checking, which is very similar to the symptoms of obsessive-compulsive disorder. However, while people with hypochondriasis are afraid of having an illness, patients with OCD worry about getting an illness or of transmitting an illness to others. Although some people might have both, these are distinct conditions.

     Somatic symptom disorders used to be recognized as Somatoform disorders in the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association. The following were conditions under the term Somatoform Disorders:

• Conversion Disorder: A somatic symptom disorder involving the actual loss of bodily function such as blindness, paralysis, and numbness due to excessive anxiety
• Somatization Disorder
• Hypochondriasis
• Body Dysmorphic Disorder: wherein the afflicted individual is concerned with body image, and is manifested as excessive concern about and preoccupation with a perceived defect of their physical appearance.
• Pain Disorder
• Undifferentiated Somatic Symptom Disorder : only one unexplained symptom is required for at least six months.

Conversion symptoms typically do not conform to known anatomical pathways and physiological mechanisms. It has sometimes been stated that the presenting symptoms tend to reflect the patient’s own understanding of anatomy and that the less medical knowledge a person has, the more implausible are the presenting symptoms. However, no systematic studies have yet been performed to substantiate this statement.

Conversion disorder (CD), or functional neurologic symptom disorder, is a diagnostic category used in some psychiatric classification systems. It is sometimes applied to patients who present with neurological symptoms, such as numbness, blindness, paralysis, or fits, which are not consistent with a well-established organic cause, which cause significant distress, and can be traced back to a psychological trigger.

Empirical studies have found that the prognosis for conversion disorder varies widely, with some cases resolving in weeks, and others enduring for years or decades. There is also evidence that there is no cure for conversion disorder, and that although patients may go into remission they can relapse at any point. Furthermore, many patients can get rid of their symptoms with time, treatments and reassurance.

It is thought that these symptoms arise in response to stressful situations affecting a patient’s mental health or an ongoing mental health condition such as depression. Conversion disorder was retained in DSM-5, but given the subtitle functional neurological symptom disorder. The new criteria cover the same range of symptoms, but remove the requirements for a psychological stressor to be present and for feigning to be disproved. ICD-10 classifies conversion disorder as a dissociative disorder while DSM-IV classifies it as a somatoform disorder.

A factitious disorder is a condition in which a person, without a malingering motive, acts as if they have an illness by deliberately producing, feigning, or exaggerating symptoms, purely to attain (for themselves or for another) a patient’s role. People with a factitious disorder may produce symptoms by contaminating urine samples, taking hallucinogens, injecting fecal material to produce abscesses, and similar behavior.

Conversion disorder begins with some stressor, trauma, or psychological distress. Usually the physical symptoms of the syndrome affect the senses or movement. Common symptoms include blindness, partial or total paralysis, inability to speak, deafness, numbness, difficulty swallowing, incontinence, balance problems, seizures, tremors, and difficulty walking. These symptoms are attributed to conversion disorder when a medical explanation for the afflictions cannot be found. Symptoms of conversion disorder usually occur suddenly. Conversion disorder is typically seen in individuals aged 10 to 35, and affects between 0.011% and 0.5% of the general population.

Factitious disorder imposed on self (also called Munchausen syndrome) was for some time the umbrella term for all such disorders. Factitious disorder imposed on another (also called Munchausen syndrome by proxy, Munchausen by proxy, or factitious disorder by proxy) is a condition in which a person deliberately produces, feigns, or exaggerates the symptoms of someone in their care. In either case, the perpetrator’s motive is to perpetrate factitious disorders, either as a patient or by proxy as a caregiver, in order to attain (for themselves or for another) a patient’s role.

Conversion symptoms typically do not conform to known anatomical pathways and physiological mechanisms. It has sometimes been stated that the presenting symptoms tend to reflect the patient’s own understanding of anatomy and that the less medical knowledge a person has, the more implausible are the presenting symptoms. However, no systematic studies have yet been performed to substantiate this statement.

Malingering differs fundamentally from factitious disorders in that the malingerer simulates illness intending to obtain a material benefit or avoid an obligation or responsibility. Somatic symptom disorders, though also diagnoses of exclusion, are characterized by physical complaints that are not produced intentionally.

Pain disorder is chronic pain experienced by a patient in one or more areas, and is thought to be caused by psychological stress. The pain is often so severe that it disables the patient from proper functioning. Duration may be as short as a few days or as long as many years. The disorder may begin at any age, and occurs more frequently in girls than boys. This disorder often occurs after an accident, during an illness that has caused pain, or after withdrawing from use during drug addiction, which then takes on a ‘life’ of its own.

Factitious disorder should be distinguished from somatic symptom disorder (formerly called somatization disorder), in which the patient is truly experiencing the symptoms and has no intention to deceive. In conversion disorder (previously called hysteria), a neurological deficit appears with no organic cause. The patient, again, is truly experiencing the symptoms and signs and has no intention to deceive. The differential also includes body dysmorphic disorder and pain disorder.

Common symptoms of pain disorder are: negative or distorted cognition, such as feelings of despair or hopelessness; inactivity and passivity, in some cases disability; increased pain, sometimes requiring clinical treatment; sleep disturbance and fatigue; disruption of social relationships; depression and anxiety. Acute conditions last less than six months while chronic pain disorder lasts six or more months. There is no neurological or physiological basis for the pain. Pain is reported as more distressing than it should be had there been a physical explanation.

Malingering is the fabrication, feigning, or exaggeration of physical or psychological symptoms designed to achieve a desired outcome, such as relief from duty or work. Malingering is not a medical diagnosis, but may be recorded as a “focus of clinical attention” or a “reason for contact with health services”. Malingering is categorized as distinct from other forms of excessive illness behavior such as somatization disorder and factitious disorder, although not all mental health professionals agree with this formulation.

Pain behavior highlights the psychological aspect of pain disorder. This can be demonstrated how moderate pain symptoms become more painful when rewarded in the form of solicitous and attentive behavior of others, by monetary gain, or by the successful avoidance of distasteful activities. The same can be said about excessive worry. A minor physical symptom can be aggravated or become more harmful and threatening if the person suffering engages in a constant body and symptom appraisal, which can lead to stress and maladaptive behavior when coping with the physical symptom.

There are several theories regarding the causes of pain disorder.

• Psychodynamic theory: unconscious conflicts or desires are converted into somatic symptom to protect the person from conscious awareness of it
• Emotions and communication: children show distress in what may be the only way they can, physical symptoms, when they lack the ability to speak or express their thoughts in any way
• Social influences: where psychological disorders are frowned upon, whether in families or cultures, distress may be expressed in physical terms
• Learning theory: children learn to imitate a family member or pick up on possible gains of being “sick”
• Family systems theory: a child’s role in a family may be the sick one as part of the family dynamics. Reasons why fall under four possibilities: enmeshment, overprotection, rigidity or lack of conflict resolution
• Trauma and abuse: this includes physical, psychological, or both combined with somatization. It is a common combination. People who have a history of physical or sexual abuse are more likely to have this disorder. However, not every person with pain disorder has a history of abuse. Early intervention when pain first occurs or begins to become chronic offers the best opportunity for prevention of pain disorder.

The prognosis is worse when there are more areas of pain reported. Treatment may include psychotherapy (with cognitive-behavioral therapy or operant conditioning), medication (often with antidepressants but also with pain medications), and sleep therapy.

The DSM-IV-TR specifies three coded subdiagnoses: pain disorder associated with psychological factors, pain disorder associated with both psychological factors and a general medical condition and pain disorder associated with a general medical condition (although the latter subtype is not considered a mental disorder and is coded separately within the DSM-IV-TR). Conditions such as dyspareunia, somatization disorder, conversion disorder, or mood disorders can eliminate pain disorder as a diagnosis. Diagnosis depends on the ability of physicians to explain the symptoms and on psychological influences.

Ethnicities show differences in how they express their discomfort and on how acceptable shows of pain and its tolerance are. Most obvious in adolescence, females suffer from this disorder more than males, and females reach out more. More unexplainable pains occur as people get older. Typically, younger children complain of only one symptom, commonly abdominal pains or headaches. The older they get, the more varied the pain location as well as more locations and increasing frequency.

There are, however, authors who propose that the diagnosis for unexplained pain should be adjustment disorder because it does not pathologize individuals with this medical condition. This is proposed to avoid the stigma of such illness classification.

Before treating a patient, a psychologist must learn as many facts as possible about the patient and the situation. A history of physical symptoms and a psychosocial history help narrow down possible correlations and causes. Psychosocial history covers the family history of disorders and worries about illnesses, chronically ill parents, stress and negative life events, problems with family functioning, and school difficulties (academic and social). These indicators may reveal whether there is a connection between stress-inducing events and an onset or increase in pain, and the removal in one leading to the removal in the other.

In the newest version of DSM-5 (2013) somatic symptom disorders are recognized under the term somatic symptom and related disorders:

wikipedia

• Somatic symptom disorder: Will take over many of what was formerly known as somatization disorders and hypochondriasis (hyperchondiac)
  • Factitious disorder: Can be either imposed on oneself, or to someone else (formally known as facticious disorder by proxy).
  • Illness anxiety disorder: A somatic symptom disorder involving persistent and excessive worry about developing a serious illness. This disorder has recently gone under review and has been altered into three different classifications.
  • Somatoform disorder not otherwise specified (NOS)

The classification of hypochondriasis in relation to other psychiatric disorders has long been a topic of scholarly debate, and has differed widely between different diagnostic systems and influential publications. In the case of the DSM, the first and second versions listed hypochondriasis as a neurosis, whereas the third and fourth versions listed hypochondriasis as a somatoform disorder. The current version of the DSM (DSM-5) lists somatic symptom disorder (SSD) under the heading of “somatic symptom and related disorders”, and illness anxiety disorder (IAD) under both this heading and as an anxiety disorder. The ICD-10, like the third and fourth versions of the DSM, lists hypochondriasis as a somatoform disorder. The ICD-11, however, lists hypochondriasis under the heading of “obsessive-compulsive or related disorders”. There are also numerous influential scientific publications which have argued for other classifications of hypochondriasis. Notably, since the early 1990s, it has become increasingly common to regard hypochondriasis as an anxiety disorder, and to refer to the condition as “health anxiety” or “severe health anxiety”.

Additional Information on hypochondriasis (Health Anxiety)

The ICD-10 defines hypochondriasis as follows:A. Either one of the following:

• A persistent belief, of at least six months’ duration, of the presence of a minimum of two serious physical diseases (of which at least one must be specifically named by the patient).
• A persistent preoccupation with a presumed deformity or disfigurement (body dysmorphic disorder).

B. Preoccupation with the belief and the symptoms causes persistent distress or interference with personal functioning in daily living, and leads the patient to seek medical treatment or investigations (or equivalent help from local healers).

C. Persistent refusal to accept medical advice that there is no adequate physical cause for the symptoms or physical abnormality, except for short periods of up to a few weeks at a time immediately after or during medical investigations.

D. Most commonly used exclusion criteria: not occurring only during any of the schizophrenia and related disorders or any of the mood disorders.

Among the regions of the abdomen, the hypochondrium is the uppermost part. The word derives from the Greek term ὑποχόνδριος hypokhondrios, meaning “of the soft parts between the ribs and navel” from ὑπό hypo (“under”) and χόνδρος khondros, or cartilage (of the sternum). Hypochondria in Late Latin meant “the abdomen”.

Immanuel Kant discussed hypochondria in his 1798 book, Anthropology from a Pragmatic Point of View, like this:

The disease of the hypochondriac consists in this: that certain bodily sensations do not so much indicate a really existing disease in the body as rather merely excite apprehensions of its existence: and human nature is so constituted – a trait which the animal lacks – that it is able to strengthen or make permanent local impressions simply by paying attention to them, whereas an abstraction – whether produced on purpose or by other diverting occupations – lessens these impressions, or even effaces them altogether.

Immanuel Kant

The term hypochondriasis for a state of disease without real cause reflected the ancient belief that the viscera of the hypochondria were the seat of melancholy and sources of the vapor that caused morbid feelings. Until the early 18th century, the term referred to a “physical disease caused by imbalances in the region that was below your rib cage” (i.e., of the stomach or digestive system). For example, Robert Burton’s The Anatomy of Melancholy (1621) blamed it “for everything from ‘too much spittle’ to ‘rumbling in the guts'”.

The DSM-IV defines hypochondriasis according to the following criteria:

A. Preoccupation with fears of having, or the idea that one has, a serious disease based on the person’s misinterpretation of bodily symptoms.
B. The preoccupation persists despite appropriate medical evaluation and reassurance.
C. The belief in Criterion A is not of delusional intensity (as in Delusional Disorder, Somatic Type) and is not restricted to a circumscribed concern about appearance (as in Body Dysmorphic Disorder).
D. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
E. The duration of the disturbance is at least 6 months.
F. The preoccupation is not better accounted for by Generalized Anxiety Disorder, Obsessive-Compulsive Disorder, Panic Disorder, a Major Depressive Episode, Separation Anxiety, or another Somatoform Disorder.

In the fifth version of the DSM (DSM-5), most who met criteria for DSM-IV hypochondriasis instead meet criteria for a diagnosis of somatic symptom disorder (SSD) or illness anxiety disorder (IAD).

If a person is ill with a medical disease such as diabetes or arthritis, there will often be psychological consequences, such as depression. Some even report being suicidal. In the same way, someone with psychological issues such as depression or anxiety will sometimes experience physical manifestations of these affective fluctuations, often in the form of medically unexplained symptoms. Common symptoms include headaches; abdominal, back, joint, rectal, or urinary pain; nausea; fever and/or night sweats; itching; diarrhea; dizziness; or balance problems. Many people with hypochondriasis accompanied by medically unexplained symptoms feel they are not understood by their physicians, and are frustrated by their doctors’ repeated failure to provide symptom relief. (Health Anxiety)

More on hypochondriasis: my.clevelandclinic

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Godspeed!