6 General adult psychiatry6.1 Psychiatric disorders in adulthood
6.1.8 Disorders of bodily distress and bodily experience
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Written by Resident Doctor Committee · Published
Hypochondriasis and illness anxiety
Definition and classification
Hypochondriasis (health anxiety) is a persistent fear or conviction of having one specific, named serious disease.
Patients check repeatedly, and normal tests and specialist reassurance give only brief relief.
System | Where it sits | Labels |
|---|---|---|
ICD-11 | Obsessive-compulsive or related disorders | Hypochondriasis |
ICD-11 groups hypochondriasis with obsessive-compulsive disorders because its preoccupation, checking, reassurance seeking and avoidance resemble them.
Telling it from its neighbours
Condition | How it differs from hypochondriasis |
|---|---|
Bodily distress disorder (formerly somatisation) | The focus is the bodily symptoms themselves, often many across body systems, not one feared disease |
Delusional disorder or psychotic illness | The somatic belief is a fixed delusion |
Factitious disorder | The patient deliberately deceives; in hypochondriasis the belief is genuine |
Panic disorder | Fear peaks during discrete attacks |
Depression | Illness preoccupation occurs within a depressive syndrome |
In hypochondriasis the belief is an overvalued idea: it can be briefly loosened and the patient may concede being wrong, showing partial insight.
Epidemiology and comorbidity
Hypochondriasis affects men and women at roughly equal rates (about 1:1), whereas neighbouring neurotic, mood and somatoform conditions are commoner in women.
Generalised anxiety disorder (GAD) is the most frequent psychiatric comorbidity, found in over half of cases.
Comorbidity in the classic outpatient series | Rate |
|---|---|
GAD | About 71% |
Depression and dysthymia | About 43 to 45% |
Somatisation disorder | About 21% |
Panic disorder | About 17% |
Among anxiety disorders alone, GAD is commonest (about 28.5%, roughly twice any other), then agoraphobia (about 16%), panic disorder (about 14%), and obsessive-compulsive disorder (OCD) and post-traumatic stress disorder (PTSD) at about 13% each.
In that same count, major depression is the most frequent single comorbidity overall.
Maintenance and management
Selective attention makes ordinary sensations noticeable, and people interpret them as serious disease.
Checking and reassurance lower anxiety briefly, which reinforces them; repeat tests only when clinically justified.
Cognitive behavioural therapy (CBT) reduces checking and reassurance through behavioural experiments and exposure to uncertainty.
One named clinician with planned appointments prevents fragmented assessment.
Selective serotonin reuptake inhibitors (SSRIs) are used off label, as none holds a UK licence for health anxiety; avoid routine benzodiazepines.
Somatisation disorder and somatic symptom disorder
Terminology
Classification | Category |
|---|---|
ICD-11 | Bodily distress disorder, which replaces the somatoform disorders |
"Worried well" is an informal, undefined label for people seen as over-using health services; it is patronising, unprofessional and doctor-centred, and is neither a diagnosis nor a description of healthy people.
Bodily distress disorder
Bodily distress disorder is persistent, distressing bodily symptoms with excessive attention to them, lasting months.
It brings repeated health-care contact and functional impairment, and normal investigations give only brief relief.
Symptoms are typically multiple, across several organ systems, and shift over time, rather than a fixed complaint in one system.
Symptoms need not be medically unexplained: the diagnosis can sit alongside physical illness when attention is clearly excessive for that condition's nature and course.
Severity is graded by functional impact.
ICD-11 requires symptoms on most days for at least several months, with excessive attention that persists despite appropriate examination, investigation and reassurance.
Symptoms are real and involuntary, so a normal test or repeated attendance does not mean fabrication.
Epidemiology
Prevalence is about 5 to 7% in adults and higher in primary care.
There is no sex difference before puberty and a female excess after it.
Onset is usually in adolescence or early adulthood.
Maintenance
A sensation draws attention, is read as threatening and grows more noticeable as arousal rises. Checking, rest, reassurance and avoidance relieve fear briefly but keep it going.
Differential diagnosis
Bodily distress disorder centres on the symptoms themselves.
Condition | What dominates |
|---|---|
Hypochondriasis | Fear of a named disease |
Factitious disorder | Deliberate production of symptoms, with no obvious external reward |
Malingering | Deliberate falsification for external gain; not a psychiatric disorder |
Dissociative neurological symptom disorder | Functional neurological loss |
Delusional disorder | A fixed false belief |
Depression or generalised anxiety disorder | Somatic complaints within the wider syndrome |
Fibromyalgia is chronic widespread pain with fatigue, unrefreshing sleep and cognitive symptoms, often worse with stress; examination is normal apart from tenderness, and investigations are normal.
Harms
Medical care itself is the main hazard: repeated tests, radiation, surgery and drugs, including opioid dependence in pain presentations.
Iatrogenic harm, including prescribed-drug dependence, and hostility and splitting within the treating team are characteristic.
Management
A named clinician, usually in primary care, coordinates care with planned reviews, so a new crisis is not needed to secure attention.
Clinicians give a positive explanation, validate the symptoms and check old records before repeating tests.
Adapted cognitive behavioural therapy targets interpretations, checking, reassurance and avoidance.
Depression and anxiety are treated when present.
Clinicians review opioids, benzodiazepines and unnecessary antibiotics, and taper dependence-forming drugs safely.
Investigation is not escalated without plausible benefit, but justified medical care stays available.