seen every day in medical offices
Health Anxiety: lurking in plain sight
All practitioners will learn useful information from this article.
“Many patients, despite how much they would like to, cannot do what we would like them to do: ‘stop worrying.’” As physicians, we see a few such people every day. Health Anxiety seems to be epidemic (perhaps, endemic) in our communities, yet it is poorly recognized.
“People with health anxiety do not ask relief from somatic symptom, but rather only desire freedom from worry about disease. A key component of health anxiety is rumination, so that patients cannot stop thinking about a disease once the thought has come into their minds.”
“Several highly effective psychological treatments are now available. For people who recognise that they have health anxiety, treatment over the Internet has also been found to be both cost effective and long lasting.”
(The term “health anxiety” is roughly synonymous with “hypochondriasis;” but it does not have the same stigma.) This BMJ editorial is a helpful introduction to a disorder that up to 20% of people seeing specialists may have.
Health anxiety: the silent, disabling epidemic
(Published 25 April 2016)
Peter Tyrer, professor of community psychiatry, Trine Eilenberg, psychologist, Per Fink, clinical professor, Erik Hedman, associate professor, Helen Tyrer, senior clinical research fellow Correspondence to: firstname.lastname@example.org
“We are glad to say, Mr Jones, that all your test results are normal and you have nothing to fear.” Mr Jones has received this message many times after being examined for many severe diseases such as cancer, multiple sclerosis, and heart disease, which over the years he has been convinced he must have. Yet, this is the core of his problem—despite how much he would like to, he cannot do what the doctor says: stop worrying. He used to attend his general practitioner frequently to be reassured that nothing was wrong with him, but the reassurance was only short lived and then the worrying started all over again. After many years of distress, Mr Jones is embarrassed that he cannot control his health worries and preoccupation and has lately avoided contact with his GP, knowing it does not help him very much.
Mr Jones is not alone. He joins many others with health anxiety. This diagnosis is a relatively recent one that will be unfamiliar to many readers of this journal. It overlaps with hypochondriasis and the new “illness anxiety disorder”1 in the American classification DSM-5, but it differs in several important respects. Illness anxiety disorder is narrowly defined; it includes only patients who do not display somatic symptoms, and this limits its use in clinical practice. The diagnosis of health anxiety is empirically based and defined by cognitive and emotional symptoms that allow it to coexist with other diseases. Both health anxiety and illness anxiety are primarily anxiety disorders and are unsatisfactorily lumped with somatic ones.2 3
Despite anxiety being the core component, people with health anxiety are rarely seen by psychiatrists; most attend primary care or secondary hospital clinics.4 Here, sadly, the pathology often goes unrecognised and is treated inappropriately by reassurance and investigations that invariably have negative results. Neither the patient nor the physician doubts that anxiety is present; what fails to be noticed is that, unlike people who want relief from somatic symptoms alone, people with health anxiety do not ask for such relief, only freedom from worry about disease. Research has also shown that a key component of health anxiety is rumination, so that patients cannot stop thinking about a disease once the thought has come into their mind.5
Health anxiety is remarkably common, persistent, and a generator of long term morbidity and increased sick leave.6 It is often found in conjunction with other disorders, including physical ones. Formerly, hypochondriasis could be diagnosed only in the absence of physical disease, but this can be present, and often is, in health anxiety.
There are other people with health anxiety who are so concerned that they might have a feared diagnosis that they avoid consultation altogether. Not surprisingly, it is difficult to know the size of this group. What is now abundantly clear is that people with health anxiety do not get better without the right intervention and experience great distress from their symptoms.7
Health anxiety is reaching epidemic proportions. In 2007 the Australian National survey found that 3.4% of people in the community met the diagnostic criteria.8 Much higher levels are found in secondary care. In a study carried out in 2006 in north Nottinghamshire with patients attending cardiology, respiratory medicine, gastroenterology, and endocrinology clinics, 12% had excessive health anxiety,9 but four years later in the same clinics this had risen to 20%.4
What is the explanation for this big rise? Methodological differences and change in diagnostic criteria may have a role. But a more likely explanation is the increased pathologisation of our society combined with internet browsing, appropriately called cyberchondria. Although the internet is of great value for those seeking the cause of medical symptoms, it is a menace for those with health anxiety. People with health anxiety pay selective attention to the most serious explanation of symptoms, even though these may be very uncommon. So to say to people with health anxiety that their chances of having a particular disease is only 1 in 1000 is of little benefit. This knowledge often just convinces them that they are indeed that one person.
Because many doctors are not familiar with diagnosing health anxiety, and because those affected are presenting to clinics where there is limited psychological knowledge, the right treatment is seldom given. Several highly effective psychological treatments are now available, ranging from traditional cognitive therapy10 to group based mindfulness11 and acceptance and commitment therapy.12 An additional bonus is that the benefit from these treatments tends to be long lasting.13 This is relevant to referral practice; GPs are more likely to ask for help for people with panic and generalised anxiety symptoms, even though these symptoms commonly return after initial benefit.14 For people who recognise that they have health anxiety, treatment over the internet has also been found to be both cost effective and long lasting.15 16 There is also good evidence that some of these treatments can be given successfully by trained general nurses, whom patients may be more willing to accept as therapists than psychologists.17
So what is needed now? Physicians in primary and secondary care need to be more aware of this important diagnosis and not to regard their tasks as being restricted to excluding disease in their particular specialty. The diagnosis is in most cases easy to establish using research criteria, and, contrary to what many believe, it is well accepted by patients if explained respectfully.12 All patients with health anxiety should now be offered the many established, effective, evidence based treatments.