Some Things About Health Anxiety
My Uncle Jack was always certain he was sick. My parents used to make light of it. They even remembered when it started. Like my Dad, my Uncle Jack (Dad’s bestie) was a Vietnam veteran. They’d both served multiple combat tours and were both highly decorated. My Uncle Jack had the great misfortune of fighting in the siege of Khe Sanh in 1968, a battle credited with being one of the longest and bloodiest of the Vietnam war. He made it out of Khe Sanh and home from the jungle, but he was scheduled to return a year or so later. That return never happened. He got sick, and from then (if we’re to believe my father) until he died at the ripe old age of 89, he was obsessed with illness and convinced, at least most of the time, that he had something serious that the doctors were unwilling or unable to identify.
My Uncle Jack’s real or perceived health issues were a running joke. I admit that I grew up chuckling about his obsession with his health. He laughed about it sometimes himself. As a kid, I had no idea that THINKING and WORRYING about being sick could be just as bad or worse than actually being physically ill. I also didn’t understand that his laughter didn’t necessarily mean he thought it was funny.
I know differently now. My own anxiety about my body, and specifically about any aches, pains, or strange passing sensations has been known to cause me significant distress. I’ve also worked with clients that struggled with these issues and whose daily lives are negatively impacted.
It’s important to understand that health anxiety exists on a continuum. Some concern and worry about one's health is normal - especially when there is an identified illness or risk of illness. This might even translate to nervousness around doctors and increased distress around scheduled medical appointments. For some people, however, that "normal" worry and concern clicks up to a new level that can significantly disrupt their ability to function in different areas of their lives.
The diagnostic label that used to apply health anxiety was Hypochondriasis.That label was codified in the Diagnostic and Statistical Manual of Mental Health Disorders 1st Edition (DSM-I) published by the American Psychiatric Association in 1952 and remained a recognized diagnosis in the 2nd (1968), 3rd (1980), 4th (1994), and 4th Text Revision (2000) editions. The DSM-IV-TR listed the following criteria for Hypochondriasis:
A. Preoccupation with fears of having, or the idea that one has, a serious disease based on the person's misinterpretation of bodily symptoms.
B. The preoccupation persists despite appropriate medical evaluation and reassurance.
C. The belief in Criterion A is not of delusional intensity (as in Delusional Disorder, Somatic Type) and is not restricted to a circumscribed concern about appearance (as in Body Dysmorphic Disorder).
D. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
E. The duration of the disturbance is at least 6 months.
F. The preoccupation is not better accounted for by Generalized Anxiety Disorder, Obsessive-Compulsive Disorder, Panic Disorder, a Major Depressive Episode, Separation Anxiety, or another Somatoform Disorder.
The DSM-V was published in 2013, and Hypochondriasis was removed. Two new diagnostic labels were created: Somatic Symptom Disorder and Illness Anxiety Disorder. Essentially they break down like this: People suffering from Somatic Symptom Disorder are excessively preoccupied with physical symptoms like aches and pains. Those with Illness Anxiety Disorder may not have significant physical complaints but are preoccupied with either having or acquiring a serious illness. They may also engage in what’s commonly called compulsive body-checking, looking for signs of illness like lumps and lesions. People suffering from either of these issues experience significant distress and may have difficulty functioning in one or more areas of their lives.
Does it feel like the APA is at it again - just adding more problems for people to identify with, or are they splitting hairs, creating 2 labels when 1 was just fine? Maybe. I mean, don’t get me wrong, I have a lot to say about over-diagnosing, labeling, and classifying, but I can also see some benefits, and I want to speak to those.
First, the term hypochondriac, the label hoisted on folks who struggle with the symptoms we’ve talked about, is pejorative and highly stigmatized. I didn’t understand stigma when I was a little kid, and I didn’t know that calling my Uncle Jack a hypochondriac was anything but a little funny. The truth is that stigma prevents people from getting help, and that is never ever good. The stigma associated with the word hypochondriac extends into the medical community. Folks who struggle with these kinds of symptoms often perceive and/or experience invalidation from the doctors that they go to for help. Over time, this can lead people to not only stop seeking medical help, but it can also prevent them from seeking help for the anxiety that is disrupting their lives. Anything that can help shift away from stigma is a good idea, and I believe changing the diagnostic labels, while not being a total fix, could be a move in the right direction.
The second benefit that I can see is that knowing and understanding the unique symptoms associated with the different specific struggles individuals face can be helpful in developing a more useful treatment plan, which leads to better, more focused care. If someone struggles with Somatic Symptom Disorder, helping them learn to ease the intensity of their physical symptoms through breath titration or teaching them a technique like pendulating awareness may help ease some of their distress. On the other hand, a person with Illness Anxiety may benefit from directly facing their fears by making an appointment for a physical. Good, symptom-specific treatment planning is an essential piece of the clinical puzzle. If a diagnostic label can help a clinician focus more clearly on their client’s unique needs, it’s a plus.
My Uncle Jack lived over 40 years with health anxiety. Had he walked into a clinician’s office way back in the 1970s, he probably would have been diagnosed with Hypochondriasis. If he were alive now and sought help, he might receive a diagnosis of Illness Anxiety. Chances are, he wouldn’t have sought help at all. This makes me sad because I truly believe he could have been happier, more content if he hadn’t struggled the way he did.
When health anxiety disrupts someone’s ability to function or gets in their way enjoying their lives, it has gone beyond “normal” everyday health worry. It has become unnecessary suffering. People who suffer in this way deserve to be validated and treated with dignity and respect. It’s my belief that increasing understanding of health anxiety, reducing stigma, and creating more focused appropriate care are 3 important parts of ensuring that happens.