Illness Anxiety Disorder: A Review of the Current Research and Future Directions

Abstract

Purpose of Review
We review recent evidence on Illness Anxiety Disorder (IAD), including risk factors and precipitants, diagnostic classification, clinical characteristics of the disorder, and assessment and treatment in both children and adults.

Recent Findings
IAD places a substantial burden on both individuals and society. Despite its impact, understanding of the disorder is lacking and debates remain about whether IAD should be classified as an anxiety disorder and whether it is distinct from Somatic Symptom Disorder. Cognitive behavioural therapy (CBT) is an effective treatment for IAD and there are multiple validated measures of health anxiety available. However, research on health anxiety in children and youth is limited.

Summary
IAD is chronic, and debilitating, but when identified, it can be effectively treated with CBT. Research using DSM-5 IAD criteria is lacking, and more research is needed to better understand the disorder, particularly in children and youth.

Full text

Vol.:(0123456789)
Current Psychiatry Reports (2024) 26:331–339
https://doi.org/10.1007/s11920-024-01507-2
RESEARCH
Illness Anxiety Disorder: AReview oftheCurrent Research
andFuture Directions
KatarinaKikas1,2 · AlizaWerner‑Seidler1,2 · EmilyUpton1,2 · JillNewby1,2
Accepted: 23 April 2024 / Published online: 15 May 2024
© The Author(s) 2024
Abstract
Purpose of Review We review recent evidence on Illness Anxiety Disorder (IAD), including risk factors and precipitants,
diagnostic classification, clinical characteristics of the disorder, and assessment and treatment in both children and adults.
Recent Findings IAD places a substantial burden on both individuals and society. Despite its impact, understanding of the
disorder is lacking and debates remain about whether IAD should be classified as an anxiety disorder and whether it is dis-
tinct from Somatic Symptom Disorder. Cognitive behavioural therapy (CBT) is an effective treatment for IAD and there are
multiple validated measures of health anxiety available. However, research on health anxiety in children and youth is limited.
Summary IAD is chronic, and debilitating, but when identified, it can be effectively treated with CBT. Research using DSM-5
IAD criteria is lacking, and more research is needed to better understand the disorder, particularly in children and youth.
Keywords Illness anxiety disorder· Hypochondriasis· Health anxiety· Anxiety disorders· Somatoform disorders·
Diagnostic classification
Introduction
While many individuals experience transient health concerns
throughout their lives, a subset of individuals experience
enduring and distressing anxiety about health and illness. Ill-
ness Anxiety Disorder (IAD) is a new disorder introduced in
the latest version of the Diagnostic and Statistical Manual of
Mental Disorders [DSM-5; 1], replacing the DSM-IV Hypo-
chondriasis diagnosis. IAD is characterised by an intense
fear of having or acquiring a serious medical disease or ill-
ness, such as cancer, heart disease or other significant condi-
tions. Individuals with IAD experience illness-related cog-
nitions, such as intrusive thoughts and images, and engage
in various maladaptive coping behaviours, such as seeking
excessive medical reassurance, searching for health informa-
tion online, and checking their body for signs of illness. The
DSM-5 proposes two subtypes of IAD: the ‘care-seeking’
subtype for individuals who frequently seek medical care
and the ‘care-avoidant’ subtype for individuals who avoid
medical care. As IAD is a new disorder, historically, much
of the research has focused on samples exhibiting DSM-IV
Hypochondriasis (which focused on excessive preoccupation
with having a serious illness, despite medical reassurance)
or excessive and persistent ‘health anxiety’ using dimen-
sional measures (which can encompass current and previous
DSM diagnoses and subthreshold symptoms). In this review,
we use the term IAD for research on the new DSM-5 diag-
nosis, and the term health anxiety for the broader literature
which informs current understanding of IAD.
Epidemiology: Prevalence, andImpact
Health anxiety can be conceptualised on a continuum, rang-
ing from mild to severe [2, 3], with IAD at the severe end
of this spectrum [1]. The prevalence of health anxiety in
the general adult population varies considerably across the
literature and is estimated to range between 2.1–13.1% [4,
5]. The prevalence rates of health anxiety are higher in medi-
cal settings such as primary care (i.e., general practitioner
clinics) and secondary care (i.e., specialised outpatient or
inpatient clinics) than in the general community, ranging
between 7% and 19.9% [6–8]. Health anxiety has been on
* Jill Newby
j.newby@unsw.edu.au
1 Black Dog Institute, University ofNew South Wales,
Hospital Road Randwick, Sydney, NSW2031, Australia
2 School ofPsychology, University ofNew South Wales,
Sydney, Australia
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332 Current Psychiatry Reports (2024) 26:331–339
the rise over the past three decades in both the community
and medical settings [8, 9•]. This increase has been fur-
ther exacerbated by the COVID-19 pandemic, where health
anxiety and fears of COVID-19 were common [10]. If left
untreated, health anxiety is chronic, episodic, and can last
for years [11, 12]. Unlike depression and anxiety disorders,
which tend to show higher rates in females, health anxiety
affects men and women equally [13–15]. While the onset of
health anxiety typically occurs in early adulthood [1], some
research suggests that it may start as early as childhood in
some cases [12, 13, 16–18].
Health anxiety causes significant impact and impairment
to individuals and society. For example, health anxious indi-
viduals report worse self-rated health, more interference
with daily activities such as household duties, self-care and
mobility, more personal distress, and are at increased risk
of early mortality [4, 19–21]. Health anxiety impacts at a
societal level; individuals with health anxiety report more
absenteeism from work than the general population [22] and
higher health care utilisation even compared to individuals
with well-defined medical conditions [11]. Although the sig-
nificant burden of health anxiety on individuals and society
is recognised, there are gaps in our understanding of the
condition. This review aims to summarise recent literature
on health anxiety, and specifically on Illness Anxiety Disor-
der (where research has studied the new DSM-5 diagnosis),
identify research gaps, discuss ongoing debates, and suggest
avenues for future research to enhance our understanding of
the condition.
Issues withDiagnosis andClassification
Diagnostic Criteria
According to the DSM-5, IAD is only diagnosed when a per-
son experiences either no or mild somatic symptoms. If they
experience health anxiety with moderate to severe somatic
symptoms, they may be diagnosed with Somatic Symptom
Disorder (SSD) instead [1]. For an IAD diagnosis, the indi-
vidual will experience excessive worry about either having
or developing a serious medical illness, which persists for
six months or more. The individual will be highly vigilant
about their personal health status, resulting in various mala-
daptive coping behaviours (i.e., checking their bodies for
signs of illness, excessively searching the internet for health-
related information, and making frequent visits to medical
settings). Individuals with an SSD diagnosis will experience
excessive and persistent thoughts related to the seriousness
of their moderate-to severe somatic symptoms, and/or high
levels of anxiety about their health or symptoms and dedi-
cate significant time to researching and understanding their
symptoms in depth. Their somatic symptoms must also last
longer than 6months but can change across their course.
IAD and SSD were put forward to replace DSM-IV Hypo-
chondriasis due to its limited clinical validity, and research
suggests that IAD and SSD are more reliable than Hypo-
chondriasis [12]. However, having two separate diagnoses is
not clinically useful, as research has found there are few dif-
ferences in how individuals with health anxiety experience
the disorders [12, 23••, 24, 25]. Specifically, the differences
that have been reported relate to symptom severity, whereby
IAD characterizes individuals with a milder form of health
anxiety and SSD represents individuals with a more severe
form of health anxiety. Additionally, research has shown that
both IAD and SSD respond similarly to psychological treat-
ment [26]. Furthermore, recent research done by our team
[25] showed that there were no differences on demographic
characteristics, clinical characteristics (i.e., depression and
generalized anxiety severity, quality of life related to mental
health), the nature and course of health anxiety, or mental
health comorbidity, between people who met IAD criteria
with no/mild somatic symptoms versus those with moderate-
to-severe somatic symptoms. These findings suggest that
the distinction in somatic symptom severity between these
disorders might be arbitrary [25, 27]. Further research is
needed to understand whether restricting IAD to only those
with minimal somatic symptoms is clinically useful.
The DSM-5 categorizes IAD into two subtypes: ‘care-
seeking’ for individuals that frequently seek medical care,
and ‘care-avoidant’ for individuals that frequently avoid
medical care. Although researchers have proposed that indi-
viduals seek care as a form of reassurance and avoid care
out of an overwhelming fear of having a serious disease
[28], evidence about these behaviours remains scarce. To
date, our team conducted the only study investigating the
prevalence of IAD subtypes and found that 25% met cri-
teria for the ‘care-seeking’ subtype, 14% met criteria for
the ‘care-avoidant’ subtype, and interestingly, 61% reported
fluctuating between seeking and avoiding care. This sug-
gests that there may be a third subtype of IAD which needs
further study [12].
Classification
There has been a long-standing debate about whether health
anxiety would be better classified under “Anxiety Disorders”
than under its current classification “Somatic Symptom
and Related Disorders” due to its shared features and high
comorbidity with anxiety disorders, namely Panic Disorder,
Obsessive–Compulsive Disorder, and Generalized Anxiety
Disorder [29–32]. For example, health anxiety involves
both hypervigilance to bodily sensations (a common char-
acteristic in Panic Disorder) and excessive worry (a core
feature of Generalized Anxiety Disorder). Research using
the DSM-IV Hypochondriasis criteria has shown higher
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333Current Psychiatry Reports (2024) 26:331–339
levels of comorbidity with anxiety disorders than comorbid
depressive or somatoform disorders [33]. Similarly, sub-
stantial comorbidity was found between DSM-5 IAD and
other anxiety disorders, particularly Generalized Anxiety
Disorder and Panic Disorder [12]. To determine whether
IAD should be better classified as an anxiety disorder, future
research should investigate whether IAD symptom profiles,
course, treatment response and comorbidities more closely
align with anxiety disorders compared with other somatic
symptom disorders.
Cognitive andBehavioural Aspects
ofHealth Anxiety
Theories
Several theories have been proposed to explain the devel-
opment of health anxiety. The most widely tested theory
is based on the cognitive-behavioural model [34] which
suggests that individuals with health anxiety tend to misin-
terpret bodily sensations, often attributing them to serious
illness or disease. This catastrophic thinking leads to the
adoption of maladaptive safety behaviours, such as seeking
excessive medical reassurance, googling of symptoms and,
in some cases, avoiding medical settings or individuals who
are sick as a way to manage anxiety symptoms. This theo-
retical model of health anxiety has been subject to empirical
investigation, and research broadly supports the components
of this model [35].
The other major theory of health anxiety is based on the
interpersonal model [36]. This model proposes that anx-
ious and insecure attachments derived from caregivers in
early childhood leads to increased maladaptive care-seeking
behaviours and reassurance seeking in adulthood [37]. The
core tenant of this theory is that insecurely attached indi-
viduals seek emotional support via complaints of physical
illness and symptoms to reduce the feelings of insecurity.
It is important to note that this theory has not been widely
tested.
Cognitive Components
One of the core characteristics of health anxiety is the pres-
ence of dysfunctional health beliefs, i.e., the preoccupation
with the inaccurate belief that one has, or is in danger of
developing, a serious medical illness [38]. These beliefs
persist despite appropriate medical evaluation and reassur-
ance [39]. Dysfunctional health-related beliefs comprise of
either disease conviction (i.e., the belief one has a feared
illness or disease) and/or fear of contracting an illness or
disease [40]. Salkovskis and Warwick’s [40] Cognitive-
Behavioural Model of health anxiety identifies four types
of dysfunctional beliefs central to health anxiety, including
the perceived i) likelihood and ii) awfulness of experiencing
a health problem, iii) the inability to cope with experiencing
a health problem, and (iv) inadequacy of medical resources
to treat a health problem [40, 41]. These beliefs are key vul-
nerability and maintaining factors in health anxiety [42, 43],
and are argued to develop in response to aversive learning
experiences during childhood or later in life, such as the
death or illness of an attachment figure [44].
It is proposed that these beliefs contribute to catastrophic
misinterpretations of the significance of health-related stim-
uli, such as bodily sensations or changes in bodily func-
tions or appearance, leading to intense anxiety [45]. A key
contribution to this misinterpretation is an attentional bias
towards health-threat related stimuli, which has shown to
be strongly associated with health anxiety in a recent sys-
tematic review and meta-analysis [46]. Health-anxious indi-
viduals have also been shown to experience more frequent
and intense illness-related intrusive thoughts [47, 48], and to
demonstrate a selective negative interpretation bias of these
thoughts or sensations [49].
Further cognitive constructs related to health anxi-
ety include higher levels of anxiety sensitivity, the fear of
arousal-related bodily sensations [50, 51], health-related
rumination [52], and health-related intolerance of uncer-
tainty which is essentially a reduced capacity to endure the
perception of missing important information [53–55].
Behavioural Components
To manage anxiety and distress triggered by these dysfunc-
tional beliefs and interpretations, health-anxious individu-
als employ a range of maladaptive coping or safety-seeking
behaviours. Each of these behaviours is maladaptive in that
although they reduce distress in the short-term, they pre-
vent the disconfirmation of incorrect health-anxious beliefs,
thus maintaining the disorder [56]. These typically com-
prise of reassurance-seeking from external sources (e.g.,
loved ones or doctors), excessive body checking behaviours
(e.g., repeatedly taking blood pressure) and/or avoidance
of disease-related cues (e.g., hospitals) [57]. Compulsive
and excessive online researching about health worries is a
key feature seen in health anxiety, also known as ‘cyber-
chondria’ [58]. Overutilisation of health services is also
considered a core maladaptive coping behaviour in health
anxiety [11, 59].
Risk Factors andPrecipitants
Research into precipitants and risk factors for IAD is lack-
ing. Several life experiences have been proposed as pre-
cipitants of health anxiety, such as experiencing major life
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334 Current Psychiatry Reports (2024) 26:331–339
stress, a serious threat to one’s health, witnessing a loved
one’s illness, and being exposed to health-threatening infor-
mation [34, 45]. However, evidence supporting these pre-
cipitants is lacking.
No studies have examined risk factors for developing
IAD using the new DSM-5 criteria. However, a recent sys-
tematic review of studies using dimensional health anxiety
measures showed some evidence of a positive association
between childhood experiences of illness, intergenerational
transmission of health anxiety (including genetic heritability
and vicarious observations of parents with health anxiety),
childhood traumatic experiences, and the development of
health anxiety [60]. However, it is unclear whether these risk
factors were specific to health anxiety or general risk factors
for internalizing disorders. Of the limited research that has
been conducted investigating the intergenerational transmis-
sion of health anxiety, a twin study found that 34–37% of
health anxiety traits, such as fear of illness and interference
with functioning caused by bodily sensations, were related
to genetics, whereas the remaining traits were attributed to
environmental factors [61].
Neurobiology
There has been a lack of research examining the neurobio-
logical basis for IAD and health anxiety more broadly. Stud-
ies using the emotional stroop task and implicit association
test have both showed increased amygdala activation, as well
as activity in the rostral anterior cingulate cortex [62] and
right posterior parietal cortex and nucleus accumbens [63]
in response to body-symptom words between health anxious
and healthy controls. In contrast, a recent study found no dif-
ferences in amygdala activity or any brain activity between
patients with health anxiety and healthy controls when
exposed to health-related pictures [55]. More research is
needed to understand the biological underpinnings of IAD.
Assessment andTreatment
Assessment
Dimensional measures of health anxiety are widely used to
determine the presence of severe and pathological health
anxiety. The three most widely used assessment measures
are the Whitley Index [64], Illness Attitude Scale [65], and
the Health Anxiety Inventory [66]. All three measures have
been psychometrically validated and shown good reliability
[66, 67]. A shortened version of the Health Anxiety Inven-
tory [66] and Whitley Index 6 [68] have been developed and
widely used in clinical settings due to their practicality and
brief nature [69, 70]. However, due to the lack of research
in IAD samples, the optimal cut-off scores to detect IAD on
these widely used measures are unknown (as studies have
validated them against Hypochondriasis criteria).
Diagnostic instruments have also been developed and
used to assess IAD. The three most widely used stand-
ardized, semi-structured interviews are: The Anxiety and
Related Disorder Interview Schedule for DSM-5 – Adult
Version [71], the Health Preoccupation Diagnostic Inter-
view [72], and the Structured Clinical Interview for DSM-5
(SCID-5) [73].
Treatment
The most widely supported evidence based psychological
treatment for health anxiety and IAD is Cognitive Behav-
ioural Therapy (CBT). CBT typically consists of strategies
including psychoeducation; cognitive restructuring of cata-
strophic beliefs about health and bodily symptoms; behav-
ioural strategies to reduce hypervigilance to body sensations
and compulsive coping behaviours such as body checking,
reassurance-seeking, and avoidance; and relapse preven-
tion. Evidence from meta-analyses [74, 75••, 76] shows that
CBT is a highly efficacious and cost-effective treatment for
health anxiety, with a moderate to large pooled effect size on
health anxiety [Hedge’s g = 0.81, 95% CI [0.37, 1.26]; 76]
compared to non-CBT controls, with improvements largely
maintained over 12–18months [74]. Evidence also supports
the delivery of CBT for health anxiety and IAD online [26,
58, 77], with large effect sizes when delivered in routine care
[78, 79]. For example, a non-inferiority trial compared inter-
net-delivered to face-to-face CBT (including health anxious
sample with either IAD and SSD) and found no difference
in outcome, but with internet-delivered therapy resulting in
lower net societal costs [80].
Although less research has been conducted on other psy-
chological therapies for health anxiety, some evidence also
supports the use of third-wave therapies for health anxiety
such as Mindfulness-Based Cognitive Therapy (MBCT)
[81, 82] and Acceptance and Commitment Therapy (ACT)
[83, 84], although no studies have tested them in IAD spe-
cifically. MBCT treats health anxiety through applying
mindfulness techniques to defuse from catastrophic health
cognitions, reduce attentional bias towards physiological
symptoms, and confront rather than experientially avoid
feared body sensations, thus reducing unhelpful avoidance
or safety-seeking behaviours [85]. Acceptance and Commit-
ment Therapy (ACT) similarly aims to treat health anxiety
by reducing experiential avoidance of distressing illness-
related thoughts, feelings, and body sensations, promoting
acceptance of these inner states, while clarifying values
and encouraging behaviours that contribute to a meaning-
ful life [84]. A recent randomised controlled trial involving
ACT delivered online showed large effect sizes in reducing
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335Current Psychiatry Reports (2024) 26:331–339
health anxiety at six-month follow up compared to control
(d = 0.80, 95% CI 0.38–1.23) [83]. Pharmacotherapy studies
are lacking, but two studies into treatments for Hypochondri-
asis support the use of Fluoxetine in combination with CBT,
or alone [86, 87], and another earlier study found Paroxetine
yielded similar effectiveness to CBT for hypochondriasis
[88]. No pharmacological studies have yet been conducted
on the new IAD diagnosis.
Children andYouth
Cross-sectional studies have shown that children and adoles-
cents can experience severe health anxiety as assessed using
dimensional measures [89, 90]. However, research examining
the prevalence of health anxiety using diagnostic criteria sug-
gests that very few children meet full diagnostic criteria [18,
91, 92], leading researchers to argue that this could be due to a
lack of appropriate descriptions of how severe health anxiety
presents in children and youth [93]. No specific CBT treat-
ments have been developed to treat health anxiety or IAD in
children or youth [94••] meaning that there are no treatment
studies yet conducted in this age group. Further, there have
been no studies investigating third wave therapies or pharma-
cological approaches to treat health anxiety or IAD in young
people. More research in children and adolescents is needed,
particularly early intervention studies given the chronic and
life-long nature of health anxiety when left untreated.
Conclusions
This review highlights the recent literature on Illness Anxi-
ety Disorder (health anxiety) and identifies current gaps and
points for future directions. First, the long-lasting impact
of health anxiety on the individual and society is well-
documented in the literature. Individuals with health anxi-
ety are debilitated by dysfunctional health beliefs, which, in
turn, manifest into maladaptive coping behaviours. There
are reliable dimensional measures of health anxiety and
diagnostic instruments to assess IAD. CBT is an effective
treatment option for this population, in both face-to-face and
digital formats. However, further research is needed into
third-wave treatments (i.e., MCBT and ACT) and pharma-
cotherapy in samples with IAD.
Second, there is some evidence of a relationship between
illness experiences, intergenerational transmission of health
anxiety, and childhood traumatic experiences as risk factors
for health anxiety. However, it is unclear whether these fac-
tors cause health anxiety.
Third, although the limitations of DSM-IV Hypochondria-
sis were addressed in the DSM-5 with two new disorders,
a debate continues about whether the two disorders should
be combined or remain distinct. Early evidence suggests that
differences between IAD and SSD are a matter of severity
rather than of any distinctive qualitative characteristics, but
replication research is needed across varying populations and
groups. It is also debated whether IAD should be reclassified
into the anxiety disorders category in the next iteration of the
DSM, due to its shared characteristics and high comorbidity
with other anxiety disorders. Future research should exam-
ine the predictive validity of IAD with and without comorbid
anxiety in terms of course and treatment response. In addition,
there has been little done to investigate the ‘care-seeking’ and
‘care-avoidant’ subtypes of IAD. Future research is necessary
to advance knowledge of this condition, particularly if there
are differences between these groups in terms of their nature
and experience, and response to treatment.
Finally, recent evidence suggests health anxiety may start,
at least for some, in childhood and adolescence. However,
due to a lack of developmentally appropriate diagnostic cri-
teria for young people, there is a need to investigate how
health anxiety presents in children and young people and an
urgent need to develop or adapt treatment options that are
appropriate for this population.
Overall, the most significant gap in this field is the limited
number of studies utilising the current diagnostic criteria
for Illness Anxiety Disorder. Addressing this gap is crucial
if we are to significantly advance knowledge, improve our
understanding of the disorder, intervene early, and develop
targeted, effective treatments for the disorder.
Author Contributions K.K. wrote the main manuscript text and E.U.
wrote the 'cognitive and behavioral component's and 'treatment' section
of the manuscript. J.N. and A.WS. reviewed and edited the manuscript.
All authors approved the final version of the manuscript.
Funding Open Access funding enabled and organized by CAUL and
its Member Institutions
Data Availability No datasets were generated or analysed during the
current study.
Declarations
Competing Interests The authors declare no competing interests.
Human and Animal Rights and Informed Consent This study does not
contain any studies with human or animal subjects performed by any
of the authors.
Open Access This article is licensed under a Creative Commons Attri-
bution 4.0 International License, which permits use, sharing, adapta-
tion, distribution and reproduction in any medium or format, as long
as you give appropriate credit to the original author(s) and the source,
provide a link to the Creative Commons licence, and indicate if changes
were made. The images or other third party material in this article are
included in the article’s Creative Commons licence, unless indicated
otherwise in a credit line to the material. If material is not included in
the article’s Creative Commons licence and your intended use is not
permitted by statutory regulation or exceeds the permitted use, you will
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336 Current Psychiatry Reports (2024) 26:331–339
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copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
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