Anxiety

Illness Anxiety Disorder

Real or fake in the wake of COVID-19?

Posted Nov 21, 2020

As of mid-October 2020, over 39 million confirmed cases of COVID-19 had been reported worldwide. The United States is the most affected country, with over 8 million confirmed cases. 

Frank John Ninivaggi MD
Psychiatric Screening Notes
Source: Frank John Ninivaggi MD

COVID-19 symptoms lead to respiratory distress but also can affect other organ systems, including the brain, with neurological and psychiatric symptoms emerging. Physical and social isolation, the disruption of daily routines, financial stress, food insecurity, and many triggers for the stress response intensify this pandemic's burden.

Illness Anxiety Disorder

COVID-19 has generated pervasive anxiety almost in everyone with and without the virus.

The Centers for Disease Control (CDC) (June 2020) found that 40 percent of people experienced mental health problems with new-onset symptoms.

Illness Anxiety Disorder was new to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition in 2013 (DSM-5). About 20 to 25% of those previously having the DSM-IV diagnosis "hypochondriasis" are subsumed under Illness Anxiety Disorder (code: F45.21) in DSM-5. Characteristics are a preoccupation with having or acquiring a serious illness. Somatic symptoms are not present. The primary anxiety focuses on the concern about getting sick, not on the symptoms. If physical symptoms are present, they are few and mild. There is a high level of health anxiety. Patients present these problems in medical rather than mental health care settings.

In Illness Anxiety Disorder, no or very mild symptoms may be present. The patient's primary concern is fear about having or getting a serious disease despite normal physical findings and laboratory testing. High health anxiety is dominant. Behavioral symptoms of avoidance or repeated bodily checking occur. Persons may become care-seeking or care-avoidant. People riddled with this troubling health anxiety misinterpret their bodily sensations. This disorder impairs daily life activities and causes significant distress and substantial role impairment in relationships, family, and job. While this disorder's etiology is unknown, its estimated prevalence ranges from about 0.1 to 6 percent in the general population. 

Another mental health disorder does not better explain the individual's illness preoccupation, yet excessive health-related behaviors exist. You cannot have another anxiety disorder and "illness anxiety" by the current definition. Because Illness Anxiety Disorder is a new classification, DSM states that exact comorbidities are unknown. Illness anxiety complaints are more than what one would expect from typical patient histories, physical examinations, or laboratory findings. There may be an absence of objective conclusions fully to explain the clinical presentation. Other mental disorders, such as depressive and anxiety disorders, may coexist with Illness Anxiety Disorder. However, these other disorders do not explain the circumscribed "illness anxiety." It becomes a problem in itself.

Illness anxiety disorder is not present if the person is anxious about becoming ill but has insight. Not reaching irrational proportions and resorting to unnecessary life-impairing behaviors is key.

The Challenge of Discerning COVID's Nuances

Differentiating Illness Anxiety Disorder from real illness has become a challenge to both psychiatrists and other health professionals. Since COVID-19 is now a universal part of our shared experience, issues related to it are plentiful. There are tests available detecting the presence or absence of COVID-19, even though patients may need repeat testing. Although respiratory symptoms may be present, many other symptoms and signs (e.g., fever, fatigue, muscle pain, loss of smell and taste, GI distress, and others) may be found. Precautions such as quarantine of exposed cases and isolation of those infected bring bouts of loneliness to the forefront. Thus, differentiating real illness from its absence requires contextualizing individual patients and their worries.

When a patient has distressing anxiety as the primary or isolated complaint, a psychiatrist needs to rule out real medical and psychiatric problems. Past history and current circumstances need to be detailed. Also, routine laboratory screening, referral to appropriate medical caregivers, and assessing for a primary anxiety disorder, an obsessive-compulsive disorder, anxiety secondary to depression, a body dysmorphia, an emerging delusional or substance-induced disorder, to name a few, are done.

When the above prove negative, the presumption of an Illness Anxiety Disorder is made. This finding is discussed collaboratively with the patient so that psychoeducation forms the platform for informed consent and devising a collaborative treatment plan. Interventions may include psychotherapies such as cognitive-behavioral therapy and consideration of antianxiety medications. Precision dosing to attain efficacy and minimize toxicity is the goal. Frequency and duration are determined by context and individual responses.

Illness Anxiety Disorder was coined well before DSM-5 but has increased prominence now. Its fate may ride on the wave that COVID-19 takes.

References

Czeisler ME, Lane RI, Petroski E, et al. Mental Health, Substance Use, and Suicidal Ideation During the COVID-19 Pandemic---United states, June 24-30, 2020. MMWR Morb Mortal Wkly Rep. 2020;69 (32):1049-1057.

Ninivaggi F J. Malingering. In Sadock BJ, Sadock, VA eds. Kaplan & Sadock's Comprehensive Textbook of Psychiatry, 10th Ed. Baltimore, Maryland; Wolters Lippincott, Williams & Wilkins 2017:2399-2413.

Rogers R, Granacher RP. Conceptualization and assessment of malingering. In: Drogin EY, Dattilio FM, Sadoff RL, Gutheil TG, eds. Handbook of Forensic Assessment: Psychological and Psychiatric Perspectives. Hoboken: Wiley; 2011:659–678.

Saeed SA, Hebishi K. The psychiatric consequences of COVID-19: 8 studies. Current Psychiatry. 2020:19(1):23-35.

Scarella, T M, Boland, R J, Barsky, A J. Illness Anxiety Disorder: Psychopathology, epidemiology, clinical characteristics, and treatment. Psychosomatic Medicine. 2019: (5):398-407. doi: 10.1097/PSY.0000000000000691.

Taquet M, Luciano S, Geddes JR, Harrison PJ. Bidirectional associations between COVID-19 and psychiatric disorder: retrospective cohort studies of 62 354 COVID-19 cases in the USA.Lancet Psychiatry. 2020. Published Online November 9, 2020, https://doi.org/10.1016/ S2215-0366(20)30462-4.