Why We Don’t Call It Hypochondria Anymore

It’s been just 10 short years since the fifth edition of the Diagnostic and Statistical Manual, DSM, updated hypochondriasis to illness anxiety disorder. While this may appear to be nothing more than a simple word change, it actually has great importance and implications. Clinical language, while necessary for diagnostic purposes, can also risk pathologizing clients and making them feel they are nothing more than a diagnostic label. Consider the difference between “I have anxiety” and “I struggle with anxiety.” These linguistic subtleties can positively or negatively affect clients’ prognosis and progress.

If you read some of the classic psychological literature (see Karen Horney, who authored multiple books with neurotic in the title, as well as Rollo May, Alfred Adler, and others), you’ll find numerous and repeated use of words like neurosis, histrionic, phobic, and delusional. While many of these works remain important tomes, they miss the boat when it comes to how clients view themselves and speak of themselves, and how psychological language can impact self-perception.

A humanistic approach
In my experience working with clients who have illness-related anxiety, I have found it more useful to take a humanistic approach than to take a wholly clinical one. The anxious person already feels threatened and layering clinical language on top of that feeling, often, worsens their anxiety. As an early therapist, I once showed the DSM criteria for illness anxiety to a client, thinking it would help him see that he was thinking irrationally and anxiously. In retrospect, I see this as a blunder on my part. Not only did seeing the criteria make this client feel I was immediately pathologizing him, but it also caused him to feel he had been labeled and that he was now a page in a manual.

As I became more seasoned, I learned that the client’s level of psychological safety in the therapy room is more important than the diagnostic criteria they might fit. What had started out sounding like “you might have illness anxiety disorder,” now sounds more like “physical health is a common source of anxiety for many people.” You can almost feel yourself breathing easier just hearing the latter.

Thankfully, we now view illness anxiety not as phobic or neurotic but rather, as an anxiety response. Understood this way, the client shifts from viewing themselves as a neurotic, irrational worrier to being a person who has an anxious response to frightening stimuli.

A softer designation can bring about positive treatment implications:

• The client is humanized rather than pathologized, which can lead to a greater ability toward self-efficacy and self-advocacy. In simple terms, the client discovers that they have power over their anxiety and not the other way around.
• The client recognizes that there is a commonality in their anxious presentation. They are not part of an esoteric group of neurotics and, therefore, feel that they are experiencing a challenge that is normal for humans. This normalization often paves the way for healing and developing adaptive coping skills.
• Softer, more compassionate diagnostic language directly impacts gentler self-talk. The client begins to challenge and change harsh and unhelpful self-messages: “You’re just being weak.” "Why are you being such a baby?” Replacing them with messages: “You are anxious right now and that is OK.” “Thinking about illness makes many people feel worried; there is nothing wrong with me for feeling this way.”
• The client feels that the problem is solvable rather than static. A word like neurosis, by definition, implies that one is experiencing a mental condition that is difficult or impossible to reverse, whereas illness anxiety implies a greater ability to find ways to cope and heal. The word neurosis, too, implies that one is close to losing touch with reality. The illness anxiety client, while worried, has not lost touch with reality, and it is unhelpful for them to view themselves this way.

When we are mindful of the language we use when working with clients, we ensure that they feel heard, understood, and safe. It took the DSM decades to begin softening some of its harsh, clinical diagnostic language and terminology, but it is a change for the better and for the ultimate benefit of the anxious client.