Clinical Psychiatry

Hypochondriasis

ICD-10F45.2Hypochondriacal disorder
DSM-5-TRF45.21Illness Anxiety Disorder

1. Definition and nosology

Hypochondriasis (ICD-11: 6B23; DSM-5-TR: F45.21 Illness Anxiety Disorder — new name, separated from somatic symptom disorder) — persistent preoccupation and anxiety about having or developing a serious medical illness. The patient either checks repeatedly — clinic visits, internet searches, advice from friends — or, conversely, avoids medical care altogether.

DSM-5 (2013) — hypochondriasis diagnosis split into two new categories:

  • Somatic Symptom Disorder (F45.1) — somatic complaints present;
  • Illness Anxiety Disorder (F45.21) — somatic symptoms minimal or absent, anxiety dominant.

ICD-11 (2019) — hypochondriasis included within the OCD spectrum (separated from somatoform disorders) — this conceptual transition reflects the evidence base (shared neurobiology and treatment response similar to OCD).

2. History

  • Greek medicine — “hypochondrium” (below the ribs) — ancient humoral theory.
  • DSM-III (1980) — In the category of somatoform disorders.
  • DSM-5 (2013) — separation of illness anxiety disorder and somatic symptom disorder.
  • ICD-11 (2019) — transition to the spectrum category of OCD.

3. Epidemiology

  • Lifetime prevalence: 1–6% (Bleichhardt G., Hiller W. Br J Health Psychol 2007).
  • In primary care patients: ~3–10%.
  • Sex: approximately equal.
  • Onset: early to middle adulthood.
  • Comorbidity: MDD, GAD, OCD, panic disorder.

4. Etiology and pathogenesis

  • Genetic overlap with OCD and anxiety disorders.
  • Experience with childhood trauma or medical illnesses.
  • Cognitive — catastrophizing of bodily sensations; selective attention; “medical information seeking” (cyberchondria).
  • Modeling — high familial vulnerability to illness.

5. Clinical features

  • Fear of developing a serious illness (cancer, heart attack, various chronic diseases).
  • Interpretation of normal bodily sensations (palpitations, headache, sluggish bowel) as markers of serious illness.
  • Behavioral models (two polar opposites):
    • Care-seeking — repeated medical check-ups, multiple doctor consultations (‘doctor shopping’), internet searches (cyberchondria), body checks.
    • Care-avoiding — avoidance of medical check-ups (fear of hearing bad news), avoidance of hospitals, medical equipment.
  • Medical reassurance provides temporary relief, then anxiety returns.
  • Functional impairment — absenteeism from work, social isolation.

6. Diagnosis

6.1 Unified diagnostic criteria

A. Preoccupation with having or developing a serious illness.

B. Somatic symptoms minimal or absent; if present, preoccupation disproportionate to severity.

C. High anxiety about health.

D. The patient exhibits excessive health behavior (checking) or maladaptive avoidance.

E. Duration ≥ 6 months (DSM-5-TR); typical content of the illness may change over time.

F. Not better explained by another mental disorder (MDD, panic, GAD, OCD, BDD, somatic delusions).

6.2 Differences between sources

  • DSM-5-TR — Illness Anxiety Disorder (F45.21); care-seeking and care-avoiding subtypes.
  • ICD-11 — within the OCD spectrum category (6B23); new placement distinct from classic somatoform location.

6.3 Diagnostic algorithm

  1. Clinical interview.
  2. Medical evaluation — exclusion of genuine illness (however excessive testing should be avoided).
  3. Scale — Whiteley Index, SHAI (Short Health Anxiety Inventory).
  4. Comorbidity screening.

6.4 Differential diagnosis

Condition Distinguishing feature
Bodily distress disorder (6C20) Somatic complaints dominant.
Real medical illness Clinical and laboratory confirmation.
OCD (6B20) Multiple obsessions; illness not restricted.
GAD (6B00) Multiple areas of worry.
Panic (6B01) Fear of ‘heart attack’ during an attack.
Delusional disorder (6A24) — somatic Insight absent.
Major depressive disorder — somatic focus Affective component predominates.

7. Examination and assessment

  • Whiteley Index (14 items), SHAI.
  • Medical examination — once complete, not repeated.
  • PHQ-9, GAD-7 comorbidity.

8. Treatment

  1. CBT first-line — cognitive restructuring (catastrophizing), prevention of body checking and reassurance seeking (exposure + ritual prevention), attention training. Effect: Cooper K. et al. Behav Cogn Psychother 2017 meta-analysis.
  2. SSRIs — for moderate-to-severe cases or comorbid depression/GAD.
  3. Single physician model (single physician) — patient works only with one primary care physician; avoids multiple checks and “doctor shopping”.
  4. Reassurance limit — clinician does not provide excessive proof in response to anxiety; short, consistent message.
  5. Mindfulness-based approach adjunct.

8.1 Treatment methods

  1. CBT for hypochondriasis — Salkovskis P., Warwick H. — Cognitive model — “catastrophization” of bodily sensations central. Intervention: psychoeducation, exploration of alternative explanations, behavioral experiments of body checking and reassurance seeking, exposure. 12–16 sessions.
  2. Whiteley Index — 14-item Illness Concern Scale — widely used validated screening scale.
  3. Short Health Anxiety Inventory (SHAI) — Salkovskis — 18 items; clinical and population research.
  4. Single Physician Model (single physician approach) — The patient works only with one physician; all complaints are managed via that physician; multiple checks and contradictory opinions are prevented.

8.2 Differences between sources

  • Cooper K. et al. Behav Cogn Psychother 2017 meta-analysis — CBT significant effect; medium effect size.
  • Greeven A. et al. Am J Psychiatry 2007 RCT — CBT and paroxetine both superior to placebo.

9. Prognosis

  • CBT or SSRIs result in significant improvement in most patients.
  • Chronic without treatment; persistent use of medical resources.

10. Myths and misconceptions

Myth 1: “The patient is ‘faking’ illness, playing games”

Evidence: hypochondriasis is a clinical psychiatric disorder; patient’s concern is genuine; not ‘play’ or simulation. Differs from factitious disorder (6D50).

Myth 2: “The more medical tests performed, the more the patient will be reassured”

Evidence: repeated checking gives short-term relief, then anxiety returns; ‘checking dependency’ develops. Single clinician model and check restriction recommended.

Myth 3: “Reassurance (‘you are healthy’) is a treatment tool”

Evidence: repeated reassurance reinforces disorder — patient continues seeking proof. Structured clinician response: one-time assessment, then brief standard message.

Myth 4: “Internet search helps the patient’s self-education”

Evidence: “Cyberchondria” — internet searches increase anxiety, enhance catastrophizing; limitation or structuring recommended.

Myth 5: “Hypochondriasis only occurs in elderly patients”

Evidence: onset early-middle adulthood; age range wide.

Myth 6: “Only antidepressants are effective; therapy is useless”

Evidence: Greeven 2007 — CBT and paroxetine both superior to placebo; CBT first-line (long-term effect comparable to SSRIs).

11. Sources

  1. WHO. ICD-11. 6B23 Hypochondriasis. 2024.
  2. APA. DSM-5-TR. 2022.
  3. Cooper K. et al. Cognitive behavior therapy for health anxiety: a systematic review and meta-analysis. Behav Cogn Psychother 2017;45(2):110–123.
  4. Greeven A. et al. Cognitive behavior therapy and paroxetine in the treatment of hypochondriasis: a randomized controlled trial. Am J Psychiatry 2007;164(1):91–99.
  5. Salkovskis P.M., Rimes K.A., Warwick H.M. The Health Anxiety Inventory: development and validation of scales for the measurement of health anxiety and hypochondriasis. Psychol Med 2002;32(5):843–853.
  6. Bleichhardt G., Hiller W. Hypochondriasis and health anxiety in the German population. Br J Health Psychol 2007;12(Pt 4):511–523.