Learning Objectives
By the end of this section, you will be able to:
- Discuss DSM-5-TR diagnosis relative to illness anxiety disorder
- Identify risk factors for illness anxiety disorder
- Give examples of client symptoms and behaviors associated with illness anxiety disorder
- Describe stress responses reported by clients due to illness anxiety disorder
- Plan nursing and collaborative care for clients in treatment for illness anxiety disorder
Illness anxiety disorder is a condition that also involves the complex relationship between physical health and psychological well-being. Nurses’ understanding of illness anxiety disorder is essential for providing compassionate care and support to individuals who experience excessive worry and anxiety about their health. This section discusses the details of illness anxiety disorder, examining its causes, symptoms, and impact on individuals’ lives. It explores evidence-based nursing interventions and strategies that can empower nurses to assist individuals in managing their health anxieties, promoting their overall well-being, and fostering a therapeutic relationship grounded in empathy and understanding.
Medical Diagnosis
The mental health condition characterized by excessive worry and fear about having a serious medical condition, despite having little or no medical evidence to support the belief, is called illness anxiety disorder (IAD). With illness anxiety disorder, somatic symptoms are not present, or if they are, are mild in intensity. The client’s concerns persist despite lack of symptoms and despite medical reassurance, and often cause significant distress and impairment in daily functioning. The key features/diagnostic criteria of illness anxiety disorder include:
- illness preoccupation must be present for six months for diagnosis
- clients often misinterpreting or exaggerating normal bodily sensations, such as dizziness or belching, as evidence of an underlying illness
- excessive health-related behaviors done as a result of their fears and driven by the need for reassurance and validation of their concerns
- high levels of anxiety, distress, and preoccupation with illness that impairs their ability to function normally in various aspects of daily life
- seeking out multiple, different providers for various opinions or exhibiting avoidance behaviors due to fears about a “worst-case scenario” diagnosis or being dismissed as overly anxious
- excessive reassurance-seeking, which either briefly decreases or fails to decrease their anxiety
- heightened awareness and continuous self-examination for signs and symptoms of illness
(Substance Abuse and Mental Health Services Administration [SAMHSA], 2019)
Risk Factors
The risk factors for illness anxiety disorder include a history of trauma, learned behavior, and stress. History of experience with serious illness also increases the likelihood of developing IAD.
Psychosocial Risk Factors
Certain developmental and familial factors may increase the likelihood of developing illness anxiety disorder, such as traumatic experiences in childhood. Having a family member with a history of anxiety disorders or somatic symptom disorders may also increase the likelihood of developing illness anxiety disorder. Observing family members or close friends who exhibit excessive health concerns or engage in frequent doctor visits for minor issues can also influence its development.
Constant exposure in the home environment to medical information, particularly from the internet or media, can lead to excessive health-related concerns. Misinterpretation of medical information or exposure to stories of severe illnesses from family or others can fuel anxiety and hypervigilance.
Specific personality traits and coping styles may be associated with a higher risk of developing illness anxiety disorder. These include high levels of anxiety, neuroticism, and a tendency to catastrophize or amplify physical sensations. Significant life stressors, such as major life changes, job loss, relationship difficulties, or financial problems, can contribute to the onset or worsening of illness anxiety disorder, especially in those with poor coping skills.
Negative experiences with the health-care system, such as misdiagnosis or inadequate medical care, may contribute to the development of illness anxiety disorder. Additionally, individuals who have experienced a genuine medical condition in the past may develop a heightened fear of recurrence or new illnesses.
Behavioral Risk Factors
Certain behaviors may predate, reinforce, and maintain excessive health concerns. Individuals with illness anxiety disorder have often engaged in other excessive behaviors, such as worrying and seeking reassurance from others. People with illness anxiety disorder may spend excessive time online researching medical conditions or diseases, contributing to IAD. Misinterpretation of information or exposure to alarming stories can further fuel anxiety.
Behaviors and Symptoms Associated with Illness Anxiety Disorder
Individuals with illness anxiety disorder may frequently schedule medical appointments, seeking validation or reassurance about their perceived symptoms. They may consult multiple health-care providers or request numerous diagnostic tests and procedures, even in the absence of medical indications. Yet while some clients with illness anxiety disorder actively seek out medical information, others may avoid it altogether to prevent further anxiety or triggering their health-related worries. They may avoid reading or watching news about diseases or medical conditions because it can increase their anxiety and reinforce their fears.
People with illness anxiety disorder tend to be hyperaware of bodily sensations and may interpret normal bodily functions as signs of a severe illness. They may constantly monitor their bodies for any perceived abnormalities and attribute them to serious medical conditions. Individuals with IAD often seek reassurance from others, including health-care professionals, family members, or friends, regarding their health concerns. They may repeatedly ask for confirmation that their symptoms are not indicative of a serious illness.
The preoccupation and anxiety associated with illness anxiety disorder can significantly affect a person’s daily functioning. They may experience difficulty concentrating on tasks, have impaired social interactions due to excessive health-related discussions, or experience interference in work or relationships. Some individuals with illness anxiety disorder may develop strict routines or rituals that provide a sense of control and temporary relief from stressors and concerns.
Clinical Judgment Measurement Model
Recognizing and Analyzing Cues: Illness Anxiety Disorder
Dimi is a thirty-five-year-old female referred to psychiatry from the hospital emergency department (ED) where she presented demanding diagnostic imaging. The client stated that she was fired from her job for attendance and performance issues and wanted to have “proof” to take to the employer. Before meeting Dimi in the mental health unit admission room, the nurse reviews the electronic record from the ED, noting client vital signs and other examination elements to be normal, except for heart rate of 106. The nurse plans to spend an hour completing the admission interview and assessment while establishing a therapeutic relationship with the client.
The nurse introduces themself, describes the environment, asks the client to share what has brought her here today, and begins the nursing data collection.
Client’s responses: “Well, I was fired because of my health problems. I know I have some disease and I’m tired all the time and I need a special diet because of my medical problems. I have a lot of doctor’s appointments, so I miss work. I live by myself and I really can’t date or go out because I never know how I’ll be feeling. I’ve lost three jobs this year.”
The client begins to cry, and the nurse offers her some tissues and waits for her to continue.
“I just really don’t want to have cancer or something bad! I can’t help it if I’m sick, can I? Doctors don’t listen to you! I can’t find one I really like. They do a bunch of tests, but they never find anything. I go online and I see those commercials and I know I have something wrong with me!”
The client is restless in the chair, wringing hands, shaking head. “I try to keep my mind off it . . .”
The nurse collects the data as listed in Table 21.1.
| Recognized Cues from Assessment | Nursing Thought Process: Analyze Cues Using Objective and Subjective Data | Present in Somatic Symptom Disorder | Present in Illness Anxiety Disorder |
|---|---|---|---|
| Objective | |||
| Heart rate 106 | Anxiety | ✔ | ✔ |
| Crying, restless in the chair, wringing hands, shaking head | Anxiety | ✔ | ✔ |
| Demanding diagnostic imaging; wanted to have “proof” | Seeking validation; high levels of services utilization | ✔ | ✔ |
| Fired from job for attendance and performance issues | Interferes with daily life | ✔ | ✔ |
| Subjective | |||
| Was fired because of health problems | Interferes with daily life Somatic symptoms are not present |
✔ | ✔ ✔ |
| I have a lot of doctor’s appointments, so I miss work | Interferes with daily life; high levels of services utilization | ✔ | ✔ |
| I know I have some disease and I’m tired all the time and I need a special diet because of my medical problems | Excessive worry and fear about having a serious medical condition | ✔ | |
| I live by myself and I really can’t date or go out because I never know how I’ll be feeling | Interferes with daily life | ✔ | ✔ |
| I’ve lost three jobs this year | Interferes with daily life | ✔ | ✔ |
| I just really don’t want to have cancer or something bad! I can’t help it if I’m sick, can I? | A tendency to catastrophize | ✔ | ✔ |
| Doctors don’t listen to you! I can’t find one I really like. They do a bunch of tests, but they never find anything. I go online and I see those commercials and I know I have something wrong with me! | Somatic symptoms are not present; no medical evidence; high levels of services utilization Exposure to and misinterpretation of medical information |
✔ ✔ |
|
| I try to keep my mind off it . . . | Ineffective coping | ✔ | |
Stress Responses Reported by Clients
Illness anxiety disorder can have varied and serious effects on the lives of clients. People with illness anxiety often experience persistent worry and preoccupation with the idea of having a serious medical condition. This preoccupation can consume a significant amount of their time, attention, and mental energy, making it difficult for them to focus on other aspects of their lives. Individuals may constantly feel on edge, experience panic attacks, or be overwhelmed by fear and worry about their health. This anxiety can interfere with their ability to relax, enjoy activities, or maintain positive relationships. Individuals may withdraw from social interactions or avoid social events due to their health-related fears. They might be reluctant to share their concerns with others or may seek reassurance excessively, which can strain relationships with family, friends, and health-care providers.
While illness anxiety disorder is primarily a psychological condition, the constant stress and anxiety associated with it can have physical effects on the body. Chronic stress can lead to fatigue, sleep disturbances, muscle tension, headaches, and other physical symptoms, further adding to the individual’s distress.
The preoccupation with health concerns and the associated anxiety can interfere with occupational or academic functioning. Individuals may have difficulty concentrating on tasks, experience reduced productivity, or miss work or school due to medical appointments or health-related worries. This can have a negative impact on their career or educational progress.
People with illness anxiety often seek repeated medical evaluations and undergo numerous medical tests, even when there is no evidence of an underlying medical condition. This excessive health-care utilization can lead to increased medical expenses, time spent in health-care settings, and unnecessary procedures, potentially straining the health-care system.
The persistent worry and preoccupation with health, along with the associated anxiety, can significantly reduce the overall quality of life for individuals with illness anxiety. They may feel trapped in a cycle of fear, distress, and uncertainty, which can impact their overall well-being and satisfaction with life.
Nursing Care
Nursing care of the individual with illness anxiety disorder begins with building a trusting relationship. The nurse should foster an environment where the client feels comfortable expressing their concerns, fears, and anxieties openly. The nurse should actively listen, validate their feelings, and provide reassurance that their concerns are being taken seriously.
Assessment/Screening Tools
When assessing and screening clients with illness anxiety, it is important for nurses to employ a comprehensive and sensitive approach. Begin by conducting a thorough medical history, paying attention to the individual’s health concerns, past medical experiences, and any significant life events that may have contributed to their anxiety. Explore their thoughts, ideas, and beliefs about their symptoms.
Assess the specific symptoms that are causing distress for the individual. Document the nature, duration, severity, and impact of these symptoms on their daily life. Use open-ended questions to encourage the individual to express their concerns and fears regarding their health. Evaluate the impact of illness anxiety on the individual’s daily functioning, relationships, and quality of life. Determine if the anxiety is causing significant distress, avoidance behaviors, or interference with their ability to engage in normal activities.
Evaluate the individual’s mental health status, including any history of anxiety disorders, depression, or previous psychological treatments. Assess their overall emotional well-being, coping strategies, and stress levels. Determine if there are any significant life stressors that may be contributing to their anxiety. Observe the individual’s behavior and communication patterns during the assessment. Document their nonverbal cues, such as body language or physical manifestations of anxiety, which can provide additional insights into their condition.
Utilize validated screening tools/questionnaires, such as the Health Anxiety Inventory, the Illness Attitude Scale, or the Whiteley Index, to assess illness anxiety symptoms and severity. These tools can help quantify the level of anxiety and provide a standardized measure for monitoring changes over time.
Link to Learning
Access the Health Anxiety Inventory to see an example of a standardized screening tool for IAD.
Make sure to engage the individual in a collaborative discussion, allowing them to express their concerns, fears, and beliefs openly. Be mindful of cultural factors that may influence the individual’s beliefs, attitudes, and expression of health concerns. Respect cultural diversity and incorporate cultural sensitivity into your assessment approach. Foster a nonjudgmental and empathetic environment that encourages trust and promotes effective communication.
Approaches to Treating Illness Anxiety Disorder
The treatment of illness anxiety disorder aims to alleviate the excessive health-related worries and anxiety experienced by individuals and restore maximum functioning. Here are some approaches commonly used in treating IAD (French & Hameed, 2023):
- Cognitive behavioral therapy: CBT helps individuals identify and challenge their irrational thoughts and beliefs about health concerns. The therapist works with the individual to reframe catastrophic thinking patterns and replace them with more realistic and balanced thoughts.
- Exposure and response prevention (ERP): ERP is a component of CBT with specific focus on prevention, that is, confronting anxious thoughts, objects, or situations and making a choice not to respond. It involves gradually exposing individuals to situations that trigger health-related anxiety and allowing them to confront their fears in a controlled manner.
- Mindfulness techniques: Mindfulness techniques, such as “here and now” exercises, meditation, and breathing exercises, can be helpful in managing anxiety and reducing the preoccupation with physical symptoms.
- Education: Providing education about illness anxiety disorder and how it differs from genuine medical conditions can be beneficial. It also helps clients recognize triggers and develop strategies to cope with anxiety effectively.
- Supportive therapy: Supportive therapy focuses on providing emotional support, empathy, and validation to individuals with illness anxiety disorder. Supportive therapy can help individuals feel understood and can facilitate the development of a trusting relationship with health-care providers.
- Medication: In some cases, medication may be part of the treatment plan for illness anxiety disorder. Antidepressant medications, such as selective serotonin reuptake inhibitors (SSRIs), can help manage associated anxiety. A psychiatrist or advance practice provider should collaborate to evaluate and monitor medication carefully.