Illness anxiety vs somatic symptom disorder: what’s the difference?

You might have heard someone called a hypochondriac. It’s a word that can sound dismissive, as if people are making things up. In 2013, the diagnostic manual used by US doctors and therapists (the DSM-5) replaced hypochondriasis with two conditions: illness anxiety disorder and somatic symptom disorder.

Both involve intense, distressing worry about health. The difference is mostly about physical symptoms. Here’s how to tell them apart, and what helps.

The short answer

Illness anxiety disorder is a persistent fear of having, or getting, a serious illness, even though you have few or no physical symptoms, or only mild ones. The fear itself is the main problem.

Somatic symptom disorder is when real physical symptoms, like pain, tiredness or breathlessness, come with so much worry, attention and distress that they take over your life. The symptoms may or may not have a medical explanation, but they are always real.

For both, the worry has usually been going on for at least six months.

Side by side

	Illness anxiety disorder	Somatic symptom disorder
Physical symptoms	None, or mild	Prominent and distressing
Main focus	“What if I have a serious illness?”	“What do these symptoms mean, and how do I cope with them?”
Common worries	Cancer, heart disease, neurological illness	That the symptoms mean something serious, or will never get better
Common behaviours	Checking your body, searching symptoms, seeking reassurance, or avoiding doctors altogether	Frequent appointments and tests, spending a lot of time and energy on symptoms
Reassurance	Brings brief relief, then the worry returns	Normal test results often don’t ease the distress

What illness anxiety disorder feels like

People with illness anxiety disorder often:

• worry for long periods that they have a serious illness, or will get one
• read normal body feelings, like a headache, a lump or a skipped heartbeat, as signs of disease
• check their body repeatedly, or take their pulse, temperature or blood pressure
• spend a lot of time researching symptoms online
• ask others for reassurance, or share health worries often
• feel relieved after a normal test result, but only briefly

Cleveland Clinic describes two types: care-seeking, where people visit doctors and ask for tests often, and care-avoidant, where people stay away from doctors, sometimes because they fear what they’ll find, or feel they won’t be taken seriously.

What somatic symptom disorder feels like

People with somatic symptom disorder have one or more physical symptoms that cause real distress, such as pain, tiredness, stomach problems or breathlessness. Along with the symptoms, they often:

• think about the symptoms constantly, and fear they’re a sign of something serious
• feel very anxious about their health
• spend a lot of time and energy on the symptoms: appointments, tests, research, rest
• find it hard to feel reassured, even when tests are normal
• find everyday life increasingly hard to manage

The symptoms are not imagined. Cleveland Clinic is clear that they’re real, even when there’s no clear medical cause, and that the condition isn’t “all in your head”. The brain may be more sensitive to body signals, and stress and attention can make them stronger.

Where health anxiety fits in

“Health anxiety” is an everyday term that covers both. Many people have some health anxiety without it becoming a disorder, for example after a scare or when someone close to them is ill. It becomes a problem when it takes up a lot of time, causes a lot of distress, or gets in the way of life.

Why the worry keeps going

Both conditions are kept going by a similar loop:

1. You notice a body feeling, or have a worrying thought about your health.
2. You read it as a sign of something serious.
3. Anxiety rises, which can create more body feelings.
4. You check, search or seek reassurance, and feel better for a moment.
5. The relief fades, the doubt returns, and the loop starts again.

Checking and reassurance feel helpful, but they keep your attention on your body and teach your brain the worry was important. Our post on why reassurance keeps OCD going explains this loop, and much of it applies to health anxiety too.

What helps

Cognitive behavioural therapy (CBT) is the main treatment for both. It helps you notice and question catastrophic thoughts, gradually cut back on checking, searching and reassurance-seeking, and get back to the things you’ve been missing. For somatic symptom disorder, it also helps you manage symptoms and stay active.

Medicine, such as an antidepressant, can help with anxiety or depression that often come alongside, and sometimes with symptoms like pain.

A steady relationship with one doctor helps too. Regular, planned check-ins, rather than appointments driven by fear, can make it easier to trust that you’re being looked after.

Things you can try now:

• Notice the urge to check or search, and delay it by 30 minutes. Often the urge fades.
• Limit health searching, or take a break from it altogether.
• Keep doing the things you enjoy, even when you feel worried.
• Breathe slowly when worry spikes, to calm the body feelings that fuel it.

How Breatheasy can help

Breatheasy can help you break the checking loop. Breatheasy’s “Ride out an urge” tool waits with you for 5, 10 or 15 minutes while the urge to check, search or ask for reassurance rises, peaks and falls, with gentle check-ins along the way. Ten-second check-ins and a journal help you notice your health worries rising and falling over time. Breatheasy is coming soon to iPhone and Android.

When to get help

Talk to a doctor if worry about your health is taking up a lot of your time, causing you distress, or stopping you living your life. And always get new or changing symptoms checked: health anxiety and physical illness can happen together.

Sources

• Illness anxiety disorder (hypochondria), Cleveland Clinic
• Somatic symptom disorder, Cleveland Clinic
• Health anxiety, NHS