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Health Anxiety: Current Perspectives

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Gordon Asmundson

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Curr Psychiatry Rep (2010) 12:306–312
DOI 10.1007/s11920-010-0123-9
Health Anxiety: Current Perspectives and Future Directions
Gordon J. G. Asmundson & Jonathon S. Abramowitz &
Ashley A. Richter & Margaret Whedon
Published online: 12 June 2010
# Springer Science+Business Media, LLC 2010
Abstract Health anxiety is a ubiquitous experience that
arises when bodily sensations or changes are believed to be
indicative of a serious disease. Severe expressions of health
anxiety are most often classified as hypochondriasis in the
current DSM-IV-TR; however, various alternative classifi-
cation schemas have been proposed for the DSM-V.
Regardless of classification, severe health anxiety has
significant negative impacts on well-being, social and
occupational functioning, and health care resource utiliza-
tion. In this review, we focus on classification issues
pertinent to severe health anxiety, summarize recent
research regarding potential mechanisms underlying the
condition, and summarize the state of the art with respect to
assessment and treatment. Future research directions are
noted and suggested throughout.
Keywords Health anxiety . Hypochondriasis . Cognitive .
Treatment . Review
Introduction
Health anxiety is a ubiquitous experience that arises when
bodily sensations or changes are believed to be indicative
of a serious disease. Because the magnitude of health
anxiety can differ from person to person, contemporary
models conceptualize it along a continuum ranging from
G. J. G. Asmundson (*) : A. A. Richter
Department of Psychology, University of Regina,
3737 Wascana Parkway,
Regina, Saskatchewan S4S 0A2, Canada
e-mail: gordon.asmundson@uregina.ca
J. S. Abramowitz : M. Whedon
Department of Psychology,
University of North Carolina at Chapel Hill,
Chapel Hill, NC 27599, USA
mild to severe [1, 2]. Mild expressions of health anxiety can
be adaptive by motivating one to seek clinical care in cases
in which clinical care is warranted; however, when
characterized by preoccupation and worry, health anxiety
can lead to undue personal suffering, impaired social and
occupational functioning, and overutilization of general and
specialty health care services [2].
Excessive health anxiety is characterized by several core
cognitive, somatic, and behavioral features that typically
manifest following periods during which one is stressed,
seriously ill, or has suffered the loss of a family member [3]. It
can also manifest following exposure to disease-related
popular media [2]. The core cognitive feature is disease
conviction—the belief that bodily sensations and changes are
due to disease processes (eg, “This headache means I have a
brain tumor”) rather than benign bodily perturbations,
symptoms of minor ailments, or autonomic nervous system
arousal. Other dysfunctional beliefs (eg, viewing the self as
weak or vulnerable) may accompany disease conviction and,
together with preoccupation and worry about the cause and
authenticity of bodily sensations and changes, motivate
maladaptive coping behaviors. Reassurance seeking
(ie, wanting affirmation from others that there is nothing
physically wrong) and recurrent checking (eg, repeated
palpation of internal lumps or external abrasions, searching
the Internet for information about dreaded diseases) serve to
perpetuate the belief that benign bodily sensations and
changes are caused by disease. Although reassurance seeking
and checking behaviors provide some relief from health
anxiety, the effects are transient [4], and the process is
detrimental in the long term [2, 5].
Classification
Clinically significant expressions of health anxiety include
hypochondriasis, symptom presentations failing to meet full
diagnostic criteria for hypochondriasis, and disease phobia
Curr Psychiatry Rep (2010) 12:306–312
and delusional disorder, somatic type. Details of disease
phobia and delusional disorder, somatic type are discussed
elsewhere [2]. In the context of current diagnostic nomen-
clature used in the DSM-IV-TR, hypochondriasis is con-
sidered a somatoform disorder [6]. Presentations of
hypochondriasis are consistent with the core features of
severe health anxiety described above; as such, the DSM-
IV-TR emphasizes that a diagnosis of hypochondriasis
requires preoccupation with fears of having a serious
disease based on misinterpretations of benign bodily
sensations, and disease conviction that persists despite
appropriate medical evaluation and reassurance of good
health. It also emphasizes that hypochondriasis is associated
with considerable personal cost. Although hypochondriasis
is currently classified as a somatoform disorder, there have
been several suggestions for alternative classification in the
forthcoming DSM-V. These suggestions include, for example,
reclassifying hypochondriasis as an anxiety disorder
(ie, health anxiety disorder), as part of the putative
obsessive-compulsive spectrum disorders, or as a new
somatoform disorder—complex somatic symptom disorder—
that might be more inclusive of conditions characterized
by unexplained bodily sensations and changes plus
associated severe health anxiety [7•]. The final disposition of
severe health anxiety in the DSM-V remains to be determined
[7•, 8].
Historically, hypochondriasis has been regarded as
resistant to psychological treatments, but this view is
largely attributable to the absence of a unified conceptual
model of the problem. It has been argued that hypochon-
driasis is best viewed as a personality disorder, a result of
psychic conflicts, and as a secondary manifestation of
depression [9]. Most recently, however, the development
of a cognitive-behavioral model of hypochondriasis has led
to an efficacious psychological treatment. The cognitive-
behavioral approach is derived largely from the observation
that symptoms of hypochondriasis—at both a topographical
and functional level—overlap remarkably with those of
certain anxiety disorders, namely panic disorder and
obsessive-compulsive disorder (OCD).
Overlaps between hypochondriasis and other disorders
may be found on two levels. The first is overt symptom
similarity. Like OCD, hypochondriasis involves intrusive,
distressing thoughts and repetitive behaviors. Similarities
have been noted between hypochondriasis and certain
presentations of OCD, such as contamination fear, in terms
of preoccupation with health and disease, and the repetitive
and pervasive nature of such preoccupation. The prominent
preoccupation with bodily sensations and changes in both
hypochondriasis and panic disorder has also invited
comparisons between these conditions. Like those with
hypochondriasis, patients with panic disorder are hyper-
vigilant to benign, arousal-related body sensations and
307
often erroneously attribute these to organic causes such as
heart attacks, strokes, and other serious medical conditions.
To examine these overlaps empirically, Deacon and
Abramowitz [10••] used discriminant function analysis to
explore how patients with a principal diagnosis of hypo-
chondriasis (n=23), OCD (n=21), or panic disorder (n=50)
varied with respect to cardinal features of these disorders
(ie, health-related concerns, obsessions and compulsions,
panic-related anxiety, and phobic avoidance). Results
indicated that whereas individuals with hypochondriasis
experience panic attacks, obsessions, and compulsions,
these symptoms are less pronounced than they are among
individuals with OCD and panic disorder. These findings
indicate that there is symptom overlap among hypochon-
driasis, OCD, and panic disorder yet also show that
hypochondriasis is a separate condition that is typified by
health-related anxiety.
The second level of potential overlap, which is arguably
more conceptually important than the first, is the cognitive
basis for the observed symptoms. If two or more conditions
are typified by similar dysfunctional beliefs, some congruence
may be expected. To this end, Deacon and Abramowitz [10••]
also compared patients with hypochondriasis, OCD, and
panic disorder on measures of cognitive biases hypothesized
to be present among these disorders. They found that beliefs
about somatic sensations and the tendency to pay close
attention to these sensations were equally present in panic
disorder and hypochondriasis, whereas the need for certainty
was elevated and comparable among patients with OCD and
those with hypochondriasis. Thus, there appear to be
common psychological processes in hypochondriasis and
each of these anxiety disorders.
The extent to which health anxiety is a dimensional or a
categorical construct also has important implications for
how it is studied and conceptualized. Ferguson [11••] used
taxometric procedures to examine this question in a sample
of more than 700 adults who completed the Whiteley Index
[12] and indicated their current health status. Data from
those who were currently healthy (n=501) and receiving no
medical treatment were examined using three common
taxometric procedures. Results indicated that health anxiety
is most accurately represented as a dimensional rather than
a categorical (or taxonic) construct. This finding has several
theoretical, research, and clinical implications. First, it is
consistent with the suggestion of the contemporary
cognitive-behavioral model that health anxiety varies along
a continuum. Second, it supports the notion that attempts to
explain the development and maintenance of severe health
anxiety should include examination of a range of potential
risk and maintenance factors, such as cognitive processes,
behavior, and biological correlates. Third, it supports the
use of large, unselected samples in which delineation of
clinical “cases” is optional but not necessary in empirical
308
efforts to delineate risk and maintenance factors. Finally,
from a clinical perspective, this finding implies that it may
be possible to identify points at which health anxiety
rapidly worsens and then develop and test prevention
programs for individuals at high risk.
Mechanisms
Although a sound contemporary cognitive-behavioral model
of health anxiety exists [1, 2], researchers continue to
examine the nature of its underlying mechanisms. Some
important recent findings, which facilitate current under-
standing and serve to inform future research efforts, are
discussed subsequently.
Disgust
A burgeoning interest in the role of disgust in psychological
disorders led Olatunji [13•] to hypothesize that individuals
high in disgust propensity may also be more vigilant for—
and consequently misinterpret—ambiguous physical sensa-
tions as an indication that they may have a serious disease.
He sought to determine the incremental specificity of
disgust propensity in the prediction of health anxiety
features using a large nonclinical sample. The results
indicated that three dimensions of health anxiety—
the tendency to overestimate the likelihood of disease, the
tendency to overestimate the severity of disease, and the
tendency to closely attend to one’s bodily sensations—were
positively and significantly associated with the tendency to
respond to stimuli with disgust. These findings suggest that
disgust may play a role in the development or maintenance
of hypochondriasis. Additional research in nonclinical
samples and clinical samples with hypochondriasis is
needed to clarify the nature, extent, and specificity of the
role played by disgust propensity.
Vulnerability Factors
An oft-suspected vulnerability factor for developing exces-
sive health anxiety is personal experience with serious
illness—either in one’s self or a close friend or relative [1,
2, 14]. However, little research has examined whether
exposure to the suffering of unknown individuals might
play a role in health anxiety. To address this issue,
Karademas [15•] randomly assigned 89 healthy participants
to view photos of human suffering or photos depicting
relaxing situations. Interestingly, despite no differences in
self-rated physical health, participants exposed to photos of
human suffering reported higher health anxiety and lower
internal health locus of control compared with those who
viewed the relaxing photographs. These findings suggest
Curr Psychiatry Rep (2010) 12:306–312
that in vitro exposure to human suffering activates
cognitive and emotional reactions, affecting evaluations
about self and personal well-being that in turn may
influence health anxiety.
Anxiety sensitivity (AS)—the tendency to fear the
sensations of anxious arousal based on the belief that they
are dangerous—is a key cognitive distortion in anxiety
disorders, as well as a known risk factor for panic disorder
[16]. Some authors have also suggested that AS plays a role
in health anxiety [14]. To replicate and extend previous
findings on the role of AS in health anxiety, Olatunji et al.
[17] administered measures of AS, health anxiety, depres-
sion, current stress level, and negative affect to large
samples of nonclinical participants. In one of their analyses,
they found a positive association between AS and health
anxiety, even after controlling for depression and negative
affect. However, the association between AS and health
anxiety was not moderated by stress levels. These authors
also prospectively examined whether AS predicted changes
in health anxiety symptoms during a 12-week period. No
significant findings emerged. The findings of this series of
studies collectively suggest that although AS is related to
health anxiety, it does not seem to be predictive of future
experiences with increases in health anxiety symptoms.
Replication and extension is warranted in a clinical sample
to determine whether AS or similar individual difference
factors, such as illness/injury sensitivity and the previously
mentioned disgust propensity, denote vulnerability for
hypochondriasis.
Genetics and Heritability
The contemporary cognitive-behavioral model of health
anxiety emphasizes environmental factors, such as learning
experiences (eg, episodes of actual illness, receiving treats
or other reinforcements only when sick, observing how
significant others cope with illness), as being primary
contributors to the development of hypochondriasis. Only
recently have researchers started to examine the possible
role of genetic factors and interactions of these with the
environment with respect to understanding and explaining
presentations of severe health anxiety. It was demonstrated
that one correlate and potential vulnerability factor of health
anxiety—AS—is moderately heritable [18]. More recently,
it was shown that when potentially heritable general
medical conditions are controlled, various features of severe
health anxiety (eg, disease conviction, fear of disease,
related interference in functioning) are influenced by a
common set of genes and feature-specific environmental
influences [19, 20••]. The relevant genes remain to be
identified but may include the genes implicated in the
modulation of emotion, such as the serotonin transporter
gene.
Curr Psychiatry Rep (2010) 12:306–312
Assessment
Comprehensive assessment of health anxiety is described in
detail by Taylor and Asmundson [2]. Important steps
include ruling out general medical conditions that may be
responsible for presenting problems, ruling in severe health
anxiety (or a diagnosis of hypochondriasis), and obtaining
sufficient information to establish that the presenting
disease-based concerns are associated with severe health
anxiety. A variety of self-report questionnaires are available
to facilitate assessing the severity and consequences of
health anxiety, including the Illness Behavior Questionnaire
[21], Illness Attitudes Scale (Kellner, unpublished manual),
and Health Anxiety Inventory [22]. Although several
structured and semistructured interviews have been devel-
oped to assess health anxiety [2], little psychometric
evaluation of these interviews has been done. The excep-
tion is a recent modified version of the Yale-Brown
Obsessive Compulsive Scale (YBOCS) [23, 24], a widely
used measure of OCD. The YBOCS was recently modified
to assess three dimensions of severe health anxiety—
hypochondriacal obsessions, compulsions, and avoidance
behavior—using a semistructured interview format [25•]. In
this study, 112 patients with hypochondriasis were inter-
viewed using a 16-item version of the interview, called the
H-YBOCS, and responses were submitted to exploratory
factor analysis as well as analyses of reliability, construct
validity, and sensitivity to change. Results indicated a three-
factor model comprising the hypothesized dimensions of
health anxiety (ie, hypochondriacal obsessions, compul-
sions, and avoidance). Interrater reliability was excellent,
whereas internal consistency was only satisfactory, and
construct validity unsatisfactory. The interview demonstrat-
ed some sensitivity to changes in symptom severity. These
data collectively indicate that the H-YBOCS could be
useful in the assessment of hypochondriasis; however,
further assessment and refinements are warranted. The
addition of clinician-administered measures with sound
psychometric properties will expand opportunities for in-
depth inquiry about health-related concerns and behaviors
in ways that self-report assessments do not permit.
Treatment
Individuals with severe health anxiety typically oppose the
notion that that their condition is caused by anything other
than disease, making it difficult to engage them in
appropriate treatment. Several evidence-based treatments
are available for those who can be motivated to consider
alternatives to disease-based explanations [2, 26]. Details of
these treatments are described by Taylor and Asmundson
[2] and summarized below. Effective pharmacotherapies as
309
well as data regarding patient preferences for psycho-
therapy versus pharmacotherapy are also summarized.
Psychoeducation
Psychoeducation programs involve providing an individual
with information about the nature of his or her presenting
concerns and potential strategies for addressing these
concerns. Psychoeducation has the advantage of being
relatively simple to administer to individuals or groups
[27]. Psychoeducation contrasts the provision of reassur-
ance in that the individual is presented with new informa-
tion rather than the repeated presentation of old information
(eg, repeating messages assuring good health, unnecessary
medical tests to placate concerns). Emotion regulation
strategies (eg, relaxation training) are often used in psycho-
education, but systematic exposure exercises are usually not
included. Studies examining the merits of group psycho-
education as the main component of treatment suggest that
it is superior to wait-list control in reducing health anxiety,
with a corresponding reduction in frequency of medical
service utilization and gains maintained at follow-up
periods of up to 1 year [28–30]. Participants in psycho-
education also value the opportunity to share their
concerns, and most are relieved to learn that they are not
the only ones suffering from severe health anxiety [29].
Exposure and Response Prevention
People with severe health anxiety are often fearful and
avoidant of stimuli that they associate with disease.
Accordingly, clinicians have used various forms of expo-
sure therapy to reduce severe health anxiety, including in
vivo exposure (eg, exposure to hospitals), interoceptive
exposure (eg, physical exercise to induce rapid heartbeat),
and imaginal exposure (eg, imagining that one has
developed a feared disease). Exposure is conducted in
treatment sessions and as homework assignments. Response
prevention is often combined with exposure to encourage the
patient to delay or refrain from behaviors that maintain
health anxiety (ie, bodily checking, seeking reassurance).
Uncontrolled trials indicate that exposure and response
prevention tend to effectively reduce health anxiety [31,
32]. In a controlled study, this treatment was found to be
effective and superior to a wait-list control, with gains
maintained at 7-month follow-up [33].
Behavioral Stress Management
Behavioral stress management emphasizes the role of stress
in producing harmless but unpleasant bodily sensations and
changes. It involves training the patient in various stress
management exercises (eg, relaxation training, time man-
310
agement, effective problem solving), as well as reintroduc-
ing regularly scheduled pleasurable activities that promote a
healthy lifestyle as a means of managing stress [2]. These
strategies collectively reduce the bodily sensations that fuel
health anxiety and increase a sense of well-being. Behav-
ioral stress management was originally developed as a
control condition in a randomized controlled study com-
paring cognitive-behavioral therapy, behavioral stress man-
agement, and wait-list [34]. Although planned as a control
condition, behavioral stress management proved to be
effective at reducing health anxiety. When used, it is
important to ensure that patients understand that the
rationale for using stress management is to reduce unpleas-
ant but harmless bodily sensations rather than to avoid
sensations believed to be dangerous.
Cognitive-Behavioral Therapy
Cognitive-behavioral therapy incorporates psychoeducation
as well as exposure and response prevention along with
cognitive restructuring and behavioral exercises. Cognitive
restructuring is used to examine beliefs about the meaning
of bodily sensations and changes, whereas behavioral
exercises are used to further test the consequences of these
beliefs and to examine the effects of behavior patterns that
maintain and exacerbate severe health anxiety (eg, to test
the effects of reassurance seeking vs not, to test the effects
of directing attention toward rather than away from bodily
sensations and changes). Patients often discover that their
patterns of behavior and attentional focus drive their fears
and feelings of vulnerability. Many uncontrolled trials have
suggested that cognitive-behavioral therapy can effectively
reduce severe health anxiety [35, 36]. Trials comparing
cognitive-behavioral therapy with wait-list controls, other
treatment conditions, and medical treatment as usual have
also produced results suggesting the superiority of
cognitive-behavioral therapy [34, 37, 38]. Cognitive-
behavioral therapy studies have most often used individual
treatment protocols, but several researchers have reported
that group treatment for severe health anxiety is also
effective [29, 36].
Pharmacotherapy
Case studies and a small number of trials have shown
clomipramine, imipramine, fluoxetine, fluvoxamine,
paroxetine, and nefazodone to be effective in alleviating
symptoms of hypochondriasis [2]. These medications can
reduce all aspects of severe health anxiety, including
disease fears and beliefs, pervasive anxiety, somatic
symptoms, avoidance, and reassurance seeking [39, 40].
In clinical studies, these medications are typically admin-
istered over a period of 12 weeks, although they may be
Curr Psychiatry Rep (2010) 12:306–312
taken over a much longer period (eg, years) in routine
clinical practice to prevent relapse. Little is currently known
about the long-term efficacy of various medications for
treating severe health anxiety or about the relapse rates
once the medications are discontinued. To the best of our
knowledge, there has been only one placebo-controlled
pharmacotherapy trial [41]. Initial mid-study results indi-
cated no significant difference between fluoxetine and
placebo, but trends favored fluoxetine. Although not
published, a presentation of the final results from the
completed study indicated that fluoxetine is superior to
placebo, both in terms of outcome after 12 weeks and at
9-month follow-up [42]. Meta-analytic findings suggest that
effect sizes are larger for all selective serotonin reuptake
inhibitors and nefazodone compared with wait-lists [26].
Fluoxetine was especially promising; however, effect sizes
for fluoxetine and all other medications were smaller than
for cognitive-behavioral therapy.
Treatment Preference
Given the roughly equivalent efficacy of the cognitive-
behavioral–based psychotherapies and selective serotonin
reuptake inhibitor pharmacotherapies described previously,
patients may be given the opportunity to choose their
preferred method of treatment. When given such a choice,
74% of a sample of 23 treatment-seeking individuals with
severe health anxiety selected cognitive-behavioral therapy
as their preferred treatment (with 48% indicating they
would accept only cognitive-behavioral therapy), whereas
only 4% preferred medication [43]. The availability of
choice may enhance treatment acceptability and adherence
and, in cases in which patients fail to benefit from one
intervention, may provide alternative courses of action;
however, several caveats must be considered when using
pharmacotherapy to treat severe health anxiety. For exam-
ple, even for short trials using medications with few side
effects, about 15% of patients drop out of treatment [26],
and in some cases, symptoms worsen as patients become
alarmed by side effects such as gastrointestinal discomfort
[39, 44]. Consequently, at least for some, it seems that the
benefits of medication are offset by health-related concerns
prompted (and amplified) by their side effects.
Conclusions
Once considered a personality disorder, the result of
psychic conflict, or a problem that occurred secondary to
other psychiatric illnesses (eg, mood disorders), hypochon-
driasis is now well-understood as a primary complaint.
Advances in understanding the psychological, genetic, and
biological processes associated with this condition continue
Curr Psychiatry Rep (2010) 12:306–312
to elucidate the factors that give rise to its development and
maintenance. Recent research has also led to the development
of effective treatments—both psychological and pharmaco-
logic. Growing evidence suggests that a cognitive-behavioral
conceptualization forms the basis for an effective set of
psychological interventions that are especially effective in
reducing disease conviction, avoidance behavior, checking,
and reassurance seeking while improving overall functioning
and quality of life. Nevertheless, hypochondriasis remains
somewhat of a diagnostic enigma, as evidenced by the current
debate over how to incorporate its symptoms in the
forthcoming iteration of the DSM.
Disclosure No potential conflicts of interest relevant to this article
were reported.
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