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Health Anxiety and Body Image Disturbance, Understanding and Therapeutic Approaches
Abnormal Psychology · Chapter 14: Somatic Symptom and Related DisordersSection 14.3 · lesson 53 of 9714 min · free with a free account
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In this lesson
2 common, under-recognized conditions - and the cycles that maintain them.
- Describe illness anxiety disorder, and health anxiety as a dimension
- Describe body dysmorphic disorder, including the role of insight
- Explain why reassurance can work like a compulsion
- Describe the treatment approaches for both
Transcript
Everything said in the video, section by section (1,901 words). Read along, or search it.
Somatic Symptom and Related Disorders
Health Anxiety and Body Image Disturbance
This section covers two conditions centered on fear about the body. The first is health anxiety, and the diagnosis of illness anxiety disorder. The second is body dysmorphic disorder, a preoccupation with a perceived flaw in appearance. We look at what maintains each one, why reassurance can make things worse, and what treatment involves.
Read This First
Common, Treatable, Often Missed
A few things first. Both of these conditions are common, and under-recognized. Many people live with them for years before anyone recognizes what is happening. Some viewers may find this section personally affecting. If it is difficult, it is reasonable to pause. And if something here feels familiar, that is a reason to seek assessment from a qualified professional, not to conclude anything yourself. Both conditions are treatable. This section contains no weight, shape, or appearance targets, and no comparisons of any kind. Body dysmorphic disorder is described at the level of category only. No body areas are named, and no behaviors are described in a way that could be adopted. And the word hypochondriac is not used. In ordinary speech it means someone inventing illness, and that misdescribes a condition in which the fear is genuine.
Health Anxiety
A Dimension Everyone Sits On
Health anxiety is anxiety about having, or developing, a serious illness. It is a dimension, not a category. Everyone sits somewhere along it. So what places someone past the clinical threshold? Not the intensity of their worry alone. It is a judgment on three things together. Proportion, persistence, and functional cost. The other end of the continuum is easy to forget. Too little vigilance about health has real costs of its own. So the aim of treatment is proportionate concern. Not no concern at all.
The Reclassification
Hypochondriasis, Split in 2
The former diagnosis of hypochondriasis was split into two in the current classification system, depending on whether distressing bodily symptoms are present. Where distressing symptoms are present, and the response to them is disproportionate, the diagnosis is somatic symptom disorder, covered in the first section of this chapter. Where symptoms are minimal or absent, and the preoccupation is about having or acquiring an illness, the diagnosis is illness anxiety disorder. The rationale was that the old category mixed two different groups. People distressed by symptoms they have, and people frightened of illness they do not yet have. They present differently, and to different services. The criticism is that the split is hard to apply, since most people have some bodily sensations, and minimal is unclear. Most people once diagnosed with hypochondriasis now fall under somatic symptom disorder, a category whose central problem for them is anxiety, not symptoms. And a well-researched literature was divided across two categories, which complicates reading the earlier findings.
Illness Anxiety Disorder
2 Presentations - 1 Routinely Missed
Illness anxiety disorder is a preoccupation with having, or acquiring, a serious illness. Bodily symptoms are absent, or only mild. There is high anxiety about health, and the person is easily alarmed. The preoccupation lasts at least six months, although the specific illness feared may change during that time. There are two presentations, and one of them is routinely missed. The care-seeking presentation is the familiar one. Frequent consultations, requests for tests, repeated checking, and extensive research into symptoms. The care-avoidant presentation is its mirror image. The fear is so great that the person avoids anything that might confirm it. Medical appointments, screening, sometimes even conversations about health. It is missed for a structural reason. The person does not present, so services never see them. When they do appear, it is often late, with an advanced condition. And they may be called neglectful of their health, when in fact they were too frightened to look.
The Cognitive Model
4 Beliefs That Make Vigilance Feel Rational
The cognitive model applies a familiar idea to health. Ordinary bodily sensations are read as evidence of serious disease, and that interpretation drives everything else. Four kinds of belief are commonly involved. Likelihood. Overestimating the probability that the feared illness is present, or will develop. Awfulness. Imagining the illness as unbearable, rather than simply as bad. Coping. Underestimating one's own ability to cope if it were true. And rescue. Underestimating what medicine could do, or overestimating how much depends on catching it at exactly the right moment. Put the four together, and the person has built a situation where constant vigilance is the only rational response. That is why arguing about probability alone rarely works. Treatment addresses all four beliefs.
Figure 14.3.2
The Health Anxiety Cycle
Here is the cycle that maintains health anxiety. It starts with an ordinary bodily sensation, the kind everyone has constantly, and mostly never notices. The sensation is read as a sign of serious illness. That is the first intervention point. Anxiety rises, which itself produces more bodily sensations. The person checks, researches, or seeks reassurance. That behavior is the second intervention point. Relief follows. It is real, but it is brief. Then doubt returns, and the loop begins again with the next sensation. Notice that both intervention points come before the relief. Treatment targets the interpretation and the behavior, not the anxiety directly.
Reassurance
Why Reassurance Works Like a Compulsion
Reassurance deserves special attention, because it is counter-intuitive for everyone involved. Reassurance works, briefly. That is the problem, not the solution. The relief reinforces the seeking. So the behavior becomes more likely, and the time before it is needed again gets shorter. Then doubt attaches to the reassurance itself. He was only being kind. I didn't describe it properly. And the person goes back. Over repeated episodes, the pattern is clear. Each drop in anxiety is real and brief, the peaks rise, and the level between episodes rises too. So what should families and clinicians do instead? Not flat refusal, which feels like abandonment, and usually sends the person elsewhere. The approach is agreed in advance, with the person. Information is given once, clearly, and the pattern is explained so they understand why. This applies only to reassurance about the feared illness. It never replaces ordinary kindness, or proper assessment of a genuinely new symptom. Getting that wrong in the direction of under-assessment is the more dangerous error.
Differential Diagnosis
The Structure of the Fear, Not Its Intensity
Illness anxiety disorder has to be distinguished from several other conditions. In every case, the question is about the structure of the fear, not its intensity. In somatic symptom disorder, distressing symptoms are central. In illness anxiety, the fear is about illness itself, with few symptoms. In generalized anxiety, worry ranges across many areas of life. In illness anxiety, it is focused on illness. In obsessive-compulsive disorder, concerns range more widely, and are often experienced as senseless. Here, the health fear feels reasonable to the person. In panic disorder, the feared catastrophe is immediate, happening within the attack. Here, it is a disease process unfolding over time. And delusional illness beliefs are held with complete fixity, and are not open to evidence at all. That is developed in chapter nineteen. So asking how worried someone is settles none of these distinctions. The shape of the fear does.
Body Dysmorphic Disorder
A Flaw Others Can't See
Body dysmorphic disorder is a preoccupation with one or more perceived defects in physical appearance. The defects are not observable to others, or appear slight to them. In response, the person performs repetitive behaviors or mental acts, and the preoccupation causes significant distress or impairment. The behaviors are named here only as categories. Checking, excessive grooming, concealing, comparing with others, and seeking reassurance about appearance. Onset is typically in adolescence. And the delay before anyone presents for help is commonly long. That is because of shame about the concern itself, the belief that the problem is appearance rather than distress, and presenting to appearance services instead of psychological ones. The impact is substantial, disrupting education, work, and social life, and in severe cases, leaving home at all. The condition is associated with elevated distress and elevated risk, and it warrants professional assessment. If you are affected, please speak with a qualified professional.
Insight
When the Belief Feels Simply True
Insight is central to understanding this condition, and it runs along a range. With good or fair insight, the person recognizes that their belief about their appearance is probably, or possibly, not accurate. With poor insight, they think it is probably accurate. With absent insight, they are completely convinced. That is common in this condition, and it is recorded as a specifier, not as a separate psychotic diagnosis. Poor insight complicates engagement. From the person's point of view, they do not have a psychological problem. They have an appearance problem, and the obvious remedy is an appearance intervention. Arguing about whether the perception is accurate rarely helps, and often ends the conversation. Engagement is built instead around what the person does recognize. The distress, and the impairment in their life.
Appearance Services
Why Appearance Intervention Doesn't Resolve It
People with this condition commonly seek appearance intervention, rather than psychological help. That follows directly from how the problem looks from the inside. The findings on outcome are consistent. The preoccupation is not a response to the appearance itself, since the perceived flaw is not observable, or is slight, to others. So altering it does not address what is causing the distress. Satisfaction afterward is typically poor. And where one concern resolves, it commonly migrates to another aspect of appearance. That migration is the clearest sign that the problem was never located where the person believed. Repeated intervention is common, and carries accumulating physical, financial, and emotional costs. So cosmetic intervention is not a treatment for body dysmorphic disorder. That is a finding about this condition, not a judgment about anyone's choices. And recognition in appearance services matters. A clinician there may be the only one who ever encounters the condition.
Treatment
Principles for Both Conditions
Treatment for both conditions is described here at the level of principle only. Cognitive-behavioral approaches have the best evidence for both, adapted to each. For health anxiety, they target the four belief types, how sensations are interpreted, and the checking and reassurance that keep the cycle going. For body dysmorphic disorder, they target appearance-related beliefs and attention, with engagement built around distress rather than disputing the perception. Exposure and response prevention is a component of treatment for both. It must be delivered by a trained clinician. It is not something to attempt on yourself or anyone else. The pacing and the management of distress are exactly the parts that need training. Reducing checking and reassurance-seeking is central to both, agreed with the person, and with family where relevant. Behavioral experiments test specific predictions in the real world, rather than arguing about them. And certain classes of antidepressant medication have evidence in both conditions. Prescribing decisions rest with a prescriber.
2 Composite Cases
Rosalind and Daniel
Two composite cases, constructed for instruction, bring this together. They describe no real people. Rosalind, forty-one, consulted her doctor twenty-two times in fourteen months, each time about the possibility of a serious illness. She reports no significant symptoms. She researches for hours most evenings, and asks her husband several times a week whether she looks unwell. That places her in illness anxiety disorder. Her husband's kind reassurance is one of the strongest maintaining factors. So the plan agreed with both of them redirects his kindness, rather than withdrawing it. Daniel, twenty-four, was referred by an appearance service, where he had requested a third intervention. After his first, he was satisfied for about two months before the concern returned. After his second, the concern moved to a different aspect of his appearance. His insight is poor. He believes his perception is accurate, and that others are just being polite. So the clinician did not argue about the perception. Engagement was built on his own history, and on eight months without seeing friends, which he recognizes as a problem.
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