Panda’s Top Tip 🐼
●In a history taking scenario, avoid dismissing concerns or becoming frustrated; acknowledge the distress first, then gently explore the role of anxiety.
●When explaining hypochondriasis to an individual in CASC, relate the diagnosis and symptoms to the experience of the patient.
●If required to explain the management of hypochondriasis, it may be helpful to use a diagram to explain the role of CBT and relate it to the patient.
Key Knowledge
What is Hypochondriacal Disorder?
Hypochondriasis (or health anxiety) is a relatively common psychological condition. ICD-11 defines hypochondriacal disorder (6B23) as a disorder characterised by persistent preoccupation with the possibility of having one or more serious, progressive or life-threatening illnesses.
Core features include:
●Persistent beliefs about having a serious illness
●Misinterpretation of normal bodily sensations, minor symptoms, or physical appearance
●Persistent preoccupation causing significant distress and/or functional impairment
●Excessive health-related behaviours (e.g., repeated self-examination, frequent GP visits, extensive internet searching) or maladaptive avoidance (e.g., avoiding medical appointments, refusing to discuss symptoms)
The preoccupation is not:
●Better explained by another mental disorder (e.g., somatic symptom disorder, delusional disorder, obsessive compulsive disorder)
●Solely focused on appearance concerns (which would suggest body dysmorphic disorder)
●The level of insight can vary. Some people can acknowledge their worry may be excessive, while others have very poor insight. ●However, if the conviction is held with complete certainty and cannot be shaken by evidence or reasoning, consider delusional disorder, somatic type.
Management:
●Mild cases may respond to self-help resources. For more moderate/severe cases, cognitive behavioural therapy is recommended, with medication considered to manage anxiety symptoms.
Differential Diagnosis for Hypochondriasis
Differential Diagnosis for Hypochondriasis
1. Somatic symptom disorder (SSD)
Key distinctions: In SSD, the focus is on distressing somatic symptoms themselves rather than worry about having an undiagnosed disease. People with SSD experience multiple, often changing physical symptoms; those with hypochondriasis may have minimal or no symptoms but are preoccupied with the fear of illness.
2. Generalised anxiety disorder (GAD)
Key distinctions: In GAD, health may be one of several worry domains (finances, relationships, work), whereas in hypochondriasis the preoccupation is predominantly or exclusively focused on health. However, the conditions commonly coexist.
3. Obsessive-compulsive disorder (OCD)
Key distinctions: Illness-related obsessions in OCD are typically experienced as intrusive, unwanted thoughts that the person tries to resist, and are accompanied by compulsions. In hypochondriasis, the thoughts are experienced more as worries or concerns rather than ego-dystonic intrusions. That said, there can be overlap, particularly with checking behaviours.
4. Panic disorder
Key distinctions: In panic disorder, physical symptoms occur in discrete episodes (panic attacks) with acute autonomic arousal. The person may fear the symptoms themselves (e.g., “I’m having a heart attack”) during attacks, but between episodes doesn’t maintain the same persistent preoccupation with having an illness. In hypochondriasis, the preoccupation is continuous.
5. Body dysmorphic disorder (BDD)
Key distinctions: In BDD, the preoccupation is specifically focused on perceived defects or flaws in physical appearance, rather than on having an internal disease or medical condition.
Risk Assessment in Hypochondriasis
Risk assessment in Hypochondriasis
As with every risk assessment, you must consider risk to self, to others and from others. There are some specific things you should consider when assessing risk in hypochondriasis:
To self:
●Suicide risk – Particularly when illness anxiety coexists with depression or when the person feels hopeless about their health concerns
●Iatrogenic harm – Excessive investigations, unnecessary procedures, or polypharmacy from multiple medical consultations
●Self-harm or extreme measures – Rare, but severe health anxiety can lead to drastic attempts at self-treatment or prevention
●Financial difficulties – From excessive healthcare seeking, private consultations, or complementary therapies
●Social withdrawal and isolation – Avoiding activities due to health fears, leading to loss of social support
●Substance misuse – Using alcohol or drugs to manage anxiety
To others:
●Generally low, though relationship strain may occur
●Reassurance-seeking can place burden on family and friends
●Occasionally, preoccupation may extend to children’s health
From others:
●Vulnerability to exploitation by unscrupulous practitioners offering unproven treatments
●Risk of medical dismissal, if genuinely unwell, an individual’s concerns may not be taken seriously due to previous presentation pattern
Communication Tips
Communication Tips
Think CASC: hypochondriasis requires careful balance between validating distress and gently exploring the psychological component. Avoid collusion with health fears while remaining empathic and non-dismissive.
Opening and validation:
●”I can see this has been causing you a lot of worry. Can you tell me what’s been concerning you most?”
●”It sounds like you’ve been through a difficult time with these concerns about your health”
●Acknowledge their distress as real, even if disease is absent
Exploring the preoccupation:
●”How much time would you say you spend thinking about your health each day?”
●”When you notice a symptom or sensation, what goes through your mind?”
●”What illness are you most worried about?”
●”Have you had medical tests or seen doctors about this? What did they find?”
●”How did you feel after being reassured? Did that feeling last?”
Health-related behaviours:
●”Do you find yourself checking your body frequently e.g. for lumps, changes, symptoms?”
●”How often do you look up symptoms online or in medical books?”
●”Are there medical appointments or tests you’ve been avoiding?”
●”Have family or friends commented on your health concerns?”
Impact on functioning:
●”How are these worries affecting your day-to-day life?”
●”Are there things you’ve stopped doing because of your health concerns?”
●”How are things at work/home? Have your worries affected relationships?”
●”Are you able to enjoy activities you used to, or do health worries get in the way?”
Screen for comorbidities:
●Depression: low mood, anhedonia, hopelessness, sleep, appetite
●Generalised anxiety: worry about other areas (finances, relationships, work)
●OCD: other obsessions or compulsions beyond health
●Panic disorder: discrete panic attacks
●Substance use: using alcohol or drugs to manage anxiety
Exploring psychological understanding:
●”Some people find that stress or worry can make physical sensations feel more intense, have you noticed anything like that?”
●”Looking back, is there anything that was happening in your life when these worries started?”
Ending positively:
●Offer a formulation that validates their experience while introducing psychological factors (if asked to in the station)
●Be collaborative: “I wonder if we could work together to understand what’s maintaining these worries”
CASC Practice Scenarios
Scenario 1: History Taking
Candidate Instructions:
You are the SpR in the general adult psychiatry outpatient clinic. You have been asked to see Mr Graham Patterson, a 44-year-old IT project manager, who has been referred by his GP. Over the past two years, Mr Patterson has attended the GP surgery 37 times with various physical concerns, primarily relating to chest pain and headaches. He has undergone extensive investigations including three ECGs, two echocardiograms, CT head, CT chest, blood tests including tumour markers, and upper GI endoscopy, all of which have been normal.
Your tasks are to:
●Take a psychiatric history
●Perform a risk assessment
Scenario Summary:
Graham Patterson is a 44-year-old man with hypochondriasis (health anxiety disorder). For the past two years, he has been preoccupied with the belief that he has a serious undiagnosed illness, primarily heart disease. He misinterprets normal bodily sensations (muscle soreness, appropriate shortness of breath following exertion, heartbeat awareness) as evidence of heart disease. Despite extensive investigations showing no pathology, he remains unconvinced and seeks repeated medical reassurance, which provides only brief relief before his anxiety returns. He spends 3-4 hours daily googling symptoms online, monitoring his heart rate, and self-examining. He has significantly reduced his physical activity due to fear of a heart attack. The preoccupation began following the sudden death of a work colleague from a heart attack two years ago. He has developed secondary depression and his relationship with his wife Karen is under strain. He has partial insight, he can acknowledge that doctors say there’s nothing wrong, but he cannot shake the conviction that something has been missed.
Actor Brief:
You are Graham Patterson, a 44-year-old IT project manager for a software company. You live with your wife Karen, 42, who’s a primary school deputy head, and your two children, Ben (14) and Lucy (11), in a four-bedroom house.
Two years ago, your life changed. A colleague at work, Martin, collapsed at his desk and died from a massive heart attack, aged 48. You were there when it happened and called the ambulance. He seemed fine that morning. Since then, you’ve been terrified that you have heart disease and the same thing will happen to you. You started noticing things; chest tightness, your heart skipping beats, aches in your left arm. You went to your GP and she did an ECG. It was normal. But the symptoms didn’t stop, so she referred you to a cardiologist. You’ve had several echocardiograms, a stress test, multiple ECGs, and everything has come back as normal. They keep telling you your heart is fine, but you remain unconvinced. What if they’ve missed something? What if there’s a small blockage they haven’t detected yet?
You spend hours every day thinking about your health. You check your pulse constantly; at your desk, in the car, before bed. If it’s above 80, you panic. If it feels irregular, you panic more. You examine yourself in the mirror; looking for lumps, checking the colour of your skin, pulling down your eyelids to check for anaemia. You spend at least 3-4 hours a day on medical websites, reading about symptoms, checking if what you’re experiencing matches heart disease. You know every warning sign for every major disease.
You’re constantly seeking reassurance. You ask Karen multiple times a day: “Does my chest look swollen? Do I look pale? Can you feel my pulse, does it feel normal?” At first, she was patient, but now she’s frustrated. She tells you you’re fine, that the doctors have checked everything, but her reassurance only helps for a few minutes. Then the doubt creeps back in. You’ve asked her to feel your pulse so many times that she now refuses.
You’ve stopped exercising completely. You used to play football on Saturdays with a local team but you’ve not played for 18 months. You’re terrified your heart will give out if you exert yourself. You avoid stairs when you can, you drive short distances instead of walking, you don’t lift heavy things. Karen says you’re being ridiculous, but you think you know your body better than she does.
Work is suffering. You’re distracted, anxious, checking symptoms on your phone during meetings. Your manager, Steve, pulled you aside last month and said your performance has dropped.
Your mood has deteriorated over the past year. You feel low, hopeless about ever getting a diagnosis, frustrated that no one believes you. You cry sometimes out of fear, exhaustion and despair. You’re not sleeping well because you lie awake feeling your heartbeat, convinced something’s wrong. Your appetite is reduced and you’ve lost about half a stone. You have fleeting thoughts that if you’re going to die anyway from an undiagnosed illness, what’s the point, but you’d never act on them, because your kids need you. You don’t drink much, maybe two beers at the weekend, and do not take recreational drugs. You have no previous psychiatric history. Your dad died of a heart attack at 62, which has always been in the back of your mind. Your mum is still alive and healthy at 68.
You’ve been to A&E eleven times in the past two years with chest pain. They’ve done blood tests and ECGs, and each time they’ve sent you home saying it’s anxiety or muscle strain. You feel dismissed, invalidated and unheard.
When you’re in the interview, you’re polite but somewhat tense and preoccupied. You’re keen to explain your physical symptoms in detail and you want the doctor to understand how real they are. If the doctor tries to suggest it might be anxiety, you become slightly defensive. You explain that you’re frustrated that yet another doctor is implying there’s nothing wrong.
You have partial insight. If asked directly whether you can see how anxiety might play a role, you’ll admit, reluctantly, that maybe stress is making things worse, but you maintain that the symptoms are physical and that something could still be undiagnosed. You ask the doctor at some point: “But what if they have missed something? It does happen, doesn’t it?”
You’re desperate for help, but you’re also desperate for validation that your concerns are legitimate. You’ve come to this appointment because your GP and wife insisted, not because you think you have a mental health problem.
Feedback for Scenario 1
Knowledge & Clinical Skills
A good candidate will:
●Elicit the core features of hypochondriasis systematically: persistent preoccupation with having or acquiring a serious illness (heart disease/having a heart attack), misinterpretation of bodily symptoms as evidence of disease, persistence of preoccupation despite appropriate medical evaluation and reassurance, and significant distress and functional impairment
●Explore the pattern of health-related behaviours comprehensively, identifying both excessive behaviours (repeated GP consultations and A&E attendances, internet searching for symptoms, body checking, pulse monitoring, reassurance-seeking) and maladaptive avoidance (cessation of exercise, avoidance of physical exertion), both of which maintain the disorder
●Identify the precipitating event (colleague’s sudden cardiac death) and explore the role of this trauma in triggering health anxiety.
●Assess the brief relief followed by return of anxiety after medical reassurance.
●Screen for comorbidities, particularly depression (present in this case with low mood, anhedonia, sleep and appetite disturbance, hopelessness), generalised anxiety disorder, panic disorder, and OCD, recognising that these commonly coexist with hypochondriasis and require specific treatment.
Communication
A good candidate will:
●Validate the patient’s physical symptoms and distress without colluding with the belief that serious disease has been missed, using phrases like “I can hear that these symptoms are very real and very frightening for you” rather than “there’s nothing wrong” or “it’s all in your head,” which damage rapport and are clinically inaccurate
●Explore health beliefs and concerns with genuine curiosity rather than skepticism, asking “What are you most worried might be happening?” and “What makes you certain it’s something serious?” to understand the cognitive processes maintaining the anxiety, rather than immediately challenging the beliefs
●Manage the patient’s direct question “But what if they have missed something?” with honesty and validation, acknowledging that diagnostic uncertainty exists in medicine while also gently highlighting the extent of investigation already completed and the pattern of repeated normal results
●Demonstrate empathy for the functional impact (work performance, relationship strain, loss of activities like football) and the secondary depression, recognising that even if the core issue is health anxiety, the suffering and impairment are real.
Video
Authors/Reviewers
Dr Damir Rafi is a Psychiatry Speciality registrar in forensics, currently working in London.
Dr Rebecca Goodall is a Psychiatry Specialty Registrar, specialising in children & adolescents.
References and Resources
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
World Health Organization. (2019). International classification of diseases for mortality and morbidity statistics (11th ed.). https://icd.who.int/browse11/l-m/en
National Institute for Health and Care Excellence. (2011). Generalised anxiety disorder and panic disorder in adults: Management (CG113). https://www.nice.org.uk/guidance/cg113
Disclaimer:
This article is intended for use as a learning resource for doctors training in Psychiatry in the UK. It is not intended for patients. If you are looking for information about mental health conditions, please visit www.rcpsych.ac.uk/mental-health to find readable, user-friendly and evidence-based information on mental health problems, treatments and other topics written by qualified psychiatrists, with help from patients and carers. If you are looking for help for a mental health condition, please visit https://www.mind.org.uk/ for information about where help is available.
The article was written by UK doctors and cross-checked against various published sources (see Reference list). We endeavour to keep information up to date, but it should not be relied on for clinical decision making. Consult local guidelines and senior colleagues whenever you are not sure.
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