Will hypochondriasis be “alive and well” in the ICD-11?

To the Editor

Aubrey Lewis (1975) famously commented in reference to hysteria that some psychiatric concepts tend to outlive their obituarists. In this regard, is hypochondriasis of the 2010s similar to hysteria of the 1970s?

The DSM-5 has controversially discarded hypochondriasis and replaced it with illness anxiety disorder and somatic symptom disorder. This decision has been met with both criticism (Starcevic, 2014) and cautious approval (Tyrer and Tyrer, 2014).

While hypochondriasis has been officially “dead” in the United States for more than a year insofar as the DSM-5 is the “law of the land” there, the term has been revived in the proposals for ICD-11. The description of hypochondriasis in the ICD-11 Beta Draft (available online) is quite similar to the DSM-IV diagnostic criteria for hypochondriasis. Thus, hypochondriasis is depicted as a persistent preoccupation with or fear of the possibility of having a serious disease or the conviction that one is already seriously ill. Misinterpretation of bodily symptoms is also included in the description. Using exactly the same wording as the DSM-IV, it is stipulated that hypochondriasis persists despite appropriate medical evaluation and reassurance.

Classifying hypochondriasis has always been challenging. Importantly, the ICD-11 Beta Draft suggests that it should be classified among both obsessive-compulsive and related disorders (OCRD) and “anxiety and fear-related disorders”. The classification of hypochondriasis as an OCRD is due to an emphasis on “preoccupation” in its description, a questionable assumption that preoccupations and obsessions are conceptually related to the point of being almost synonymous and the fact that some cases of hypochondriasis resemble obsessive-compulsive disorder. The conceptualisation of hypochondriasis as an anxiety disorder makes sense when it is primarily characterised by fear and avoidance behaviour, but hypochondriasis could also be grouped along with “bodily distress disorders” when its predominant features are distressing bodily symptoms. Such a “multiple” classification would resemble the DSM-5 classification of schizotypal personality disorder both among personality disorders and schizophrenia spectrum and other psychotic disorders and classification of antisocial personality disorder both as a personality disorder and as one of disruptive, impulse-control and conduct disorders.

Although the proposed ICD-11 description and classification of hypochondriasis are not final, it is clear that hypochondriasis possesses a remarkable resilience. Perhaps that is not surprising for an ancient term that has survived many psychiatric perturbations. Indeed, we may still have something to learn from the concept it embodies instead of eliminating it as a presumably useless and politically incorrect term.