The departure of hypochondriasis is no loss

DSM digest

Starcevic’s concerns about the removal of the diagnosis of hypochondriasis from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) are initially understandable but can be assuaged on reflection (Starcevic, 2014). For centuries opinions about hypochondriasis have oscillated between gallows humour on the one hand – encapsulated by Spike Milligan’s gravestone inscription ‘I told you I was ill’ – and untreatability on the other. These extremes are now redundant. Health anxiety, or its equivalent antonym, illness anxiety disorder, is one of the strong assets of the DSM revision, as it places the former symptoms of hypochondriasis firmly amongst the anxiety disorders. Although health anxiety has a higher prevalence than DSM-IV hypochondriasis (Sunderland et al., 2013), there is a great deal of overlap, and if health anxiety is defined as a chronic condition with persistent symptoms lasting 6 months or longer most people also satisfy the requirements for DSM-IV hypochondriasis (Tyrer et al., 2014a).

More importantly, the diagnosis of health anxiety gives impetus to successful treatment. Starcevic recognised this in his recent editorial when he commented that a ‘carefully tailored therapeutic approach may therefore improve the outcome of psychological treatments (such as cognitive–behavioural therapy) that have been used with somewhat mixed results for the heterogeneous group of patients with hypochondriasis’ (Starcevic, 2013). Both mindfulness-based and cognitive behaviour therapy for health anxiety (CBT-HA) are excellent examples of such tailored approaches that Starcevic is looking for. These treatments are highly effective both in face-to-face treatment and in computerised form over the Internet (Hedman et al., 2011; McManus et al., 2012; Tyrer et al., 2014a) and are more straightforward and standardised than CBT in many other anxiety disorders, as there is a clear, easily learnt, treatment strategy to tackle the fear of, rather than actual, disease (Tyrer et al., 2014b). We also suspect, as do other researchers in the subject (Muse et al., 2012), that the incidence of health anxiety is increasing as a consequence of ready access to medical knowledge on the Internet, a condition now described as cyberchondria. In our recent studies, more than 70% of health-anxious patients used this medium as their main source of medical information.

The other symptoms covered by the old diagnosis of hypochondriasis may not be served very well by ‘somatic symptom disorder’ in DSM-5, but, as many of its symptoms are linked to depressive symptomatology, when these are subsumed under the depressive diagnoses and treated accordingly, this may also remove the impression of untreatability. ‘The hypochondriacal patient does not seek cure but palliation through a long-term relationship with the physician. If cure is the goal of physicians they will almost certainly be disappointed’, wrote Adler authoritatively in The New England Journal of Medicine (Adler, 1981). It is this kind of passive acceptance of a highly morbid condition that has to be eradicated, and the field has not been helped by the continued use of an outmoded diagnosis. Now hypochondriasis can be dispatched to the history of psychiatry, it will no longer be a therapeutic millstone to its former sufferers.