Health anxiety – the silent treatable epidemic
Health anxiety – the silent treatable epidemicPeter Tyrer professor of community psychiatry1, Trine Eilenberg psychologist2, Per Fink clinical professor3, Erik Hedman associate professor4, Helen Tyrer senior clinical research fellow1 1 Centre for Mental Health, Imperial College, London W12 0NN2 Department of Occupational Medicine, Aarhus University Hospital, Denmark3 Department of Clinical Medicine, Aarhus University, Denmark4 Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden‘We are glad to say, Mr Jones, that all your tests 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, disseminated 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 fearing! He used to attend his GP frequently to be reassured that nothing was wrong with him, but the reassurance only lasted shortly and then the worrying started all over again. After many years of suffering, 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 suffering from health anxiety. This diagnosis is a relatively recent one that will be unfamiliar to many readers of this journal. It overlaps with hypochondriasis, a diagnosis that is much more familiar, but it differs in several important respects1. Although health anxiety is listed among the mental and behavioural disorders, it is rarely seen by psychiatrists as most of the sufferers from this condition attend primary care or secondary hospital clinics2. Here, sadly, they often go unrecognised and treated inappropriately by reassurance and investigations that invariably turn out to be negative.Neither the patient nor the physician doubts that anxiety is present, but what is so seldom recognised is that for someone suffering from health anxiety it is not the physical symptoms (e.g. muscle pain) per se that are the core complaint; it is the fear and rumination about the meaning, significance, or cause of the symptoms. The essential features of health (or illness) anxiety are ‘a preoccupation with the idea that one has, or will get, a serious illness’, are ‘hyper vigilant about their health’, often including ‘ frequent self-monitoring for signs of illness’ such as repeatedly checking of blood pressure or pulse3. Research has also shown that a key component of health anxiety is rumination, i.e. that the patient cannot stop thinking about a disease once the thought has come into their mind4. This is in contrast to patients with what is, somewhat confusingly,5 called somatic symptom disorder in DSM-53 as these are people who are primarily disturbed by physical symptoms, but usually do not worry much about them. Health anxiety is remarkably common, persistent and a generator of long-term morbidity and increased sick leave6. It is often found in conjunction with other disorders including physical ones. Formerly, the diagnosis of hypochondriasis could only be made in the absence of physical disease, but this can be present, and often is, in health anxiety. There are many others with health anxiety who suffer for years before being recognised. This includes a group who are so concerned that they might have a feared diagnosis and 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 in the absence of appropriate interventions and suffer greatly as a consequence of their symptoms7.The word ‘epidemic’ is not chosen lightly. In 2007 the Australian National survey found that 3.4% of people in the community met the diagnostic criteria for health anxiety8. Much higher frequency levels are found in secondary care. In a study carried out in 2006 in North Nottinghamshire (Kings Mill Hospital) with patients attending cardiology, respiratory medicine, gastroenterology, and endocrinology clinics, 12% had excessive health anxiety9 but four years later in the same clinics this had risen to 20%2. What is the explanation for this dramatic rise? Methodological differences and change in diagnostic criteria may in part explain it. A more likely explanation is the increased pathologisation of our society and Internet browsing, appropriately called cyberchondria. Although the Internet is a great value for those seeking the cause of medical symptoms, it is literally 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 incredibly uncommon. So to say to someone with health anxiety that the chances of him/her having a particular disease is only 1 in 1000 is of little benefit. This knowledge often just convinces the person that he/she is indeed that 1 person. Because many doctors are not familiar with establishing the health anxiety diagnosis and most people with health anxiety are presenting to clinics where there is limited psychological knowledge, the appropriate treatment is seldom given. There is now a range of highly effective psychological treatments ranging from traditional cognitive therapy10 to group-based mindfulness11 and Acceptance and Commitment Therapy12, that have been shown to be highly effective in this condition. An additional bonus is that the benefit from these treatments tends to be long-lasting13. In this respect, these treatments are probably more effective than equivalent ones for generalised anxiety disorder, in which relapse is common14. For those who recognise that they have health anxiety, the additional option of treatment over the Internet has also been found to be cost-effective and long-lasting15,16. There is also good evidence that some of these treatments can be given by trained general nurses and these may be regarded by patients as more acceptable therapists than psychologists and possibly more effective as a consequence17.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 only to excluding disease in their particular speciality. The diagnosis is in most cases easy to establish using research criteria and, contrary to what many believe, the diagnosis is well accepted by the patients if explained in a respectful manner 12. The many established effective evidence-based treatments should be offered to all patients with severe health anxiety. Acknowledgements: We thank Gavin Andrews for helpful comments. Declarations of Interest: HT is the author of a book Tackling Health Anxiety: a CBT Handbook (RCPsych Press, 2013).All authors contributed to the writing of the manuscript. A worldwide licence for reproduction is approved. Scarella TM, Laferton JA, Ahern DK, Fallon BA, Barsky, A. The relationship of hypochondriasis to anxiety, depressive and somatoform disorders. Psychosomatics 2016; 57: 200-7.2. Tyrer P, Cooper S, Crawford M, Dupont S, Green J, Murphy D, et al. Prevalence of health anxiety problems in medical clinics. J Psychosom Res 2011; 71: 392-4.3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. Washington, DC, p.315, 2013. 4. Fink P, Toft T, Christensen KS, ?rnb?l E, Frostholm L, Olesen F. A New, Empirically Established Hypochondriasis Diagnosis. Am J Psychiatry 2004,161;9:1680-91.5. Mayou R. Is the DSM-5 chapter on somatic symptom disorder any better than DSM-IV somatisation disorder. Br J Psychiatry 2014; 204: 418-9. 6. Eilenberg T, Frostholm L, Schroder A, Jensen JS, Fink P. Long-term consequences of severe health anxiety on sick leave in treated and untreated patients: analysis alongside a randomised controlled trial. J Anxiety Disord 2015; 32: 95-102.7. Fink P, ?rnb?l E, Christensen KS. The outcome of Hypochondriasis / Health anxiety in primary care. A two-year follow-up study on health care costs and self-rated health. PLoS ONE 2010;5:e9873.8. Sunderland M, Newby JM, Andrews G. Health anxiety in Australia: prevalence, comorbidity, disability and service use. Br J Psychiatry 2013; 202: 56-61. 9. Seivewright H, Mulder R , Tyrer P. Prevalence of health anxiety and medically unexplained symptoms in general practice and hospital clinics. Aust NZ J Psychiatry 2007; 41 suppl 2: A159. 10. Thomson AB, Page LA. Psychotherapies for hypochondriasis. Cochrane Database Syst Rev 2007; Oct 17 (4): CD006520.11. McManus F, Surawy C, Muse K, Vazquez-Montes M, Williams JM. A randomized trial of mindfulness-based cognitive therapy versus unrestricted services for health anxiety (hypochondriasis). J Consult Clin Psychol 2012; 80: 817-28. 12. Eilenberg T, Fink P., Jensen JS, Rief W, Frostholm L. Acceptance and Commitment Group Therapy (ACT-G) for Health Anxiety: A randomized, controlled trial. Psychol Med 2016; 46: 103-15.13. Tyrer P, Cooper S, Salkovskis P, Tyrer H, Crawford M, Byford S, et al. Clinical and cost-effectiveness of cognitive behaviour therapy for health anxiety in medical patients: a multicentre randomised controlled trial.. Lancet 2014; 383: 219-25.14. Durham RC, Chambers JA, Power KG, Sharp DM, Macdonald RR, Major KA, et al. Long-term outcome of cognitive behaviour clinical trials in Scotland. Health Technol Assess 2005; 9: 1-174. 15. Hedman E, Andersson G, Andersson E, Ljitsson B, Rück C, Asmundson GJ, et al. Internet-based cogniive-behavioural therapy for severe health anxiety: randomised controlled trial. Br J Psychiatry 2011; 198: 230-6. 16. Hedman E, Andersson E, Ljótsson B, Axelsson E, Lekander M. Cost-effectiveness of internet-based cognitive behaviour therapy and behavioural stress management for severe health anxiety BMJ Open In Press17. Tyrer H, Tyrer P, Lisseman-Stones Y, McAllister S, Cooper S, Salkovskis P, Crawford MJ, Dupont S, Green J, Murphy D, Wang D. Therapist differences in a randomised trial of the outcome of cognitive behaviour therapy for health anxiety in medical patients. Int J Nurs Stud 2015; 52: 686-94. ................
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