Background
Although generalized anxiety disorder (GAD) is characterized by multiple worries, anxiety about one's health is absent in the DSM-IV description of the illness.
Method
A random community-based telephone survey (N = 2005) that covered DSM-IV symptoms of GAD, two core symptoms of major depression, Rome-III criteria of Irritable Bowel Syndrome (IBS), Sheehan Disability Scale (SDS), and help-seeking behavior was conducted.
Results
The 1-year prevalence of 3-month GAD was 5.4%. Among affected individuals, 78.9% reported worry about personal health while 21.1% did not. The former subgroup was significantly older, had higher mean numbers of associated anxiety symptoms and worries, more likely to have worry about finances and sought professional help than the latter subgroup. The two subgroups had similar sex distribution, core depressive symptoms, IBS, distress and SDS impairment profiles.
Conclusion
Health anxiety is common in GAD. Some but not all illness severity indicators differed between GAD with and without health anxiety.
Hypochondriasis, as strictly defined in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR) (American Psychiatric Association [APA], 2000) or the tenth revision of the International Classification of Diseases (ICD-10) (World Health Organization [WHO], 1993), is uncommon and has a 6-month clinical prevalence ranging from 0.8% to 4.6% (Escobar et al., 1998, Fink et al., 1999 and Gureje et al., 1997). When thus clinically defined, it does not capture less severe forms of health anxiety that is dimensionally distributed in community and clinical settings (Asmundson et al., 2010 and Ferguson, 2009). Community-based studies indicated that as many as 10% of people exhibited health anxiety or the conviction of a serious illness, as measured by item 64 of the Screening for Somatoform Symptoms (SOMS) which measures the core feature of hypochondriasis (Rief, Hessel, & Braehler, 2001). Another community study using the Illness Attitude Scales (IAS) reported that 9.9% of subjects were often or usually worried that they would develop a serious illness (Bleichhardt & Hiller, 2007). Regarding clinical studies, Abramowitz, Olatunji, and Deacon (2007) noted that “Hypochondriasis is not the only psychological disorder that involves health concerns. Clinical observations and empirical research indicate that anxiety over health-related matters is a feature of several anxiety disorders.” (p. 1). Among the anxiety disorders, generalized anxiety disorder (GAD) is characterized by multiple worries and may be particularly likely to involve health concern. It is not surprising that the DSM-V has proposed to include “health anxiety” as one of the domains of worry in GAD (APA, 2010).
Intriguingly, the DSM-IV-TR and ICD-10 have not included “health anxiety” in the diagnostic description of GAD. The DSM-IV-TR (APA, 2000) says that “Adults with GAD often worry about everyday, routine life circumstances such as possible job responsibilities, finances, the health of family members, misfortune to their children, or minor matters (such as household chores, car repairs, or being late for appointments”) (p. 473). Although worry about the health of family members is described, worry about one's own health is missing. The ICD-10 (WHO, 1993) also does not include health anxiety in the diagnostic description of GAD, though it mentions that “Fears that the patient or a relative will shortly become ill or have an accident are often expressed.” The Structured Clinical Interview for DSM-IV (SCID) (First, Spitzer, Gibbon, & Williams, 2002) does not specify the domains of worries that may occur in GAD. It suggests that interviewers should probe “worry about a number of events or activities” but does not mention health anxiety specifically. SCID interviewers may therefore not ask about health anxiety prior to the somatoform disorders module unless an interviewee initiates to mention it earlier on during the assessment. Consequently, clinical studies on GAD and other anxiety disorders may not document the presence of health anxiety that does not reach the diagnostic threshold of hypochondriasis. It is perhaps not surprising that a detailed review of GAD does not mention health anxiety (Rickels & Rynn, 2001). Yet, in discussing the DSM-V options for GAD, Andrews et al. (2010) advised that “The DSM-IV examples of the worry domains appear accurate but inserting ‘family, health, and finances’ would better reflect the events that are of most concern to GAD patients” (p. 5). The epidemiological and clinical implications of including health anxiety in the diagnosis of GAD are presently unknown.
To our knowledge, no study has examined how common health anxiety in GAD is and how GAD with and without health anxiety may differ in a general population. As a result, the prevalence, socio-demographic profile, severity, impairment, and help-seeking behavior of GAD with and without health anxiety are unknown. Yet, such information is helpful for both nosological and clinical reasons. In this present study, we hypothesize that GAD with health anxiety is common in the community and differs from GAD without health anxiety by some sociodemographic and illness severity indicators.
