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Epidemiology of Hypochondriasis and Health

Anxiety: Comparison of Different Diagnostic
Criteria

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DOI: 10.2174/1573400509666131119004444

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14 Current Psychiatry Reviews, 2014, 10, 14-23

Epidemiology of Hypochondriasis and Health Anxiety: Comparison of

Different Diagnostic Criteria

Florian Weck*, Samantha Richtberg and Julia M.B. Neng

Department of Clinical Psychology and Psychotherapy, University of Frankfurt, Frankfurt, Germany

Abstract: This review addresses the prevalence of hypochondriasis and less restrictive subtypes of hypochondriacal
phenomena (abridged hypochondriasis and health anxiety). Altogether, 55 papers based on 47 independent samples
reporting prevalence rates of hypochondriasis, abridged hypochondriasis, and health anxiety were taken into account.
Investigations of the general population, general medical samples (e.g., primary care) and specific clinical samples (e.g.,
cancer patients) were included in the present review. In general populations a weighted prevalence of 0.40% was found
for hypochondriasis (range 0.0-4.5%) and a weighted prevalence of 1.00% (0.6-2.0%) was found for abridged
hypochondriasis. Health anxiety was frequently reported in general populations with a wide range (2.1-13.1%). In general
medical samples a weighted prevalence rate of 2.95% (range 0.3-8.5%) was found for hypochondriasis. Abridged
hypochondriasis was only reported in one study; however, the prevalence of abridged hypochondriasis was three times
higher than the full diagnostic criteria of hypochondriasis. In specific clinical samples (e.g., cancer patients, psychiatric
outpatients) hypochondriasis and health anxiety were frequently reported as well. Comparisons of persons with the full
hypochondriasis diagnosis and abridged hypochondriasis show large similarities regarding psychopathological
characteristics and clinical impairment, which underline the importance of a less restrictive definition of hypochondriasis
considered in DSM-5. Findings regarding potential risk factors were very inconsistent and no clear risk factors could be
identified. The high prevalence of hypochondriasis in medical settings should be addressed in the future with effective
screening instruments in order to optimize treatment strategies for patients with hypochondriasis and persons with
elevated health anxiety.
Keywords: Epidemiology, health anxiety, hypochondriasis, illness anxiety disorder, illness fears, illness worry, prevalence,
primary care.

INTRODUCTION [5, 6]: For example, the “appropriate” medical evaluation

Hypochondriasis is classified as a somatoform disorder in
ICD-10 [1] and DSM-IV-TR [2]. The disorder is associated
with high costs for medical consultations [3] and a high
persistence of the diagnosis [4]. According to DSM-IV-TR,
the main characteristics of hypochondriasis are the
preoccupation with fears of having, or the idea that one has a
serious disease based on the person’s misinterpretation of
bodily symptoms (Criterion A), the persistence of the
preoccupation despite appropriate medical evaluation and
reassurance (Criterion B), the necessity that the beliefs in
Criterion A are not of delusional intensity (Criterion C), that
the preoccupation causes clinically significant distress or
impairment in social, occupational, or other important areas
of functioning (Criterion D), and the duration of those
features for at least six months (Criterion E).
However, the operationalization of the diagnostic criteria
for hypochondriasis, in particular the B Criterion, bears
serious problems and has been criticized by several authors
*Address correspondence to this author at the Department of Clinical
Psychology and Psychotherapy, University of Frankfurt, Varrentrappstrasse
40-42, Frankfurt D-60486 Frankfurt, Germany; Tel: +049 69 798 23250;
Fax: +049 69 789 28110; E-mail: weck@psych.uni-frankfurt.de
and reassurance is not defined precisely and therefore subject
to various interpretations. It seems inadequate to define
hypochondriasis in dependency of the anxiety reducing or
non-reducing effect of the reassurance given by a medical
practitioner and his or her ability to give this reassurance.
Moreover, some persons with health-related anxieties have
no access to medical reassurance and some avoid medical
consultations because of their fears. Further, some
individuals with health anxieties seek reassurance mainly
from their family or on the Internet and not from medical
practitioners. Thus, an “abridged” definition of hypo-
chondriasis was suggested which includes all criteria of
hypochondriasis except the B Criterion [7].
In addition, suggestions for DSM-5 take the critique on
DSM-IV into account and modify the diagnostic criterion
regarding the reassurance behavior of patients with
hypochondriasis. The suggestion states: “The individual
performs excessive health-related behaviors (e.g., repeatedly
checking one’s body for signs of illness), or exhibits
maladaptive avoidance (e.g., avoiding doctors’ appointments
and hospitals)” [8].
Moreover, the categorical perspective of the diagnosis of
hypochondriasis favored by ICD and DSM was criticized
and a dimensional perspective of hypochondriacal phenomena

17-/14 $58.00+.00 © 2014 Bentham Science Publishers

Epidemiology of Hypochondriasis
was suggested, which describes differences between hypo-
chondriacal and non-hypochondriacal persons as quantitative
rather than qualitative [6]. This perspective was picked up by
many researchers who investigated illness-related fears
below the diagnostic criteria of hypochondriasis, most often
labeled as health anxiety (synonyms: illness fear, illness
worry). While hypochondriasis refers to the DSM- or ICD-
diagnosis, health anxiety refers to a continuous construct
ranging from milder and transient forms of illness-related
concerns and worries to the full hypochondriasis diagnosis
[6]. One concrete definition of health anxiety is given in the
Diagnostic Criteria for Psychosomatic Research (DCPR)
which were proposed in order to present a more complete set
of psychological clusters to be considered in the context of
medical conditions [9]. According to the DCPR, health
anxiety is defined as a generic worry about illness, concern
about pain, and bodily preoccupations (tendency to amplify
somatic sensations) of less than 6 months’ duration (Criterion
A), worries and fears readily respond to appropriate medical
reassurance, even though new worries may ensue after some
time (Criterion B), and worries and fears are not secondary
to mood or anxiety disorders (Criterion C). However, not all
studies investigating the phenomenon of health anxiety
consider the DCPR for health anxiety and therefore assessment
strategies and cut-off criteria regarding health anxiety are
heterogeneous. Nevertheless, investigations of health anxiety
in different populations are important in order to improve the
understanding of hypochondriacal occurrences and their
relevance for psychiatry and clinical psychology.
The aim of the current review was to give an overview of
the prevalence and potential risk factors for hypochondriasis
in the general population, general medical samples (e.g.,
primary care), and specific clinical samples (e.g., cancer
patients, psychiatric outpatients). In order to take the critique
of the current diagnostic criteria and the dimensional
perspective of hypochondriasis into account, we also
consider two less restrictive subtypes of hypochondriacal
manifestations apart from the full ICD/DSM diagnosis of
hypochondriasis, namely abridged hypochondriasis and
health anxiety. Moreover, we evaluated the clinical relevance
of these subgroups by exploring similarities and differences
between persons with the full ICD/DSM hypochondriasis
diagnosis, abridged hypochondriasis, health anxiety, and
non-hypochondriacal control groups.
METHOD
Literature Research
A literature research was performed using MEDLINE
and PsycINFO. In order to enhance comparability of
different studies (due to similar diagnostic criteria and
measures) we only included studies from 1990 up to June
2012. The main search terms were “hypochondriasis”,
“illness anxiety disorder”, “somatoform disorder”, “health
anxiety”, “illness worry” and ”illness fear” in combination
with “epidemiology”, “prevalence”, “population”, “primary
care”, “classification” and “diagnosis”. On the basis of these
search criteria a total of 912 abstracts were screened for
inclusion by two of the authors. Papers were included that
were written in English or German, reported prevalence rates
for hypochondriasis, abridged hypochondriasis, or health
Current Psychiatry Reviews, 2014, Vol. 10, No. 1 15
anxiety, reported data from adults, used a standardized
measure or diagnostic criteria and investigated a sample of
the general population, general medical samples (including
family practice and primary care), or specific clinical
samples (e.g., cancer patients, psychiatric outpatients).
Studies which reported prevalence rates of hypochondriasis
or health anxiety in specific mental disorders (e.g., major
depressive disorder) were not included in the current review.
The reason being that those studies rather focus on co-
occurrence of hypochondriasis and other mental disorders
which is beyond the aims of our review and topic of another
paper in the current special issue [10]. We narrowed our
focus mainly on sociodemographic variables (e.g., sex, age)
for the search of potential risk factors while rarely reported
risk factors, like previous experiences with illnesses or
traumatic events in childhood, were not included in the
present review.
In addition to the presented prevalence rates of
hypochondriasis in different samples, we computed overall
prevalence rates weighted by sample sizes (weighted
average) for studies investigating general populations and
general medical samples. Weighted prevalence rates were
not calculated for specific clinical samples because these
samples were too different and therefore not directly
comparable.
RESULTS
Fifty-five papers based on 47 independent samples
fulfilled inclusion criteria and were considered in the present
review. Altogether, 12 studies report prevalence rates of
the general population based on nine independent samples
(see Table 1). Twenty-four studies present data from the
general medical setting (including family practice and
primary care) based on 19 independent samples (see Table 2).
Furthermore, 20 studies provide data from specific clinical
samples (e.g., cancer patients) based on 19 independent
samples (see Table 3).
General Population Based Samples
The Composite International Diagnostic Interview
(CIDI) and variants of this standardized interview were
the instruments most often used for the estimation of the
prevalence of hypochondriasis in general populations [11-
14]. Furthermore, in two samples structured diagnostic
interviews were used [15-17] and in three samples self-rated
questionnaires were used for the estimation of the prevalence
of hypochondriasis and health anxiety [18-21]. Almost all
studies reported prevalence rates smaller than one percent for
the full diagnostic criteria of hypochondriasis (range 0.0-
0.8%). One exception was the study of Faravelli et al. [15]
who found a prevalence rate of 4.5% of hypochondriasis in a
community sample in Florence (Italy). The weighted mean
prevalence rate of all seven studies [11-15, 17-18] which
reported prevalence rates for hypochondriasis in the general
population is 0.40%. Without considering the study of
Faravelli et al. [15], the weighted mean prevalence rate for
hypochondriasis is only 0.13%.
Three studies also investigated the prevalence rates of
abridged hypochondriasis in samples of the general
16 Current Psychiatry Reviews, 2014, Vol. 10, No. 1 Weck et al.

Table 1. Epidemiology of hypochondriasis in population based samples.

Authors Sample Diagnostic Prevalence rates: Possible risk factors Similarities and differences between the
size Assessment hypochondriasis / hypochondriacal diagnostic subgroups and
(response abridged persons without hypochondriacal features
rate) hypochondriasis/
health anxiety

Bleichhardt 1575 DSM-IV 0.4%/2.0%/6.7% sex (-); higher age (+); Persons with health anxiety had experienced
& Hiller (71.7%) (criteria were marital status (-) psychiatric or psychotherapeutic treatment more
[18] asked by often and reported a lower health-related quality
questionnaire) of life in comparison to persons without health
IAS anxiety. Only 1.3% of the persons with health
anxiety (0.9% of the total sample) actually had
the illness they feared.

Faravelli 673 DSM-III-R 4.5%/-/- - -

et al. [15] (84%) (1-year prevalence)

Lieb et al. 2548 M-CIDI 0%/-/- - -

[11] (84%) (life-time prevalence)

Looper & 576 CIDI 0.2%/1.3%/6% sex (-); age (-); single (-); Persons with health anxiety had more chronic
Kirmayer (72%) (1-year prevalence) education (-); conditions, more medical problems, more
[12] unemployment (-); functional somatic symptoms, more life events,
ethnocultural group (-) and more psychological distress in comparison to
persons without health anxiety. Additionally, the
CIDI-probe questions for panic and generalized
anxiety were endorsed more often by persons
with health anxiety in comparison to persons
without health anxiety. Persons with health
anxiety showed elevated health care utilization in
comparison to persons without health anxiety.

Martin & 4181 M-CIDI 0.05%/0.58%/2.12% sex (-); higher age (+); In comparison to persons without health anxiety,
Jacobi [13] (61.4%) (1-year prevalence) single (+); socioeconomic persons with abridged hypochondriasis and health
status (-) anxiety had a mental disorder (81.8%, 74.3%)
more often, had a comorbid mental disorder
(means: 3.3, 1.5) more often, showed a lower
health-related quality of life, a higher number of
health care visits during the past 12 months (20,
18), a larger number of disability days during the
past 12 months (means: 57.3, 29.3), and a lower
physical activity rate. No differences in those
characteristics were found between abridged
hypochondriasis and health anxiety.

Noyes 937 CIDI 0%/-/6.9-13.1% female (+), age (-) marital Persons with health anxiety had more psychiatric
et al. [14] (55.2%) short-form (1-year prevalence) status (+); lower income and physical conditions as persons without health
(+); experience with anxiety. 54.6% of the persons with health anxiety
illness in childhood (+) had the illness they worried about. Persons with
health anxiety reported more utilization of health
care in the past 12 months and rated their health
and physical and mental functioning as worse
than persons without health anxiety. In the
subgroup of persons with health anxiety; those
persons who had health anxiety for more than 6
months reported an earlier age at onset, more
severe worry, greater distress, and impairment in
comparison to persons which had health anxiety
for less than 6 months.
Epidemiology of Hypochondriasis Current Psychiatry Reviews, 2014, Vol. 10, No. 1 17

Table 1. contd….

Authors Sample Diagnostic Assessment Prevalence rates: Possible risk factors Similarities and differences
size hypochondriasis / between the hypochondriacal
(response abridged diagnostic subgroups and
rate) hypochondriasis/ persons without
health anxiety hypochondriacal features

Noyes 500 DSM-IV (structured 0.8%/-/10.6% higher age (+); lower health status (+); -
et al. [17]; (62%) interview developed by lower education (+); lower income (+)
Malis et al. the authors)
[16]

Rief et al. 2050 SOMS -/-/8.2-10% female (+); higher age (+) -
[20]; Hinz (69.4%) Whiteley-Index
et al. [19]

Sunderland 8841 WMH-CIDI -/-/5.7% (life-time sex (-); middle age (+); marital status -
et al. [21] (60%) Health anxiety was prevalence), 4.2% (1- (-); physical conditions (+); education
assessed by a four-item year prevalence) (+); unemployment (+);
questionnaire developed socioeconomic status (-); smoking (+)
by the authors
Note. (+) a significant relationship to hypochondriasis was found; (-) no significant relationship to hypochondriasis was found; CIDI = Composite International Diagnostic Interview;
DSM = Diagnostic and Statistical Manual of mental disorders; IAS = Illness Attitude Scales; M-CIDI = Munich Composite International Diagnostic Interview; SOMS = Screening for
Somatoform Symptoms; WMH-CIDI = World Mental Health version of the Composite International Diagnostic Interview.

population and found a considerably higher prevalence rate
(0.6-2.0%) for this hypochondriacal subtype [12, 13, 18]. For
illustration, the study of Martin and Jacobi [13] can be
mentioned, in which the prevalence rate of abridged
hypochondriasis was nearly twelve times higher than the
prevalence rate of the full DSM-IV diagnosis. The weighted
prevalence rate of abridged hypochondriasis, based on the
three given studies, is 1.00%.
Additional information about the prevalence of health
anxiety in general populations was reported based on seven
independent samples [12-14, 17-21], however, the definitions
of health anxiety were heterogeneous. Some studies used
screening questions of diagnostic interviews, specifically
developed questions, or cut-off scores of questionnaires [17-
21] to identify health anxiety while others used one or more
ICD/DSM criteria of hypochondriasis evaluated by
diagnostic interviews [12-14]. Consequently, a wide range
for the prevalence of health anxiety in general populations
was found (range 2.1-13.1%). Moreover, different information
is given about the relationship between health anxiety and
illnesses currently present. For example, Noyes et al. [14]
used an interview and found that 54.6% of the persons with
health anxiety had the illness they feared while Bleichhardt
and Hiller [18] used a questionnaire and reported that only
1.3% had the feared disease.
Reported results regarding risk factors for hypochondriasis
and health anxiety in general population-based samples were
inconsistent (see Table 1). In four samples it was found that
hypochondriacal characteristics are significantly associated
with a higher age [13, 17-20], one sample found an association
with middle-age [21], but two samples found no relation
between hypochondriasis and age [12, 14]. In two samples
women were more often affected by hypochondriasis [14,
19-20] but results of three other samples did not confirm this
finding and found no association regarding sex [12, 13, 18,
21]. One study found a connection between hypochondriasis
and the status of being single [13] and one study found that
patients with hypochondriasis are more often separated,
divorced, or widowed [14]. However, two studies found no
association between hypochondriacal characteristics and
marital status [18, 21]. Two studies investigated the impact
of income [14, 17] and found a significant relationship
between hypochondriasis and lower income.
Four studies [12-14, 18] also provided information on
similarities and differences between persons with abridged
hypochondriasis, health anxiety, and non-hypochondriacal
controls. The studies show that persons with abridged
hypochondriasis and health anxiety show a significant
clinical impairment by reporting more medical problems,
more psychological distress, more health care utilization,
more comorbid mental disorders, and a lower health-related
quality of life than controls (see Table 1).
General Medical Samples
Assessment strategies for the estimation of the
prevalence rates of hypochondriasis and health anxiety in
general medical samples were very divergent (see Table 2).
The same diagnostic instruments were rarely used twice. The
prevalence rates of the full hypochondriasis diagnosis were
evaluated in 12 independent samples [7, 22-36] and ranged
from 0.3 to 8.5%. The weighted mean prevalence rate based
on the 12 independent samples is 2.95%. The prevalence rate
of abridged hypochondriasis was only evaluated in one large
cross-national study (N = 5447) and is therefore not
presented in Table 2 [7]. However, the prevalence rate of
abridged hypochondriasis was 2.2% and nearly three times
higher than the full ICD-10 diagnosis of hypochondriasis.
This study was the only one providing data about similarities
and differences of different hypochondriacal diagnostic
subgroups. Persons with abridged hypochondriasis reported a
poorer overall health, more health care utilization, more
functional and physical disability, and more days of impaired
18 Current Psychiatry Reviews, 2014, Vol. 10, No. 1 Weck et al.

Table 2. Epidemiology of hypochondriasis in general medical samples (including family practice and primary care).

Authors Sample size Diagnostic Prevalence rates: Possible risk factors

(response Assessment hypochondriasis /
rate) health anxiety

Barsky et al. [22, 23] 1389 DSM-III-R 4.2%/- sex (-); age (-); marital status (-); social class (-); blacks (+)
(53.5%)

Barsky et al. [3] 1612 Whiteley Index -/14.1% -

(87.8%)

Clark et al. [37] 10507 Whiteley-7 -/30.6% male (+); age (-)
(65.9%)

Conradt et al. [24] 1800 DSM-IV 7.7%/- -

(93.3%)

El-Rufaie & Absood [25] 217 CIS 8.3%/- sex (-)

(96.9%)

Escobar et al. [26] 1456 CIDI 3.4%/- sex (-); immigrant status (-); ethnicity (-)
(50.0%)

Fernández et al. [38] 252 Whiteley Index, -/9.9% sex (-); age (-); education (-); occupation (-); marital status (-)
(94.7%) interview

Fink et al. [28, 27]; 1785 SCAN, 2.4%/4.5-5.7% female (+); age (-)
Toft et al. [35] (81.3%) Whiteley-7

Fink et al. [29] 191 SCAN 4.6%/- -

(85.7%)

García-Campayo et al. 1559 SPPI 0.26%/6.7% -

[30]; Lobo et al. [32] (81.8%) DSM-III-R

Gerdes et al. [39] 210 Whiteley Index -/14% sex (-); age (-); unmarried (+); education (-)
(not specified)

Gureje et al. [7] 5447 CIDI 0.8%/6.7% sex (-); higher age (+), only for abridged hypochondriasis
(62%) (1-year prevalence)

Hollifield et al. [40] 185 IAS -/20.5% sex (-); age (-); ethnicity (-); education (-); marital status (-)
(62.0%)

Kirmayer & Robbins [41]; 685 IBQ -/7.7% sex (-); age (-); marital status (-); income (-); medical history
Robbins & Kirmayer [43] (51.0%) (-); life events (-)

Kroenke et al. [31] 1000 (73.5%) DSM-III-R 2.2%/- -

Noyes et al. [33] 1182 (84.1%) SCID 8.5%/13.8% marital status (-); educational level (-); occupational class; (-);
social class (-); aggregated physical disease (-)

Peveler et al. [42] 179 Whiteley Index -/9% lower age (+); social class (-)
(79.0%)

Steinbrecher et al. [34] 648 IDCL 0.4%/- -

(95.7%) (1-year prevalence)

van Hemert et al. [36] 191 PSE 4.7%/- -

(78.0%)

Note. (+) a significant relationship to hypochondriasis was found; (-) no significant relationship to hypochondriasis was found; CIDI = Composite International Diagnostic Interview;
CIS = Clinical Interview Schedule; DSM = Diagnostic and Statistical Manual of mental disorders; IAS = Illness Attitude Scales; IBQ = Illness Behaviour Questionnaire; IDCL =
International Diagnostic Checklists; PSE = Present State Examination; SCAN = Schedules for Clinical Assessment in Neuropsychiatry; SCID = Structured Clinical Interview for
DSM-III-R; SPPI = Standardized Polyvalent Psychiatric Interview; Whiteley-7 = Seven-item version of the Whiteley Index.

role functioning in the previous month compared to persons characteristics from those with abridged hypochondriasis,
without abridged or full hypochondriasis. Patients with the however, patients with the full hypochondriasis diagnosis
full hypochondriasis diagnosis did not differ regarding these more often had a comorbid generalized anxiety disorder.
Epidemiology of Hypochondriasis Current Psychiatry Reviews, 2014, Vol. 10, No. 1 19

Table 3. Epidemiology of hypochondriasis in specific clinical samples.

Authors Sample size Population Measures Prevalence rates:

(response rate) hypochondriasis / health anxiety

Specific medical settings or physical illnesses

Fink et al. [45] 294 Internal medical inpatients SCAN 3.5%-4.7%/-

(75.0%)

Grandi et al. [46] 129 Cardiac patients SCID 0%/7.7%

(not specified) (after surgery) DCPR

Grassi et al. [52, 53] 146 Cancer patients DCPR -/37.7%

(91.8%)

Kehler & Hadjistavropoulos [55] 246 Multiple sclerosis patients SHAI Elevated health anxiety in comparison to a
(85.8%) matched control group

Lee et al. [44] 100 Patients with chronic fatigue SCID 3%/-
(47.4%)

Picardi et al. [51] 539 Dermatological patients DCPR -/10.6%

(84.1%)

Rafanelli et al. [47] 61 Cardiac patients SCID 0%/0%

(not specified) DCPR

Rafanelli et al. [48] 47 Cardiac patients SCID 0%/8.5%

(not specified) (after surgery) DCPR

Schmidt et al. [49] 155 Otolaryngology patients MEGAH -/13.5%

(88.1%)

Seivewright et al. [50] 696 Genitourinary patients HAI -/8-11%

(71.9%)

Tyrer et al. [54] 28991 (67.1%) Medical inpatients SHAI -/19.9%

Psychiatric, psychotherapeutic or psychosomatic settings

Bleichhardt & Hiller [56] 114 Psychotherapeutic outpatients IDCL 1.8%/19.3%-30.7%

(not specified) IAS

Galeazzi et al. [62] 100 Consultation-liaison DCPR -/9.6%

(94.3%) psychiatry

Garyfallos et al. [57] 1448 (not Psychiatric outpatients DSM-III-R 1.6%/-

specified)

Pieh et al. [58] 100607 Psychosomatic inpatients ICD-10a 0.4%/-

(not specified)

Porcelli et al. [63] 208 Consultation-liaison DCPR -/34.6%

(71%) psychiatry

Porcelli et al. [59] 190 Functional gastrointestinal SCID 7.4%/11.6%

(95%) disorders DCPR

Smith et al. [60] 4401 Consultation-liaison DSM-III-R 0.6%/-

(not specified) psychiatry

Weck et al. [61] 85 Psychotherapeutic outpatients SCID 3.5%/24-34%

(35.0%) IAS
DCPR = Diagnostic Criteria for Psychosomatic Research; DSM = Diagnostic and Statistical Manual of mental disorders; HAI = Health Anxiety Inventory; IAS = Illness Attitude
Scales; ICD = International Classification of Diseases; IDCL = International Diagnostic Checklists; MEGAH = Maastrichtse Eigen Gesondheits-Attitude en Hypochondrie
(Questionnaire developed by the authors); SCAN = Schedules for Clinical Assessment in Neuropsychiatry; SCID = Structured Clinical Interview for DSM; SHAI = Health Anxiety
Inventory (short form)
a
no standardized diagnostic procedure

Investigations in general medical samples also show a anxiety in 11 independent samples were reported and ranged
heterogeneous definition of health anxiety and the use of from 4.5 to 30.6% [3, 7, 27, 28, 30, 32, 33, 35, 37-43].
different assessment strategies. Prevalence rates of health
20 Current Psychiatry Reviews, 2014, Vol. 10, No. 1
Results regarding potential risk factors were very
inconsistent. Moreover, in most studies no potential risk
factors were identified or possible risk factors were not
reported. Accordingly, no clear tendency for any potential
risk factor can be identified on the basis of general medical
samples (see Table 2).
Specific Clinical Samples
Aside from studies investigating general populations and
general medical samples, there are also studies which
investigated the prevalence of hypochondriasis and health
anxiety in more specific clinical samples. Thereby, we
distinguished between studies which investigated patients in
specific medical settings or patients with specific physical
illnesses and investigations in psychiatric, psychotherapeutic,
or psychosomatic settings. Assessment strategies in these
studies also differed greatly and mostly smaller samples
were investigated (see Table 3).
Five studies provided prevalence rates of hypochondriasis
in specific medical settings or in patients with specific
physical illnesses. The prevalence of hypochondriasis was
3% in patients with chronic fatigue [44] in a sample in Hong
Kong (China). In a sample of internal medical inpatients,
a diagnosis of hypochondriasis according to ICD-10
and DSM-IV was found in 3.5% and 4.7% of patients,
respectively [45]. Three studies investigated prevalence rates
of mental disorders in patients with cardiac diseases and
found that none of the patients fulfilled the diagnostic criteria
of hypochondriasis [46-48]. Prevalence rates of health
anxiety in specific medical settings were provided by eight
independent samples. Investigations included otolaryngology
patients [49], genitourinary patients [50], cardiac patients
[46-48], dermatological patients [51], cancer patients [52,
53], and medical inpatients [54]. Prevalence rates of health
anxiety showed a wide range from 0% to 37.7%. Moreover,
elevated health anxiety was found in a sample of patients
with multiple sclerosis in comparison to matched controls,
however, no prevalence rates were given [55].
For psychiatric, psychotherapeutic, and psychosomatic
settings six studies provided prevalence rates for
hypochondriasis [56-61]. Prevalence rates ranged from 0.4%
to 7.4% for the diagnosis of hypochondriasis. Prevalence for
health anxiety was assessed in two samples of psycho-
therapeutic outpatients [56, 61], in two samples of
consultation-liaison psychiatry patients [62, 63], and one
sample of patients with functional gastrointestinal disorders
[59]. Prevalence rates ranged from 9.6% to 34.6%.
DISCUSSION
The present review gives an overview of the prevalence
of hypochondriasis and less restrictive subtypes of hypo-
chondriacal phenomena, namely abridged hypochondriasis
and health anxiety. Altogether, 55 studies were reported
which were based on 47 independent samples. In order to
report prevalence rates of hypochondriasis in different
samples, we included general population-based samples,
general medical samples, and specific clinical samples.
Assessment methods in the reviewed samples were very
different and therefore difficult to compare. Therefore, the
Weck et al.
calculated weighted prevalence rates must be interpreted
with caution. In particular, the inconsistency in both
assessment strategies and definitions may explain the wide
range of prevalence rates for health anxiety. Thus, weighted
prevalence rates were not calculated for health anxiety.
In population-based studies the prevalence of the full
ICD/DSM diagnosis of hypochondriasis was low (weighted
prevalence 0.40%; range 0.0-4.5%) with exception of one
study in which a prevalence of 4.5% was found. Possibly the
different findings are a result of different assessment
methods for the estimation of the prevalence rates of
hypochondriasis. In most studies a standardized diagnostic
interview (CIDI) was used while Faravelli et al. [15]
implemented the DSM-III-R criteria in a structured
diagnostic interview for the evaluation of the prevalence rate
of hypochondriasis. Furthermore, in comparison to most of
the other population-based studies, the sample size in the
study of Faravelli et al. was relatively small; therefore,
findings must be read with caution. Because the study was
the only one which investigated an Italian population, it is
also possible that cultural differences are responsible for the
differences. However, in the cross-national primary care
study of Gureje et al. [7], evidence for a higher prevalence of
hypochondriasis in Italy was not found. Even though further
studies investigating the prevalence of hypochondriasis in
general populations are necessary, the current findings
suggest that the prevalence of the full ICD/DSM diagnosis of
hypochondriasis in general populations can be expected to be
probably lower than one percent. Only one study considered
different types of prevalence rates of health anxiety at the
same time and found largely comparable prevalence rates for
the 1-year (4.2%) and life-time prevalence (5.7%) [21]. This
result suggests that health anxiety is a rather chronic
condition; however, prevalence rates of health anxiety and
not hypochondriasis were investigated. The 4- to 5-year
prevalence of hypochondriasis was found to be very high
(64%) [4], though, which gives evidence for the stability of
the diagnosis of hypochondriasis as well.
In contrast, the prevalence of less restrictive hypo-
chondriacal subtypes in population-based studies were notedly
higher and ranged for “abridged hypochondriasis” from
0.6% to 2.0% (weighted prevalence rate 1.00%) and for
health anxiety from 2.1% to 13.1%. It is an important finding
that these subtypes were significantly associated with psycho-
pathological characteristics (e.g., psychological distress,
lower health-related quality of life, elevated health care
utilization) typical for persons with the full ICD/DSM
diagnosis and on a comparably high level. This result was
also found for one large cross-national primary care study
which found no psychopathological differences between
patients with hypochondriasis and the abridged criteria of
hypochondriasis [7]. These findings underline the importance
of the current discussion about the inadequate restrictiveness
of the diagnostic criteria for hypochondriasis in DSM-IV.
Based on the limited findings to date, it can be expected
that the revision of the DSM-5 criteria regarding medical
reassurance [8] will lead to higher prevalence rates of
hypochondriasis in future epidemiological studies.
The occurrence of health anxiety was associated with
significant psychopathological characteristics as well.
Epidemiology of Hypochondriasis
However, the definition of health anxiety and the assessment
strategies in the reviewed studies were heterogeneous and it
is not clear whether prevalence rates of the same phenomena
were reported. On the other hand, persons with elevated
health anxiety also showed significant clinical impairment
and distress. Therefore, we need a unitary definition of
health anxiety and more homogenous assessment strategies.
A more consistent approach would allow us to make further
suggestions for the improvement of the diagnostic criteria of
hypochondriasis and the development of adequate treatment
strategies. For instance, the DCPR provides such a unitary
definition of health anxiety [9]. Furthermore, reliable and
valid structured interviews were developed for the evaluation
of the DCPR criteria [47, 64]. The unitary utilization of those
criteria and assessment strategies would be desirable because
it would allow a better comparability of future studies.
In comparison to population-based samples, the prevalence
rate of hypochondriasis was considerably higher in general
medical samples (weighted prevalence 2.95%; range 0.3-8.5%).
The wide range of prevalence rates can be explained by the
divergent assessment strategies and the differing populations.
For example, the study with the smallest prevalence rate was
based on a sample of patients in a health care center in
Zaragoza (Spain) [32], while the study with the largest
prevalence rates was based on a sample of outpatients from a
medical clinic in Iowa (USA) [33]. Differences in medical
settings and cultural differences restrict the comparability of
the studies further. In the more specific clinical samples
higher prevalence rates of hypochondriasis were found
(range 0.4-7.4%) in comparison to general population-based
studies. Despite the heterogeneity of the samples and the
wide range of prevalence rates, hypochondriasis can be
considered to be highly prevalent in these populations. High
prevalence in general medical settings and specific clinical
samples is particularly important because hypochondriasis is
associated with high costs for increased health care
utilization [3, 27]. Moreover, we can expect that the intended
revision of the diagnostic criteria of hypochondriasis in
DSM-5 will also lead to significantly higher prevalence rates
of hypochondriasis [7]. Furthermore, health anxiety seems to
be very common in general medical samples and specific
clinical samples as well. For example, in a sample of cancer
patients more than one third (38%) of the patients showed an
elevated level of health anxiety [52, 53]. Even though this
kind of health anxiety cannot be seen in the same light as
hypochondriasis, health anxiety is associated with significant
psychological distress for the affected persons and should be
addressed with an adequate treatment.
Findings regarding potential risk factors for hypo-
chondriasis and health anxiety were inconsistent. There was
a tendency that women and older persons might have a
higher risk for hypochondriasis but findings were discrepant.
The relationship between health anxiety and present illnesses
still remains unclear. For illustration, in population-based
samples a strong association between health anxiety and the
presence of the feared illness existed (55%) [14], while in
another sample this connection was not found (only 1% of
participants with health anxiety had the illness they feared)
[18]. It is not clear whether differences are completely
explainable by different assessment strategies (interview
vs. questionnaire) or whether varying populations are
Current Psychiatry Reviews, 2014, Vol. 10, No. 1 21
accountable for these large differences. On the other hand,
there is an obvious association between the existence of a
serious illness (e.g., cancer, multiple sclerosis) and the
presence of health anxiety. Because the assessment of
potential risk factors and the prevalence of hypochondriasis
(respectively health anxiety) took place at the same time, it is
possible that some characteristics of the participants (e.g.,
unemployment) could have occurred after the onset of health
anxiety and could present consequences rather than risk
factors.
CONCLUSIONS
It can be concluded that the prevalence of the full
ICD/DSM diagnosis of hypochondriasis is rare in general
populations. However, there is evidence that the current
diagnostic criteria are too restrictive and that at least the
adherence to the B criterion seems unjustifiable and falls
short of the clinical relevance of hypochondriacal phenomena.
In comparison, health anxiety is a common occurrence,
which should be considered in further investigations.
However, a uniform definition and homogenous assessment
methods are necessary in order to improve comparability of
different studies. In clinical populations the prevalence of
hypochondriacal aspects are very common and should
therefore be paid considerably more attention. The use of
short screening instruments for health anxiety like the
Whitely-7 [65, 24] or the subscale Bodily Preoccupations of
the Illness Attitude Scales [66, 67] have demonstrated to be
appropriate and should be routinely implemented in medical
settings for identifying persons with hypochondriasis and
elevated health anxiety in order to optimize treatment
strategies for an effective reduction of psychological
impairment and unnecessary health care utilization.
CONFLICT OF INTEREST
The authors confirm that this article content has no
conflict of interest.
ACKNOWLEDGEMENTS
This research was supported in part by grant WE 4654/2-1
from the German Research Foundation.
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Accepted: June 20, 2013