Should we deplore the disappearance of hypochondriasis from DSM-5?

Changes made in DSM-5

DSM-5 introduced two disorders to replace the DSM-IV hypochondriasis: somatic symptom disorder (SSD) and illness anxiety disorder (IAD). The architects of DSM-5 determined rather arbitrarily that about 75% of individuals with DSM-IV hypochondriasis would meet the criteria for SSD, whereas about 25% of such individuals would receive the diagnosis of IAD. The key difference between the two disorders is that ‘distressing’ and ‘disruptive’ somatic symptoms are present in SSD and absent or minimally present in IAD. Other important features of SSD and IAD are presented in Table 1.

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Table 1.

Excessive thoughts, feelings and behaviours in somatic symptom disorder and illness anxiety disorder.

	Somatic symptom disorder (at least 1 of the 3 criteria below is required for diagnosis)	Illness anxiety disorder (all 3 criteria below are required for diagnosis)
Thoughts	Disproportionate and persistent thoughts about the seriousness of one’s symptoms	Preoccupation with having or acquiring a serious illness
Feelings	Persistently high level of anxiety about health or symptoms	High level of anxiety about health, and the individual is easily alarmed about personal health status
Behaviours	Excessive time and energy devoted to symptoms or health concerns	Excessive health-related behaviours (e.g., repeated checking of one’s body for signs of illness) or maladaptive avoidance (e.g., avoidance of doctor appointments and hospitals)

Why were these changes made?

There were three key reasons for eliminating hypochondriasis. First, hypochondriasis is an antiquated term and its etymology with reference to an abdominal ailment is obsolete and has nothing to do with the modern meaning of hypochondriasis. Second, hypochondriasis is a heterogeneous concept and consists of two main dimensions or components: disease phobia and disease conviction (Pilowsky, 1967; Fergus and Valentiner, 2010). This structure of hypochondriasis has been problematic when patients with diverse clinical presentations received the same diagnostic label. Finally, hypochondriasis has increasingly been considered a pejorative and stigmatising term.

The inconsistencies of DSM-5: Was hypochondriasis ‘singled out’ for exclusion?

The DSM-5 was inconsistent in its treatment of hypochondriasis and did not us the same approach when revising the conceptualisation of other diagnostic entities.

First, if all the antiquated or etymologically incorrect terms were to be excluded from DSM-5, this should have been done with other problematic diagnostic terms, such as schizophrenia, anorexia nervosa and even agoraphobia.

Similarly, the heterogeneity of the diagnostic concepts has been inconsistently dealt with in DSM-5. For some disorders, such heterogeneity led to a creation of ‘specifiers’ (e.g., the new specifier of ‘performance only’ for social anxiety disorder), whereas the heterogeneity of other disorders played a pivotal role in their disintegration (e.g., the case of hypochondriasis) or separation of those components deemed sufficiently distinct from the ‘parent’ disorder (e.g., the case of hoarding disorder which was separated from obsessive-compulsive disorder).

Finally, if all pejorative or stigmatizing diagnostic labels were to be removed from the psychiatric classification, there would be many candidates for exclusion, perhaps most notably schizophrenia and borderline personality disorder. However, neither of these has been deleted from DSM-5.

Are there advantages to somatic symptom disorder and illness anxiety disorder over hypochondriasis?

While it was reasonable to propose changes to the concept of hypochondriasis, they could have been made in a more meaningful and clinically useful manner. The division of the concept of hypochondriasis on the basis of the presence or absence of somatic symptoms lacks sound empirical support and the heterogeneity of hypochondriasis could have been addressed more adequately by creating the specifiers with predominant disease fear (phobia) and predominant disease belief (conviction). Also, changing the name of hypochondriasis might have been premature and is not necessarily a remedy against pejorative labelling and stigmatisation: it is quite possible that over time the seemingly neutral terms such as SSD and IAD will acquire ‘bad reputation’ that is now associated with hypochondriasis.

SSD has already attracted criticism, mainly because of its low diagnostic threshold and a possibility of unnecessarily using this diagnosis in the presence of serious medical conditions (Frances and Chapman, 2013). Its criteria pertaining to thoughts and behaviours are too vague and subject to various interpretations (Table 1). Neither SSD nor IAD capture some of the key features of hypochondriasis: an overvalued idea that the person already has a serious disease and resistance to routine medical reassurance (Starcevic, 2001). Although the latter feature may be difficult to assess, it has been considered one of the crucial aspects of hypochondriasis (Sirri and Fava, 2013). In addition, SSD is intended to replace four DSM-IV disorders (somatisation disorder, hypochondriasis, pain disorder and undifferentiated somatoform disorder), which inevitably makes it too broad and non-specific. The term itself is awkward: SSD combines the symptom and a disorder in its name, which is akin to the unlikely diagnoses of ‘chest pain disease’ or ‘headache disorder’.

There are also several problems with IAD. First, no evidence exists that preoccupation with having or acquiring a serious illness should be considered interchangeably and subsumed under a single diagnostic rubric. These are two different phenomena, although they are both associated with fear. Also, the term ‘preoccupation’ leaves one wondering about its nature: is this preoccupation similar to obsessions, is it an overvalued idea and does it sometimes include delusions? Finally, IAD is similar to the loose concept of ‘health anxiety’ (Starcevic, 2013) and the DSM-IV concept of illness phobia (as a subtype of specific phobia) and may more appropriately be considered and classified as an anxiety disorder.

Conclusion: Lost in translation?

This commentary suggests that it was premature to exclude hypochondriasis from psychiatric nosology without a consistent application of the reasons for such an exclusion to all disorders and in the absence of more sound diagnostic alternatives. When the diagnostic criteria for DSM-IV hypochondriasis were ‘translated’ into those for SSD and IAD in DSM-5, some crucial components of hypochondriasis were lost, making the new concepts deficient at best and clinically useless at worst. This is an important lesson for those responsible for the revision of the mental disorders section of the International Classification of Diseases.