CLINICAL APPLICATIONS

Illness Anxiety Disorder: Psychopathology,

Epidemiology, Clinical Characteristics, and Treatment
Timothy M. Scarella, MD, Robert J. Boland, MD, and Arthur J. Barsky, MD

ABSTRACT
Illness anxiety disorder is a primary disorder of anxiety about having or developing a serious illness. The core feature is the cycle of worry
and reassurance seeking regarding health, as opposed to a focus on relief of distress caused by somatic symptoms (as in Somatic Symptom
Disorder). Clinically significant health anxiety is common, with estimates ranging up to 13% in the general adult population. There are
evidence-based treatments, including psychopharmacology and cognitive behavioral therapy, that can significantly alleviate symptoms.
An understanding of the core psychopathology and clinical features of illness anxiety disorder is essential to fostering a working alliance
with patients with health anxiety, as is the maintenance of an empathic, curious, and nonjudgmental stance toward their anxiety. Collab-
oration between medical providers is essential to avoid the pitfalls of excess testing and medical treatment.
Key words: hypochondriasis, illness anxiety disorder, somatoform disorders.

CASE then sought help with her constant worry about her health, because
she realized that in this case, the anxiety and resulting avoidance

A woman in her 20s presented for treatment of anxiety. She de-

scribed herself as a “worrier,” although generalized worry
and anxious rumination did not significantly interfere with her life.
The primary focus of her worry was her health. When she was a
teenager, her cousin died suddenly in his 30s, presumably because
of an undiagnosed heart problem. She began to have nearly con-
stant fear that she had undiagnosed cardiac disease, a belief sup-
ported by frequent sensations of heart palpitations and light
headedness. Thorough and repeated medical evaluation did not re-
veal any medical disease.
As she grew older, concerns about the presence or develop-
ment of serious illness expanded to include fear that she had ap-
pendicitis (often based on mild, physiologic gastrointestinal
sensations) and diabetes (based on feeling tired and sore after ex-
ercise). She avoided going to the doctor out of fear of receiving
a serious diagnosis and because she was afraid to have her blood
pressure checked. Multiple worrisome bodily sensations led to ex-
tensive researching of conditions on the Internet and repeatedly
calling her parents for reassurance. Panic attacks were often pro-
voked in these situations of acute worry, and at times, she would
cancel social engagements and call out of work because of fear
of having a panic attack or that she was becoming seriously ill.
She reported that both her father and paternal grandfather
seemed to have worried excessively about their health. She was
unaware of any other family history of mental illness.
The immediate precipitant to her presentation was an episode
of lower abdominal/pelvic pain for which she delayed seeking
medical attention because of anxiety. When the pain became un-
bearable, she finally went to an emergency department where an
ovarian torsion requiring emergency surgery was diagnosed. She
almost resulted in serious medical consequences.
Nonessential details of this case have been omitted or altered to
protect the patient's confidentiality.
CLARIFICATION OF TERMS
In this article, “health anxiety” refers to individuals with an ele-
vated and clinically significant level of worry about health or the
presence of disease, regardless of the diagnostic criteria applied.
References to illness anxiety disorder (IAD), hypochondriasis
(HC), somatic symptom disorder (SSD), and somatization disorder
(SD) refer specifically to the diagnoses described in the fourth and
fifth editions of the DSM-IV and DSM-V (1,2).
CLINICAL DEFINITIONS
IAD is a primary disorder of elevated health anxiety involving in-
tense fear about the possibility of having or developing a serious
illness. Diagnosis of IAD in DSM-V requires preoccupation with
having or acquiring a serious illness, absence of somatic symp-
toms (or, if present, symptoms that are only mild in severity), a
high level of anxiety about health, proneness to alarm regarding
health status, and either excessive health-related behaviors or mal-
adaptive avoidance of medical settings (Table 1) (1).
CBT = cognitive behavioral therapy, HC = hypochondriasis,
IAD = illness anxiety disorder, ICD-10-CM = International Statisti-
cal Classification of Diseases and Related Health Problems, Tenth
Revision, Clinical Modification, OCD = obsessive-compulsive dis-
order, SD = somatization disorder, SSD = somatic symptom disor-
der, STPP = short-term psychodynamic psychotherapy

From the Department of Psychiatry (Scarella), Beth Israel Deaconess Medical Center; Harvard Medical School (Scarella, Boland, Barsky); and Depart-
ment of Psychiatry (Boland, Barsky), Brigham and Women's Hospital, Boston, Massachusetts.
Address correspondence to Timothy M. Scarella, MD, Department of Psychiatry, Beth Israel Deaconess Medical Center, E Campus, Rabb-2, Boston, MA
02215. E-mail: tscarell@bidmc.harvard.edu
Received for publication May 24, 2018; revision received November 26, 2018.
DOI: 10.1097/PSY.0000000000000691
Copyright © 2019 by the American Psychosomatic Society

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Copyright © 2019 by the American Psychosomatic Society. Unauthorized reproduction of this article is prohibited.

TABLE 1. DSM-V Criteria for Ilness Anxiety Disorder
Preoccupation with having or acquiring a serious illness.
Somatic symptoms are not present or are mild in intensity.
If a medical condition is present or there is high risk of developing
a medical condition, the preoccupation is clearly excessive
or disproportionate.
High level of anxiety about health/Patient easily alarmed about
personal health status
Excessive health-related behaviors or maladaptive avoidance of
medical settings
Illness worry present for at least 6 mo
Illness worry not better explained by another psychiatric conditions
Subtypes:
Care-seeking
Care-avoidant
The diagnostic criteria for IAD in DSM-V were developed as a
modification of those previously defined for HC. In parallel,
criteria for SSD were developed from those for SD (2). The IAD
criteria emphasize the relative absence of somatic symptoms and
prominence of worry and reassurance seeking in IAD, versus
bodily symptoms as a primary focus of distress in SSD (1). It is es-
timated that only 26% to 36% of individuals meeting DSM-IV
criteria for HC would now meet criteria for IAD and not SSD
and 56% to 74% would meet criteria for SSD and not IAD (3,4).
Review of existing literature must take into consideration that clin-
ical and descriptive characteristics of IAD are approximated by,
but not equivalent to, data reported for HC. In addition, many studies
have used dimensional rather than categorical definitions to identify
participants with clinically elevated levels of health anxiety.
The International Statistical Classification of Diseases and Re-
lated Health Problems, Tenth Revision, Clinical Modification
(ICD-10-CM) (5) entity hypochondriacal disorder differs slightly
from both HC and IAD. The primary characteristic remains a
persistent belief of the presence of physical illness, although
the belief is noted to be directly related to an underlying
symptom. The ICD-10-CM definition also includes preoccupation
with presumed “deformity or disfigurement,” a complaint included
in DSM-V as the separate condition body dysmorphic disorder.
Hypochondriacal disorder is included in the ICD-10-CM category
somatoform disorders (5).
PSYCHOPATHOLOGY
The syndrome of elevated health anxiety encompasses three domains.
The first is disease conviction: a belief that one has a serious illness
from which one cannot be dissuaded by explanations of the unlikeli-
hood of disease, lack of laboratory or physical examination findings
consistent with disease, or negative diagnostic testing. Second, there
is disease fear: the worry of developing serious illness, which leads
to heightened distress when presented with any suggestion of the pos-
sibility of illness. Finally, there is bodily preoccupation: a heightened
salience of physiologic functions, benign bodily sensations and
sources of discomfort, and physical limitations. These are subjected
to intense scrutiny with the goal of identifying the warning signs of
illness (6–9). A particular aversion to bodily sensations has been ob-
served in patients with elevated health anxiety, even in comparison
with those with SD/SSD (10).
Psychosomatic Medicine, V 81 • 398-407
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Illness Anxiety Disorder
The fear of sickness persists despite the absence of symptoms,
signs, positive test results, or a practitioner's agreement about
threat or presence of illness. When seeing a medical practitioner,
the patient seeks either reassurance that they do not have the feared
illness or confirmation that the illness is present and is unable to be
reassured that no illness exists. Insight into the pathologic nature of
the worry varies; some patients can acknowledge that their worry
is excessive yet feel helpless to control it, whereas others are un-
able to be dissuaded from their fear of being ill.
Maladaptive illness behaviors include repeated self-examination,
seeking reassurance from medical practitioners and social con-
tacts, and efforts to research conditions and symptoms. In the mod-
ern age, the maladaptive use of electronic resources as a specific
form of “checking” and reassurance seeking can be particularly
challenging. This phenomenon has been described in the literature
as “Cyberchondria” (11–13).
Individuals with health anxiety overestimate the likelihood of
serious medical conditions but tend to fear minor medical prob-
lems no more than the general population (14–17). They rate their
global health as poorer than others with similar burdens of known
medical illness (18). Illness is a specific fear, as opposed to
nonhealth-related threats of physical danger (14). Somatic symp-
toms are catastrophized, fewer somatic sensations are viewed as
being consistent with good health, and ambiguous bodily sensa-
tions are more likely to be attributed to disease (16,18).
In addition to disease conviction, disease fear, and bodily pre-
occupation, the presence of somatic symptoms is an important di-
mension to consider in individuals exhibiting a pattern of health
anxiety and increased illness-related behaviors. Elevated measures
of health anxiety and clinical diagnosis of IAD or HC are both cor-
related with elevated scores on indices of somatic symptom burden
(6,19), and DSM-IV criteria for HC specifically mention “misin-
terpretation of bodily symptoms” as a route of health anxiety in
HC (20), leading to diagnostic ambiguity between HC and SD. In-
dices of somatic symptom burden do not seem to be a reliable way
to differentiate between these two conditions (21).
In response to this ambiguity, presence and severity of somatic
symptoms were incorporated as a primary delineation between
IAD and SSD in DSM-V. Somatic symptoms are prominent in
SSD, and maladaptive behaviors, affects, and thought patterns
are focused on obtaining symptom relief, with relatively little con-
cern about the cause or significance of the symptom. This is in
contrast with IAD where behaviors, affects, and thoughts are fo-
cused on the significance, meaning, and cause of the symptoms
rather than on the physical discomfort itself. If symptoms are cited
as a source of worry in IAD, they are usually of mild severity or are
normal, physiologic sensations.
CLINICAL CHARACTERISTICS
The classic presentation of health anxiety involves frequent visits
to physicians to request diagnostic testing or seek reassurance
about a feared illness, but a substantial subset of patients with
IAD avoid physicians due to intense fear of confirming the diagno-
sis they fear.
Untreated HC/IAD and elevated health worry place a substan-
tial burden on the health care system. Elevated health anxiety is as-
sociated with greater total outpatient costs, greater laboratory and
procedure costs, higher numbers of office visits to primary care
399 June 2019
 CLINICAL APPLICATIONS
and specialist physicians, higher number of specialists seen, in-
creased inpatient medical hospitalizations, and increased presenta-
tions to emergency departments (18,22–26).
One might predict that a person with elevated health anxiety
would, because of intense health-checking behaviors and frequent
contact with healthcare providers, have better overall health than
the general population. However, several studies do not indicate
a positive association of health anxiety with the development or
outcome of medical illness (27), nor does health anxiety necessar-
ily lead to more positive health maintenance behaviors (28). These
may be due to a combination of avoidance of medical settings and
biased attention toward feared and unlikely medical outcomes as
opposed to appropriate health maintenance.
Limited longitudinal data suggest that presence of clinically
significant health anxiety does not correlate with the number of
medical diagnoses (6), nor has it been shown to independently pre-
dict the development of serious illness (29). Although one study
correlated health anxiety with risk of cardiovascular disease, once
presence of general anxiety and depression symptoms was ad-
justed for, there was no specific association between health anxiety
and cardiovascular disease (27). A longitudinal study of HC sug-
gested that development of serious medical illness was actually as-
sociated with remission of HC (28). The presence of clinically
significant health anxiety in response to actual medical illness or
a realistic probability of having one is not associated with develop-
ment of persistent HC (30). Among patients with known medical
illness, heightened health anxiety has not been associated with in-
creased medical utilization (6).
IAD carries substantial risk of functional limitation. Popula-
tions with clinically significant health anxiety demonstrate more
days of work lost, increased functional impairment, and higher
rates of use of disability benefits as compared with both the gen-
eral population and medical populations without health anxiety
(29,31–34).
IAD is included (together with SSD, conversion disorder, and
factitious disorder) in DSM-V under the heading of somatic symp-
tom and related disorders (35). This grouping is meant to reflect
the fact that these disorders generally present to nonmental health
medical practitioners and the fact that they often seem initially to
be medical rather than psychologic in nature. However, health
anxiety is associated not only with somatic symptoms but also
with depressive and other anxiety symptoms (6,19), and successful
treatment of health anxiety often (but not always) improves de-
pressive and other anxiety symptoms (36–39). Thus, the family
of disorders to which HC/IAD “belong” has continued to be a
topic of debate. Although earlier literature emphasized the connec-
tions between HC and depression (40–43), more recent work has
underscored its proximity to anxiety disorders. All anxiety dis-
orders share similar cognitive patterns, including a bias toward
anticipating negative outcomes, increased sensitivity to threat
detection, enhanced cognitive and behavioral responses to de-
tected threats, autonomic hyperarousal, increased attribution
of negative valence to environmental stimuli, and failure to re-
appraise the relative risk of negative outcomes by integrating
new information; these patterns are also observed in HC
(44–47). In one study, multiple regression analysis indicated
that HC was strongly correlated with anxiety but not depres-
sion, and the correlation with anxiety was stronger than that
for somatic symptom burden (19).
Psychosomatic Medicine, V 81 • 398-407
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Careful attention must be paid to the differential diagnosis of
health anxiety. Generalized anxiety disorder often involves head-
aches, gastrointestinal distress, and muscle tension, and health
may be one of several areas of significant worry. Panic disorder
manifests intense physical symptoms as a consequence of auto-
nomic dysregulation, with associated negative cognitions regard-
ing the meaning of the symptoms and maladaptive behaviors
aimed at reassurance, and work exists delineating differences be-
tween panic disorder and HC/IAD and that many people show
symptoms of one but not the other (48). Unexplained somatic
symptoms are common in posttraumatic stress disorder (49), and
worry about contamination and development of serious illness is
a common manifestation of obsessive-compulsive disorder
(OCD). Anxiety about one's health may also be present in individ-
uals with major depression or psychotic disorders.
Although these diagnoses are frequently co-occurring with HC
and IAD, there is a distinct group of individuals who manifest
health anxiety unaccompanied by these other disorders. Studies
reporting the rate of psychiatric comorbidity in HC exhibit a wide
range of reported prevalence (19,24,36,37,50).
Thus, a useful formulation of the patient's overall symptoms re-
quires attention to specific feared stimuli and the cognitive, affec-
tive, and behavioral consequences for the individual. Care must be
also taken to differentiate IAD from somatic symptom disorder,
where a primary focus of distress is the bodily symptom itself with
resultant behaviors aimed at seeking symptom relief. These two
patterns of worry about health and distress regarding symptoms
may coexist.
ASSESSMENT
A diagnostic interview for IAD should include questioning about
symptoms of depression, anxiety, mania, psychosis, OCD, and
posttraumatic stress disorder. In assessing the somatoform illness,
it is important to inquire about the level of worry about health,
which, if any, specific diseases are feared, the evidence upon
which the patient bases these worries, any checking/reassurance
behaviors in which the patient engages, and the time spent on
these, the presence and severity of somatic symptoms, and the
functional impairment and limitations.
Because the differential diagnosis of IAD includes medical ill-
ness, it is important to ask about what medical evaluation has been
conducted and to perform a thorough review of all available med-
ical records. When possible, records from outside institutions
where the patient has previously sought care should be obtained
and reviewed, and patients should be encouraged to provide per-
mission for the current provider to obtain previous testing. If there
is any possibility that a medical condition has been overlooked,
this should be discussed with the patient's primary physician.
In addition to a diagnostic interview, standardized assessments
of health anxiety in adults are available (Table 2) (7–9,51,55–57).
The most commonly used is the Whiteley index, which assesses
the domains of disease fear, disease conviction, and bodily preoc-
cupation (7–9,51,55–57). A structured clinical interview for IAD,
the Anxiety Disorder Interview Schedule, is also available (52).
Health anxiety in children can be assessed using the 35-item Child-
hood Illness Attitudes Scale (53), and the 27-item Cyberchondria
Severity Scale may be used to measure the use of internet resources
as a means of reassurance in health anxiety (54).
400 June 2019

TABLE 2. Standardized Rating Scales for the Assessment of
Health Anxiety in Adults
Scale Items
Whitely Index (7–9,51) 14
Health Anxiety Inventory (51)
Full 64
Shortened 18
Illness Attitudes Scale (9,51–53) 29
H-YBOCS-M (54) 18
H-YBOCS-M = Modified Hypochondriasis Yale-Brown Obsessive Compulsive
Rating Scale; NA = no cutoff point defined.
Cutoff scores indicate score used to indicate significant health anxiety in studies. All
scales listed are self-report and available for use in the public domain.
In addition to direct measures of health anxiety, assessment and
diagnosis in somatoform disorder can be aided by the Patient
Health Questionnaire 15 (a measure of the variety and severity
of experienced somatic symptoms) and the Somatosensory Ampli-
fication Scale (9). Rating scales for depression and anxiety symp-
toms are also useful in a complete assessment, given their high
comorbidity with health anxiety.
In certain cultures or family systems, expressing distress
through communications around health and bodily symptoms
may be more normative than in others. Thus, care must be taken
to consider differences in cultural beliefs about health, illness,
and the meaning of bodily symptoms before attributing the
patient's presentation to a primary disorder of health anxiety.
EPIDEMIOLOGY
The epidemiology of IAD as defined in DSM-V is unclear. The
point prevalence of HC has been reported to be 0.04% to 4.5%
in population-based studies. When screened from general medical
practices, 0.3% to 8.5% of patients met criteria for HC
(26,55,58–61), as did 12% to 20% of patients screened from spe-
cialty clinics (62,63).
Clinically significant health anxiety based on continuous mea-
sures noted previously has been found in up to 20% of patients in
various medical specialty settings; a systematic review of these
studies indicated a weighted mean prevalence of 2.9% (61,62,64–72).
In the general adult population, 2.1% to 13.1% were noted to have
clinically significant health anxiety (33,45,61,73–81). These wide
ranges reported likely differences in definitions of the disorder as
well as the different sampling and recruitment methods used in
various studies, and there is a clear need for consensus criteria to
improve synergies between clinical studies of illness anxiety and
related disorders (82).
Screening in psychiatric populations found 1.6% to 3.5% of in-
dividuals' meetings criteria for HC and 19% to 31% with clinically
significant health anxiety (61,83–86). In the psychiatric
consultation-liaison setting, rates of 0.6% for diagnosis of HC
and 9.6% to 34% for clinically significant health anxiety have been
reported (61,86–90).
Studies of the sociodemographic characteristics of patients
with HC/IAD have had inconsistent findings. Many, but not all,
studies have found a relatively even distribution between men
and women, an interesting finding because both anxiety disorders
Psychosomatic Medicine, V 81 • 398-407
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Illness Anxiety Disorder
and SDs are more common in women (91,92). There have not
been consistent findings of differences between HC/IAD patients
and the general population in terms of age, socioeconomic status,
Cutoff
race, ethnicity, or level of education (6,14,19,29,45,55,92).
5–8
NATURAL COURSE OF ILLNESS
67 The age of onset of the illness seems to be in early to middle adult-
20 hood (1). Few studies have measured the incidence of HC through
47 time in adults; one study that followed a cohort with HC and a
NA matched control population found that 3% of the control popula-
tion had developed HC in the 4- to 5-year follow-up period (29).
The course and outcome of HC/IAD have also not been exten-
sively studied. The disorder is often chronic; in adults, up to 70%
of patients meeting criteria for HC continue to meet criteria in
long-term follow-up (24,29,30,93–95). Remission is associated
with less disease conviction, fewer somatic symptoms, higher
level of functioning, less disease fear, and fewer disability days
at baseline. This pattern generally suggests that more severe illness
is associated with poorer outcomes. Presence of comorbid psychi-
atric illness has not been shown to be a significant factor in remis-
sion status (29,93–97). Though less well studied in children, there
are data to suggest that HC tends to persist into adolescence (23).
NEUROBIOLOGY
Few neuroimaging studies examining functional characteristic of
HC/IAD individuals have been conducted. One study reported de-
creased activity in circuits involving dorsolateral prefrontal cortex,
striatum, and left thalamus, accompanied by increased activation
of the amygdala during tasks investigating executive functioning,
a pattern of activation suggesting hypoactivity of regions involved
in planning and executive function with increased activity of re-
gions involving anticipatory fear. These findings were not signifi-
cantly different from those noted for OCD and panic disorder (98).
HC was also associated with longer response time in a Stroop
test for words related to distressing bodily sensations. This was as-
sociated with increased activation of several frontal, temporal, and
subcortical structures. This pattern was not observed with neutral
words, suggesting a specific attentional bias that more closely mir-
rored panic disorder than OCD (99).
Specific neural circuits that involve visceral sensory pro-
cessing regions (including insula, anterior cingulate cortex,
and periaqueductal gray), in combination with the frontal and
subcortical regions noted above, may be important in those pa-
tients for whom bodily sensations form a basis for health anxi-
ety. Aberrancies in these circuits may contribute to health
anxiety by increasing negative expectancy, negative attentional
bias, and catastrophizing of bodily sensation (100,101).
There are no biomarkers of IAD and more empirical research is
needed to identify neurobiological correlates of IAD that are dis-
tinct from SSD and other psychiatric disorders that are related to
anxiety or depressive disorders.
TREATMENT
Therapeutic trials in HC/IAD may involve people meeting HC/
IAD criteria, people with elevated heath anxiety who may or
may not diagnostic criteria, or a combination. Thus, when apply-
ing research findings in clinical practice, one must be careful to
consider the pattern and severity of symptoms and the burden of
401 June 2019
 CLINICAL APPLICATIONS

significant somatic symptoms, as research populations vary with more effective than placebo and with no statistically significant dif-
respect to these variables. A summary of the evidence for treat- ference between the two (8.3-point decrease in Whiteley index with
ment of health anxiety is presented in Table 3. CBT, 6.4-point decrease with paroxetine) (37).

Psychopharmacology
There is limited but promising evidence of the effectiveness of
psychopharmacologic interventions for health anxiety.
Three randomized, double-blind, placebo-controlled trials of
medications in HC have been reported. This demonstrated efficacy
of fluoxetine (mean dose = 30–51 mg/d) (102,103) and paroxetine
(mean dose = 40 mg/d) (37) over placebo. Open-label trials of flu-
oxetine (mean dose = 52 mg/d) (20), fluvoxamine (36), and parox-
etine (104) have also supported the use of SSRIs.
In a long-term follow-up survey of hypochondriacal patients
treated with SSRIs, 60% of patients no longer met criteria for
HC at an average of 8.6 years after study completion (103). Pa-
tients who used SSRIs for at least 1 month in the interval between
study completion and follow-up showed a remission rate of 80% at
follow-up, compared with 40% of those who did not. Another pre-
dictor of nonremission included history of physical abuse in child-
hood. Similar rates of long-term response to paroxetine at
18 months have also been observed (129).
Two studies have compared medication to cognitive and behav-
ioral therapy (CBT) in the treatment of health anxiety. In a large ran-
domized control trial of 195 patients, fluoxetine and CBT showed a
44.4% and 39.6% rate of response, respectively, and the difference
between the two was not significant. Combining the two treatments
was significantly better (47.2% response) (102). Another study
compared paroxetine and CBT in 112 patients, with both being
Psychotherapy
The evidence for the use of CBT in health anxiety is more exten-
sive than that for medications; in addition, it is cost-effective
(38,130) and preferred by patients over medications (117). CBT
for health anxiety focuses on the misinterpretation of bodily symp-
toms, identification of maladaptive behavioral and cognitive pat-
terns, and generation of alternative explanatory models for
symptoms and psychologic distress (122).
Various iterations of CBT have been extensively evaluated, in-
cluding individual CBT, group CBT, and internet-based CBT, with
data consistently supporting efficacy with these treatments
(31,38,39,106–115,118–123,130–132). Three recent meta-analyses
have supported the efficacy of CBT for HC and elevated health
anxiety, with large effect size (Hedge's g = 0.95 for individual
CBT) (105,118,125). Greater effect size is associated with higher
severity of pretreatment symptoms, greater number of CBT ses-
sions, and fewer depressive symptoms (118). One study found that
participants with chronic lower back pain and HC did not respond
to CBT as compared with participants with HC and no chronic
lower back pain (117), suggesting that burden of somatic symptom
s may be a modifier of CBT efficacy.
The durability of the treatment effect of CBT over control
groups is sustained 7 to 24 months after treatment, although symp-
tomatic improvement and remission tend to diminish over time
(38,39,55,109,122).

TABLE 3. Summary of Evidence for Treatments of Health Anxiety

Psychopharmacology
Fluoxetine 2 RCTs, (102,103), 1 open-label trial (20)
Paroxetine 1 RCT (37), 1 open-label trial (104)
Fluvoxamine 1 open-label trial (36)
Psychotherapy
CBT (individual) 1 meta-analysis (105), 9 RCTs (41,106–112), and 2 open studies (113,114)
Mixed HC and elevated HA: 2 meta-analyses (115,116)
Elevated HA: 4 RCTs (117–120)
CBT (group) 1 RCT (121) and 2 open trials (122,123)
CBT (Internet-based) 1 RCT (124)
Elevated HA: 2 RCTs (125,105)
IAD: 1 RCT (126)
ACT (group) Elevated HA: 1 RCT (124,127)
MBCT Elevated HA: 1 RCT (128) and 1 open study (50)
Behavioral stress management Elevated health anxiety: 1 RCT (127)
Explanatory therapy 1 RCT (126)
Treatment comparisons
Fluoxetine versus CBT 1 RCT; fluoxetine equivalent to CBT, combined treatment superior to either treatment alone (104)
Paroxetine versus CBT 1 RCT; paroxetine equivalent to CBT (39)
Cognitive therapy versus exposure therapy 1 RCT; cognitive therapy equivalent to exposure therapy (114)
CBT versus STPP 1 RCT; CBT superior to STPP (109)

CBT = cognitive behavioral therapy; ACT = acceptance and commitment therapy; MBCT = mindfulness-based cognitive therapy; STPP = short-term psychodynamic
psychotherapy; HA = health anxiety; RCT = randomized controlled trials.
All trials, unless otherwise noted, used HC criteria to select participants.

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Several possible mechanisms could account for the treatment
effect of CBT. The previously mentioned comparison of cognitive
therapy to exposure therapy indicated that specific improvements
in the negative evaluation bias toward illness-related information
correlated with improved measures of health anxiety. The expo-
sure therapy group did not show these specific cognitive changes
despite a significant improvement in symptoms. In parallel with
the observation that patients with HC/IAD tend to overestimate
the probability of severe but not mild medical illness, cognitive
and exposure therapy were associated with decreased attributions
of sensations to severe disease but no change in attribution to mild
or moderate disease (16,124).
More recent “third-wave” iterations of CBT have also shown
promise for health anxiety, including small randomized control
studies supporting use of group acceptance and commitment
therapy (124) and individual mindfulness-based cognitive therapy
(50). These therapies focus on mindful awareness of thoughts and
changing an individual's relationship to their thoughts rather than
changing their content.
One controlled study showed that short-term psychodynamic
psychotherapy (STPP) did not improve symptoms of health anxi-
ety as compared with a wait-list control after 6 months of treat-
ment. In the same study, CBT was found to be superior to the
control group and superior to STPP (119). Other forms of psycho-
therapy with some data to suggest benefit include behavioral stress
management (123) and explanatory psychotherapy (126).
It is important to note that although several longitudinal studies
have reported decreases in clinical scales or remission of HC by di-
agnostic criteria, with and without treatment, corresponding im-
provements in functional status, social activities, health-related
quality of life, and days of lost work have not consistently been
demonstrated (29,31,38). This highlights a key difficulty in trans-
lating research findings to patient care, because the goal of treat-
ment is reduction of both distress and functional improvement.
COMMUNICATING WITH PATIENTS WITH
HEALTH ANXIETY
Aside from the formal treatment of health anxiety described previ-
ously, discussing the problem of health anxiety with these patients
is important because they often lack insight and remain convinced
that their problem is medical rather than psychological in nature.
Many patients have their own explanatory model for bodily
sensations, views regarding what constitutes “good health,” and
connections between mind and body. Listening to their concerns
with empathy, adopting an active and curious attitude toward their
experience, and asking respectful questions about their under-
standing of their symptoms and their health fosters a therapeutic
relationship.
Ultimately, many patients will eventually feel dissatisfied and
ignored by even the most empathic and caring practitioner when
their need for reassurance cannot be met. It is important to empa-
thize with the patient's distress without colluding with false beliefs.
Saying, “It must be frightening to live every day with the fear that
no one has diagnosed the cancer that you are so sure you have”
expresses empathy without agreement that cancer is present. To
avoid conflict, one might be tempted to agree with mistaken be-
liefs; for example, agreeing with a patient that a blood count to
check leukemia should have been ordered despite several
Psychosomatic Medicine, V 81 • 398-407
Copyright © 2019 by the American Psychosomatic Society. Unauthorized reproduction of this article is prohibited.
Illness Anxiety Disorder
negative tests within the past few weeks. However, agreeing
with the erroneous thoughts will only set the stage for later dis-
illusionment when the practitioner falls short of meeting the
patient's expectations.
Individuals with IAD (and other somatoform disorders) often
experience medical practitioners as treating them with contempt,
suspicion, derision, and annoyance, and these impressions are of-
ten accurate. Although it is hard to avoid a patient's disappoint-
ment, frustration, and feelings of rejection when the practitioner
cannot provide what he/she seeks a diagnosis or adequate reassur-
ance, practitioners should be mindful of their countertransference,
clearly express empathy, and avoid blaming the patient for symp-
toms. For example, patients are often told “this is all in your head.”
Not only is this statement misleading, because even the pain of a
broken bone is experienced “in the head,” it is neither empathic
nor therapeutically useful. Use of terms that imply that symptoms
are not organically based, such as “psychosomatic,” should be
avoided, because they reinforce a false dichotomy between mind
and body and are often used pejoratively to imply a lack of symp-
tom authenticity (116).
Empathy for the frustrating interactions the patient has had
with providers should avoid collusion with mistaken or erroneous
beliefs. A response of “It was so frustrating when the emergency
department wouldn't repeat a CT scan even though you were sure
you had a bowel obstruction” is likely to be more beneficial for
long-term psychiatric treatment than “You're right; it would have
been safer to do the CT scan just to be sure.” In cases where a pa-
tient was genuinely treated poorly by a practitioner, empathizing
with hurt feelings and acknowledging their appropriateness is rea-
sonable. For example, “I'm not sure why the doctor told you that
you were wasting his time; I'm not surprised you feel so angry
and humiliated.”
Mental health providers should avoid interpreting diagnostic
tests to the patient in a way that questions previous interpretations.
For example, when reviewing a brain magnetic resonance imaging
that a neurologist felt was unremarkable, a statement that “This
was read as normal, but actually to me it looks like there is more
volume loss than I would expect for your age” heightens fear
and fosters mistrust between the patient and other provider. If the
mental health practitioner thinks that a test may have been
misinterpreted, discussion should first occur between the two clini-
cians so that the patient receives a clear and consistent message. In
extreme cases in which one suspects that the medical care is truly
inadequate, recommendation for referral or a second opinion may
be appropriate.
COLLABORATION WITH MEDICAL PROVIDERS
Communication between the mental health professional and other
physicians is key when treating health anxiety. Patients' cognitive
biases may lead to distorted reporting of encounters they have had
with other practitioners. Thus, there should be direct communica-
tion between providers regarding the information given the patient
about tests, diagnoses, and treatments. This collaboration should
focus on a treatment plan that all providers agree with, foster con-
sistent communication with a patient about plans for diagnostic
testing and treatment, and avoid iatrogenic risk from testing that
is repetitive or not clinically indicated.
403 June 2019
 CLINICAL APPLICATIONS
The mental health provider is in a position to educate other pro-
viders about the nature of health anxiety. It is important to empha-
size that the patient is not malingering or “faking” and that their
symptoms are not “imagined,” intentionally produced, or feigned.
Making clear that the patient is not purposefully feigning symp-
toms makes explicit and allows for acknowledgement of the
common countertransferential anger often directed at the pa-
tient for their feelings and behaviors. Frustration stems from
frequent requests for help that cannot be satisfied, extensive
time spent providing reassurance, and the feeling of helpless-
ness that accompanies the inability to alleviate the patient's suf-
fering. Bringing these attitudes into open discussion during
consultation between providers helps the medical provider main-
tain an empathic, rather than confrontational and pejorative, stance
with the patient.
Communicating the diagnosis of health anxiety to practitioners is
important. There may be fear that “labeling” patient with health anx-
iety may lead to ignoring all future symptoms and a tendency to mis-
trust patient. Although this is certainly a possibility, the diagnosis is
nevertheless present, and medical decision-making in any specialty
is best made with a knowledge of all conditions, psychiatric and so-
matic, that are present. Practitioners should be encouraged to make a
point of explicitly telling the patient that they believe the patient is
truly experiencing the anxiety of potentially being sick and believe
that any symptoms present are real and not malingered.
Providers should be informed that, by definition, the IAD pa-
tient cannot be reassured by negative testing. Practitioners may
be tempted to repeat testing, even when it is not clinically indi-
cated, to appease the patient, to save time by avoiding arguments
or having to explain the reasoning for not ordering testing, or be-
cause they believe that one more negative test will finally dissuade
the patient. Explaining the futility of repeated diagnostic testing
undertaken for the purpose of reassurance can help the practitioner
to forgo tests that are not clinically indicated.
When a diagnostic test is ordered, it is helpful to tell the patient
clearly and explicitly the reasons the test, what results would be
considered abnormal, and what next steps would be in the case
of a positive, negative, or equivocal test. Clear documentation in
the medical record of this plan helps other providers understand
clearly what was discussed.
When documenting the diagnosis of IAD, a clear statement that
the diagnosis does not imply that medical complaints should be ig-
nored or minimized acknowledges the potential risks of bias and
negative countertransference. It also educates the reader of the
medical record about the relationship between health anxiety and
medical conditions. It should make clear that medical decision-
making is the primary responsibility of the medical provider, while
also giving “permission” to consider the presence of health anxiety
when deciding on a treatment plan. An example of such a state-
ment would be: “The diagnosis of Illness Anxiety Disorder does
not preclude the development of medical illness, nor does it imply
that future symptoms or worries about illness are without identifi-
able cause. Any new symptoms, worsening, or clinically concern-
ing symptoms should be evaluated and treated as is medically
indicated.”
Ultimately, it is the medical practitioner's decision whether a
test or treatment is indicated. Because the indications to obtain,
for example, a transesophageal echocardiogram, are outside the
area of expertise for a mental health provider, it is neither
Psychosomatic Medicine, V 81 • 398-407
Copyright © 2019 by the American Psychosomatic Society. Unauthorized reproduction of this article is prohibited.
medically nor medicolegally advisable for the final say in medical
testing to be the mental health provider's responsibility.
If a medical provider chooses to forgo a diagnostic test or a pal-
liative intervention, clear documentation in the medical record of the
medical decision-making is important for both communication with
other providers and management of medicolegal risk. The statement
should explicitly acknowledge the known diagnosis of health anxi-
ety and make clear why testing or treatment was not indicated. For
example, “This 24-year-old man with no known medical conditions
and a diagnosis of Illness Anxiety Disorder, per psychiatric evalua-
tion, presents with concern that he has colon cancer. He endorses
chronic constipation but denies blood in his stool, abdominal or rec-
tal pain, or weight loss. There are no significant findings on physical
exam. There is no family history of colon cancer. He underwent co-
lonoscopy four months ago and no lesions were noted. On my eval-
uation, the clinical suspicion for colon cancer is minimal, and I do
not think repeat colonoscopy is indicated.”
CONCLUSIONS
IAD is a disorder of worry regarding the presence or development
of serious medical diseases and manifests as pathologic thoughts,
affects, and behaviors aimed at reassurance of the absence of or
confirmation of the presence of illness. Primarily a disorder of anx-
iety, it is differentiated from SSD by the relative lack of somatic
symptoms. In patients willing to accept psychiatric care, CBT is
an effective treatment, and selective-serotonin reuptake inhibitors
may also be beneficial. Communication among the patient, the
mental health practitioner, and medical practitioners must focus
on empathy, open dialog, coordination of testing, and consistent
delivery of messages, to avoid iatrogenic harm, unnecessary test-
ing, nonindicated treatment, and to reduce the risk of viewing
the patient with a dismissive and disparaging attitude.
CASE FOLLOW-UP
The patient was diagnosed with IAD, comorbid panic disorder,
and a specific phobia related to having her blood pressure mea-
sured. She was started on escitalopram, although she never took
more than 5 mg because of worry about adverse effects, and she
engaged in psychotherapy. Repeated exposure to use of a blood
pressure cuff in the office resulted in remission of associated panic
attacks after 2-hour-long sessions. For the next 6 months, she en-
gaged in weekly sessions of acceptance and commitment therapy
that involved acceptance of bodily sensations and related worry,
imaginal exposures to feared health outcomes, and training in
strategies to “approach” rather than “avoid” health anxiety. For ex-
ample, because she feared a myocardial infarction during physical
exertion, she was encouraged to actively imagine herself dying of
this condition while she exercised. After 6 months, she experi-
enced marked reduction in the time she spent worrying about her
health, significant reduction in time spent searching the internet
for reassurance and stopped avoiding social events out of fear
of becoming ill or having a panic attack. Somatic sensations
continued to, at times, evoke anxiety, but she found herself able
to tolerate the worry without resorting to excess checking and
reassurance behaviors.
Source of Funding and Conflicts of Interest: The authors report
no conflicts of interest and no source of funding.
404 June 2019

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