Illness Anxiety Disorder and a Counselor’s Duty to Advocate

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Abstract

Illness anxiety disorder (IAD), health anxiety, and hypochondriasis are all terms used to describe a specific disorder that affects 1.3% to 10% of individuals over their lifetime.  This disorder is characterized by anxiety about normal bodily sensations; hypervigilance; checking behaviors; and seeking reassurance from the internet, family, friends, and the medical community that reinforces and perpetuates the anxiety.  Past research has found that genetics plays a part in the development of this disorder, as well as insecure attachment, faulty beliefs, attentional bias, cognitive distortions, exposure to a model with the disorder, stress, the loss of a parent, childhood abuse, and a history of personal illness.  Many who have the disorder visit their physician on a regular basis, overutilizing the medical systems and exposing themselves to unnecessary tests and procedures.  Even so, individuals with the disorder have been found to have a contentious relationship with their physicians while their physicians are unsure of what to do and might inadvertently cause the disorder to worsen.  An advocacy plan for counselors is proposed in response to this need as a way to remove the barriers that those who are living with IAD face.

Keywords: illness anxiety disorder, health anxiety, hypochondria, counselling, advocacy

Illness Anxiety Disorder: Description, Development, and a Programmatic Response

Illness anxiety disorder (IAD) can be a debilitating issue that affects not only the individual with the disorder, but their friends, families, and physician (American Psychiatric Association, 2013).  Besides the consequences to one’s physical and emotional well-being, this disorder is characterized by an overuse of the medical system through unnecessary doctor visits and tests (APA, 2013; Fink, Ørnbøl, & Christensen, 2010; Hart & Björgvinsson, 2010; Tyrer et al., 2011).  Physicians are the ones who come into contact with these individuals most often (Hart & Björgvinsson, 2010), however this is a persistent mental illness (Eilenberg, Frostholm, Schröder, Jensen, & Fink, 2015) and physicians do not have the skills needed to address this appropriately with their patients (Taylor & Asmundson, 2004).  In fact, oftentimes in the cases of a somatoform disorder (which IAD falls under), physicians are more likely to diagnose the patient as having “medically unexplained symptoms” (Dimsdale, 2013, p. 31), ignoring the fact that mental health treatment is needed.  It is a mental health counselor’s ethical duty to advocate for clients both individually and on an institutional level so as to remove barriers for clients (American Counseling Association, 2014, Standard A.7.a), and a response is needed to help open the doors of communication between the medical community and the mental health counselor.

Defining Illness Anxiety Disorder

The term illness anxiety disorder (IAD) is now used in the DSM-5 to characterize what was once known as hypochondriasis, without the presence of somatic symptoms, or only mild somatic symptoms such as normal bodily sensations (APA, 2013).  However, defining this particular disorder has been debated for years with many terms used interchangeably to describe it (van den Heuval, Veale, & Stein, 2014), adding to some of the confusion on what actually defines IAD.  This author proposes the definition that is now currently used in the DSM-V which characterizes the disorder as being preoccupied “with having or acquiring a serious illness”, mild or absent symptoms, anxiety and alarm about one’s health, excessive checking or avoidance of the body, and the above symptoms having been “present for at least 6 months” (APA, 2013, p. 315).  An important feature is that unlike the individual who has somatic symptom disorder and wants their symptoms to be medically explained, the person with IAD is looking to be reassured that they are healthy (van den Heuval et al., 2014).

Throughout this paper, this author will use the terms hypochondria/hypochondriasis, health anxiety, and illness anxiety disorder (IAD) interchangeably as they are seen in the respective research referred to.  The acronym IAD will be used when particular research is not being referred to or when various articles are being cited. Of note, the term health anxiety is considered a clearer and more appropriate term to describe the emotions and behaviors that encompassed the previous diagnosis of hypochondria (Abramowitz & Braddock, 2011; Hart & Björgvinsson, 2010), while others believe that IAD is an appropriate term, but that the term hypochondria more aptly describes the disorder (van den Heuval et al., 2014).  However, there is some concern to the negative stereotypes and stigmas that the term hypochondriasis carries with it (Fink et al., 2010; Pandey, Parikh, Brahmbhatt, & Vankar, 2017).  Even with the debate on what term is most appropriate to use, Weck, Neng, Richtberg, Jakob, and Stangier (2015) state that the research findings for both health anxiety and hypochondriasis are appropriate to use when researching this collection of symptoms.

Commonalties of the Disorder

An individual with IAD is not malingering or feeling symptoms that are not there, rather they are interpreting normal bodily sensations as cause for concern (Abramowitz & Braddock, 2006; APA, 2013; Taylor & Asmundson, 2004).  When an individual feels a twinge or pain that most would ignore, the individual with health anxiety might become preoccupied with that feeling and is hypervigilant to any ‘changes’ that might occur with these sensations (Taylor & Asmundson, 2004).  While it is useful and evolutionary for humans to be aware of changes in their bodies to alert them to seek necessary treatment, the individual with hypochondriasis feels incredible fear in relation to these ‘changes’ (van den Heuval et al., 2014).

In addition to this anxiety, the individual is extremely reactive to health-related information in the environment, such as hearing about a friend who has the feared illness or seeing any sort of media pertaining to the feared illness (Abramowitz & Braddock, 2006; Hart & Björgvinsson, 2010; Taylor & Asmundson, 2004).  Behaviors also include constantly checking the body for ‘symptoms’, asking for reassurance not only from doctors but from friends and family, requesting unnecessary medical tests, avoiding any stimuli that reminds the individual of their feared illness, and researching the suspected illness in books and on the internet (APA, 2013; Hart & Björgvinsson, 2010; Taylor & Asmundson, 2004).  IAD can become debilitating to the individual and might affect an individual’s relationships with friends and family, their performance on the job, and even their relationships with their physicians (APA, 2013; Eilenberg et al., 2015; Ferguson, 2000; Hart & Björgvinsson, 2010; Noyes et al., 2003; Taylor & Asmundson, 2004).

Development

Theories on the development of IAD differ (APA, 2013), but research indicates it might be a result of attachment, cognitive distortions, or stress and loss. However, it must also be considered in relation to the developmental debate of nature versus nurture and whether genetics or environment are the main cause.

Nature

Nature is received in genetic makeup from birth, and nurture is characterized by our physical and social world (Berk, 2014).  One study found that “genetic factors account for 34-37% of variance” in health anxiety, concluding that it is caused by an individual’s environment (Taylor, Thordarson, Jang, & Asmundson, 2006, p. 49).  Two years later Taylor, Jang, Stein, and Asmundson (2008) found that health anxiety was “moderately heritable” but that environment lent more to the development of this disorder (p. 151).  An even later study by two of the same researchers from the two previous studies found this disorder to be a mixture of both nature and nurture, as “genetic factors accounted for 54 to 69% of variance” while environment only accounted for 32 to 46% of the variance (Taylor & Asmundson, 2012, p. 1).  As can be seen, these studies found the influence of nature, but not without the same influence of nurture and the individual’s environment.

In further support of the unique contribution of nature, a research study on personality asserted that those with hypochondriasis scored higher in neuroticism and introversion, and less on agreeableness and conscientiousness (Ferguson, 2000).  This is in contrast to the fact that from adolescence to middle-age, neuroticism lessens and agreeableness and conscientiousness increase from genetic influence (Berk, 2014).  Further research also found that neuroticism was associated with hypochondria (Noyes et al., 2003).  Williams (2004) goes on to states that neuroticism might be a contributing reason for selective attention to perceived health threats in the environment.

Nurture

Interpersonal: Attachment.It is theorized that attachment patterns form as infants and children and are in response to parenting availability and the quality of caregiving (Bowlby, 1988).  Based on attachment theory, Stuart and Noyes (1999) propose a theory that individuals will somaticize based on early attachment, and later Noyes et al. (2003) test this theory and name it the ***interpersonal model of hypochondriasis***.  Since then, numerous studies have focused on this interpersonal viewpoint with Birnie at al. (2013) noting that by not regarding this model it leaves out part of the overall picture and understanding of health anxiety.

Alberts and Hadjistavropoulos (2014) found that both attachment anxiety and attachment avoidance predicted the development of health anxiety, with the latter being a better predictor.  The authors state that this difference is because those with attachment anxiety will often seek reassurance, a commonality in those with hypochondria, while those who are avoidant do not seek the same reassurance (Alberts & Hadjistavropoulos, 2014).  Sherry et al. (2014) had similar findings when their research discovered that anxious attachment was a strong predictor of health anxiety, and that high levels of anxious attachment coupled with emotional instability could lead to even higher levels of experienced health anxiety.  However, Birnie et al. (2013) did not find a correlation between anxious attachment and reassurance seeking as Alberts and Hadjistavropoulos (2014) postulated.  Instead, this study found a positive correlation between both the anxious and avoidant attachment styles with feelings of alienation (the individual believing others are not taking their concerns seriously) and worry about one’s health (Birnie et al., 2013).  These authors note that even though reassurance seeking (a hallmark of health anxiety) behaviors are not correlated with anxious attachment and are negatively correlated with avoidant attachment directly, that they were related to both feelings of alienation and worry about one’s health (Birnie et al., 2013).

Noyes et al. (2003) found a positive correlation between hypochondriasis and all forms of insecure attachment, especially the fearful attachment style.  The authors state with these attachment styles, those with hypochondriasis do not perceive themselves as deserving care and in turn do not perceive caring behaviors from others (Noyes et al., 2003).  In fact, these individuals rank low on the “desire for closeness” and “faith in others’ dependability” measures (Noyes et al., 2003, p. 294).  As a result, those who do seek care might become critical and angry to those offering it (Noyes et al., 2003).  Related, Jordan, Williams, and Smith (2015) also found a positive correlation between hypochondriasis and anxious attachment and the tendency to perceive others as uncaring towards health concerns.

Differing slightly, Wearden, Perryman, and Ward (2006) did not find a relation between hypochondriasis and the dismissing or fearful attachment styles, but did find a positive correlation with the insecure attachment style of preoccupied attachment.  The authors describe preoccupied attachment as possessing low self-esteem and feeling unworthy, coupled with a more positive perception of others, possibly resulting from caregiving that was not consistent in responding to the individual’s needs as a child (Wearden, et al., 2006).  This type of attachment style was also correlated with the behaviors of seeking reassurance from others (Wearden, et al., 2006) which is a common symptom of IAD as mentioned previously.

Cognitive Behavioral Theory

The cognitive behavior school of thought believes that those with IAD have biases towards information about health, will experience elevated physiological responses to these appraisals, will engage in the safety-seeking behaviors as mentioned previously, and will suffer on an affective level (Salkovskis, Warwick, & Deale, 2003).  Williams (2004) asserts that this cognitive school of thought is the prevailing model for conceptualizing health anxiety and hypochondriasis.  Much of the research focuses on selective attention and biases toward health threatening information and how certain behaviors reinforce these cognitions, as well as how these behaviors and cognitions might have developed through social learning.

Individual. The cognitive-behavioral theory regarding the development of IAD posits that the individual carries faulty beliefs about health, belief in the likelihood of illness manifestation, and attentional bias towards threatening health information (Abramowitz & Braddock, 2006).  These individuals tend to possess the cognitive distortions of catastrophizing, all-or-nothing thinking, and the belief in the likelihood of negative outcomes (Fulton, Marcus, & Merkey, 2011). Numerous studies have shown that those with healthy anxiety do tend to have an attentional bias to words that are considered threatening to one’s health, and this biased attention is a form of dysfunctional thinking that lends to the individual not considering other information that might go against their fears (Fulton et al., 2011).  Individuals who are more likely to seek reassurance from healthcare providers showed a stronger attentional bias towards words that they found threatening, and the more likely the individual to seek these services the more difficult for the individual to disengage from words considered threatening (Lee et al., 2013).  In terms of rating words, individuals with hypochondriasis are also more likely to label “illness-related words” as negative, and the more anxious the individual was about their health, the more negative these ratings would be (Schreiber, Neng, Heimlich, Witthöft, & Weck, 2014, p. 675).  Not only is there a perceived attentional bias towards health-related words that are considered threatening, but words that were related to symptoms showed arousal in certain areas of the brain for individuals with pathological health anxiety (Mier et al., 2017).

Those with hypochondriasis have also been found to have difficulties in finding normalized explanations for the symptoms that they do feel and are more likely to think their symptoms are a result of a more serious disease (Neng & Weck, 2015).  Singh, Fox, and Brown (2016) found that it was this very act of catastrophizing symptoms that led individuals to engage in online searches for health information.  In addition, those with health anxiety might engage in a type of all-or-nothing thinking as a common belief is that health is equivalent to not having any symptoms at all (Abramowitz & Braddock, 2006; Fulton et al., 2011).  This dysfunctional thinking that goes with health anxiety might lead an individual to doubt recommendations made by health professionals, including prevention measures (Fulton et al., 2011).

Parenting, Modeling, and Reinforcement.It has been postulated that the development of this form of thinking might be a result of parental modeling and overprotection (Taylor & Asmundson, 2004).  Parental modeling involves the child witnessing the parent receiving attention when they are ill, leading the child to learn that bodily sensations should not be ignored (Taylor & Asmundson, 2004).  Parental overprotection might also contribute to the child seeing themselves as having a vulnerability to illness (Taylor & Asmundson, 2004).

The individual with IAD is also likely to engage in the maladaptive behaviors as mentioned above of checking, seeking reassurance, requesting evaluations, avoiding stimuli, and researching (Abramowitz & Braddock, 2006; Hart & Björgvinsson, 2010; Taylor & Asmundson, 2004).  However, the cognitive-behavioral theory also hypothesizes that these actions work to maintain and reinforce the anxiety and behaviors of this disorder.  Taylor and Asmundson (2004) even believe that the beginnings of health anxiety can be found when a parent gives attention to a sick child and then the individual learns that illness is both rewarded and reinforced.  In one study, those who were encouraged to use safety behaviors not only had an increase in ratings for health anxiety and anxious thoughts concerning health, but were also more likely to believe they were going to be afflicted by illness (Olatunji, Etzel, Tomarken, Ciesielski, & Deacon, 2011).  When the individual seeks reassurance from friends, family, and their physician, checks their body for sensations, or researches it on the internet, it only provides a temporary relief of symptoms which causes the individual to continually seek this reassurance and reinforces and sustains the individual’s behaviors (Abramowitz & Braddock, 2006; APA, 2013; Baumgartner & Hartmann, 2011; Hart & Björgvinsson, 2010; Lee et al., 2013; van den Heuval et al., 2014).

As more tests are obtained through the medical system, the individual’s anxiety might increase (APA, 2013), as this seems to confirm to the individual something is wrong because their physician ordered a test (Abramowitz & Braddock, 2006; Baumgartner & Hartmann, 2011).  In addition, physicians often tell patients to be vigilant of symptoms as do media reports about a specific illness, causing the individual to check themselves and monitor for these symptoms (Abramowitz & Braddock, 2006; Hart & Björgvinsson, 2010; Taylor & Asmundson, 2004).  From the development of the disorder to the behaviors that maintain it, reinforcers seem to play a large part.  When a behavior is reinforced, the behavior is more likely to continue (Berk, 2014), perhaps a reason why this disorder is considered chronic (APA, 2013).

Stress and Loss

Finally of note, stress and loss might have a role in the development of IAD.  This could be an individual’s parent having an illness (Abramowitz & Braddock, 2006; Alberts, Hadjistavropoulos, Sherry, & Stewart, 2016; Pandey, et al., 2017) to the death of a parent (Alberts & Hadjistavropoulos, 2014; Pandey et al., 2017) to having a personal health history of importance (APA, 2014; Sandin, Chorot, Santed, & Valiente, 2004).  The assumption is that those who had a parent with an illness might believe that they are more susceptible to, will constantly check for, and feel they cannot cope with the illness if they developed it (Alberts et al., 2016; Alberts & Hadjistavropoulos, 2014; Pandey et al., 2017).  In fact, the individual will often perceive their supposed symptoms as an indicator of the parent’s disease (Abramowitz & Braddock, 2006).  As for an individual’s personal history with disease, a study found that 96.3% of participants reported a negative health occurrence in their life compared to only 28.8% of the control group (Sandin et al., 2004).

In addition, Pandey et al. (2017) also found that one-third of their participants with IAD had experienced a history of childhood abuse as compared to the only .54% of their control group.  Something that combines the idea of reinforcement and the stress of childhood abuse is that when a child is mistreated, they might have used any illness symptoms to gain attention (Jordan et al., 2015).  However, as an adult the individual will not gain the same attention as they would have previously which causes distress (Jordan et al., 2015).  In an earlier study, Barsky, Wool, Barnett, and Cleary (1994) also found that those with hypochondriacal symptoms were more likely to have been victims of sexual trauma or violence before adulthood.  Stuart and Noyes (1999) when introducing their interpersonal model even state that as a result of early childhood trauma and having an ill parent, individuals will somaticize to gain attention from others as a way to draw their own attention away from what is actually causing distress in their life.  In addition, intolerance for distress such as “intolerance of uncertainty, ambiguity, frustration, negative emotion, and physical discomfort… are significantly associated with health anxiety” as it heightens the perceived “symptoms” for the individual (Fergus, Bardeen, Orcutt, 2015, p. 40).

Interactions with Physicians and the Medical Community

Aside from the emotional cost, there is also the actual cost to the individual and the healthcare system as a whole.  While lifetime prevalence rates are from 1.3% to 10% in the general population (APA, 2013), prevalence rates in one study were 19.82% of patients in healthcare settings (Tyrer et al., 2011).  Those with health anxiety also seek healthcare 41-78% more than those who have a diagnosed condition (Fink et al., 2010).  Individuals with health anxiety utilize sick leave more than twice as much of those in the general population (Eilenberg et al., 2015).  Many who are living with IAD will go to different doctors for the same issue (APA, 2013) and receive multiple diagnostic tests that are unnecessary (Hart & Björgvinsson, 2010).

Taylor and Asmundson (2004) plainly assert that physicians do not have the expertise needed to help someone with IAD.  In fact, many doctors might inadvertently reinforce the individual’s maladaptive behavior by encouraging a monitoring of symptoms (Abramowitz & Braddock, 2006; Wheaton, Berman, & Abramowitz, 2010).  For example, this could be innocuously stated as, “If your sore throat does not improve in a week, make an appointment”.  To an individual with IAD, it is reinforcing their bias to be highly aware of bodily sensations (Abramowitz & Braddock, 2006).  The goal of the individual with hypochondriasis as opposed to somatoform disorder is not to receive a diagnosis, but to seek reassurance that they do not in fact have a medical disorder (van den Heuval et al., 2014).  This reassurance does not last long for the patient as this is a reinforcement for the safety behavior and a hallmark of the disorder (Abramowitz & Braddock, 2006; APA, 2013; Hart & Björgvinsson, 2010; Lee et al., 2013; Salkovskis et al., 2003; Singh et al., 2016).

Individuals with IAD might have the tendency to develop contentious relationships with their physicians.  Noyes, Longley, Langbehn, Stuart, and Kukoyi (2010) found that those with hypochondriacal symptoms perceived their physicians as denying they were sick, that they missed something important, that they were not as thorough as they would have liked, and were not available in their time of need.  Noyes et al. (2003) state that the interactions between those with hypochondriasis and their physicians are not as favorable and might include anger.  Research posits that his could be a result of the anxious attachment style of believing that others are not displaying the proper amount of support or that they are simply being disregarded (Birnie et al., 2013; Jordan et al., 2015).  In turn, physicians might become frustrated with their patient’s demands and respond as such (APA, 2013; Noyes et al., 2010) possibly as a result of feeling that their knowledge and authority as a physician are in question (Stuart & Noyes, 1999).  This cycle of frustration on both sides could lead to a self-fulfilling prophecy of sorts for those involved.

However, those with IAD are most often only seen by physicians, as they believe their need is medical (Hart & Björgvinsson, 2010).  In fact, it is conjectured that many physicians instead of discussing possible mental health treatment with the patient will list the patient’s complaint as “medically unexplained symptoms” (Dimsdale, 2013, p. 31).  Physicians might even be hesitant to recommend mental health treatment at risk of stigmatizing their patient (Dimsdale, 2013) and patients might feel as if they are being told its “all in their head” (Hart & Björgvinsson, 2010, p. 124), sometimes even as a way to reassure to patient (Noyes et al., 2010).  This could lead to further alienation as the patient thinks they are not being heard in the context of this relationship.

When addressing the medical community, articles recommended for physicians and nurses state that when a patient with IAD is identified, empathy should be used in interactions (MacDonald, 2011; Noyes et al., 2010).  Noyes et al. (2010) even assert that “most hypochondriacal patients are best managed by their primary physicians” (p. 65) and that physicians are the best resource to offer explanations for symptoms as well as be available for appointments.  MacDonald (2011) recommends to nurses to encourage their patients to keep a diary of symptoms stating that health anxiety will dissipate with compassion.  Both of these suggestions for the medical community counter the evidence against the ideas of reassuring the patient and the endurance of this disorder.  In fact, a follow-up in the primary care setting found that individuals with health anxiety who were not treated for the disorder became even more anxious (Fink et al., 2010) and it is an enduring disorder (Eilenberg et al., 2015) that worsens when given medical attention (APA, 2013).

Advocacy

Counseling has a vast history of advocacy that has ranged from bringing social justice issues to light, to educating the public, to encouraging clients to be their own advocates (Toporek, Lewis, & Crethar, 2009).  Toporek et al. (2009) go on to state that counselors are in the best position to engage in advocacy as they have been trained in building human relationships, noting that advocacy work should be “at the core of their professional identity” (p. 260).  The American Counseling Association (ACA) has endorsed specific advocacy competencies which are outlined on their website (ACA, 2003).  This, coupled with the above mentioned ethical duty to remove barriers to treatment for clients (ACA, 2014, Standard A.7.a.), it can only stand to reason that counselors be aware of this barrier that many individuals with IAD are facing, including the fact that physicians and other members of the medical community might be inadvertently perpetuating this disorder when they could act as a gateway to treatment.

The section in the above-mentioned competencies that pertains most to the proposed advocacy plan for helping with the issue if IAD is the “Community Collaboration” section (ACA, 2003, p. 2) which focuses on counselors advocating at a systemic level for a specific issue that does not have to be geared towards identifiable clients (Toporek et al., 2009).  The first fact highlights that counselors often become aware of the needs of a population before anyone else because of their unique work with people (ACA, 2003).  The respective competency states that counselors work to identify what in the environment might affect healthy human development (ACA, 2003).  There is vast research on IAD geared towards and available to the helping professions, which includes information that the medical community is not as aware of this situation as it needs to be nor knows how to effectively respond.  Therefore, this author argues that counselors have a specific awareness into the needs of those with IAD more than the medical community does at this time.  Because of the existing body of research, counselors can see the toll this is taking on individuals who are living with IAD and how this affects their development and interactions with others.

Secondly, community collaboration involves bringing the issue to the attention of those systems who also have an identified interest in the individuals being advocated for (ACA, 2003).  The identified competency at this stage is to make the other parties of interest aware of the issue (ACA, 2003). As stated previously, research suggests that most individuals with IAD are seen in medical settings rather than in mental health settings, often with physicians never realizing there is a mental health issue or not knowing how to address this appropriately with their clients.  Because counselors already have identified the medical community as the system that would be most involved with those who have IAD, it is our job as counselors to bring this disorder to their attention and awareness.

Thirdly, community collaboration states that counselors are to work as allies to the identified system and should offer “communications, training, and research” (ACA, 2003, p. 2).  The identified competencies call for counselors to develop these relationships, listen to the system’s needs, learn the strengths that this system already has, bring their own personal skills to this relationship, and evaluate this interaction (ACA, 2003).  Toporek et al. (2009) also state that counselors must often start advocating by encouraging their current organization to engage in outreach.  This outreach could involve developing a dialogue with medical practices in the area and offering training on this issue to help the medical community understand the symptoms of IAD as well as the reinforcing factors that perpetuate the disorder.  This way, medical staff can learn to identify those who are in need on a quicker basis.  Also, by fostering this relationship, the counselor is also able to act as a resource to whom the medical community can refer to when a patient is identified as living with IAD.  This also serves the ACA (2014) ethical standard of forming relationships “with colleagues from other disciplines to best serve clients” (standard D.1.b.) and can set the stage to provide continuity of care with the client in continued dialogue with their physician.

Conclusion

Illness anxiety disorder, hypochondriasis, and health anxiety, no matter what term is used, impacts an individual’s life and causes serious strain that affects cognitions, affects, and behaviors.  There are differing theories on the development of this disorder such as heredity, early attachment behaviors, the cognitive-behavior model, and the role of stress and loss.  Whatever the cause might be, prevalence rates and much of the research that concludes most individuals with this disorder are only seen in the medical settings where their disorder perpetuates puts counselors in a unique position to address this issue.  Counselors must advocate to remove barriers, and this barrier cannot go ignored when so many are being left untreated.  The proposed plan for advocacy involves developing informative and collaborative relationships with the medical community to help identify and refer individuals with IAD for treatment.  Future studies should focus on evaluating the effectiveness of this type of advocacy on increasing the medical field’s understanding of the issue, levels of referral, and the actual increase of clients seeking services.

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