The typical patient with health anxiety

The characteristic features of patients with excessive health anxiety are shown in Box 1. There is usually no difficulty in identifying that the patient is concerned about their health; the more demanding requirement is the recognition that the concern expressed is abnormal and almost certainly unjustified. This to some extent is hinted at by the number of times that the patient has consulted with health problems and nothing wrong has been found. The health problem may vary over time – many health-anxious patients switch their concerns from one disease to another – but the results of assessment and investigations are either normal or just outside the normal range and of no clinical significance.

What differentiates health anxiety from other anxiety disorders is that the patient does not necessarily complain of anxiety (even though it may be observed prominently). This is because the patient is perfectly aware that they are anxious, but also is convinced that their anxiety can be solved by being told that the disease (or group of diseases) that is feared is not actually present. It is therefore not at all surprising that reassurance is top of the requirement list for solving the problem. Health-anxious patients seek reassurance in many ways: asking friends or relatives, even children, and consulting health professionals of all kinds, but mainly medical doctors, on the grounds that they are expert in diagnosis and also because they have recourse to tests that may confirm or disprove a self-diagnosis.

Differential diagnosis

The diagnosis of health anxiety should be relatively easy, but because it is enmeshed with the contentious and heterogeneous group called somatoform disorders (or somatic symptom and related disorders in DSM-5 (Bass Reference Bass and Pearce2016)) it complicates the diagnostic process. Health anxiety is the equivalent of illness anxiety in DSM-5 and is the new name for hypochondriasis. It is defined in DSM-5 as ‘a preoccupation with having or acquiring a serious, undiagnosed medical illness’, with somatic symptoms not being present or ‘if present, […] only mild in intensity’, and ‘the individual's distress emanates not primarily from the physical complaint itself but rather from his or her anxiety about the meaning, significance, or cause of the complaint’ (American Psychiatric Association 2013: p. 315). In more simple language, health anxiety is excessive unjustified anxiety about illness. This diagnosis, as Mayou (Reference Mayou2014) and Scarella et al (Reference Scarella, Laferton and Ahern2016) suggest forcefully, should be placed in the anxiety disorders rather than the somatic symptom group. What has to be acknowledged is that somatic symptoms of anxiety may be very prominent in health anxiety, and to exclude this diagnosis (or ‘illness anxiety’ in DSM-5) in those with somatic symptoms is not an appropriate way to use the classification.

Some may bemoan the loss of hypochondriasis as a diagnosis in DSM-5, and it is likely to stay in ICD-11, but we do not consider this is a loss (Tyrer Reference Tyrer and Tyrer2014a), as hypochondriasis as a diagnosis has been a dead hand conferring only the notions of untreatability and ribald comment on its sufferers, rather than understanding or appropriate intervention. A significant proportion of those with the (old) diagnosis of hypochondriasis have a primary depressive disorder, and 50 years ago this was regarded as the main underlying disorder (Kenyon Reference Kenyon1964). For psychiatrists who have been trained to recognise hypochondriasis as a persistent belief in the presence of one or more serious medical disorders despite all evidence to the contrary, the new variant of health anxiety may just appear to be a synonym for hypochondriasis. It is not quite; it is a form of anxious hypochondriasis in which fear of illness associated with anxiety is the most prominent symptom, and it is now also appreciated that absence of physical illness is not relevant. Many with high health anxiety have suffered physical disorders and the onset of the physical disorder (e.g. a myocardial infarction) may have been the trigger for the onset of health anxiety.

There is considerable overlap between health anxiety and obsessive–compulsive disorder, and in ICD-11 the revision group of obsessive–compulsive and related disorders have included not only classic obsessive–compulsive disorder, but also body dysmorphic disorder, hypochondriasis, olfactory reference disorder and hoarding disorder (Stein Reference Stein, Kogan and Atmaca2016). There are commonalities between them, but health anxiety is a bit of an outlier, as many patients with the condition do not have significant obsessional symptoms and, as noted below, respond differently to pharmacological interventions. It is also much more common than the other diagnoses in the group (Box 2). Nonetheless, the ICD-11 group are very aware of the close links that health anxiety has to other anxiety disorders (Van der Heuvel Reference Van den Heuvel, Veale and Stein2014) and it is to be hoped that this can be acknowledged formally in ICD-11.

Prevalence of health anxiety in different settings

Health anxiety is common and is probably becoming more so because of increased use of the internet to seek knowledge about illness (cyberchondria): in our personal work we have seen a doubling in the prevalence of health anxiety over a 10-year period (Tyrer Reference Tyrer, Eilenberg and Fink2016a). An Australian national survey found a lifetime prevalence of 5.7% and current prevalence of 3.4%, much higher than in previous studies of hypochondriasis, and it was also associated with physical comorbidity (Sunderland Reference Sunderland, Newby and Andrews2013). One of the problems with previous definitions of hypochondriasis is that they required absence of actual disease, but in practice it is very common to get health anxiety in the context of disease, where it can be identified easily and is unequivocally a separate condition (Box 3). It is therefore not at all surprising that rates of health anxiety are higher in those attending medical facilities, with rates of around 10% in all attenders in primary care (Tyrer Reference Tyrer, Ali and Cooper2013) and up to 20% in medical out-patients (Tyrer Reference Tyrer, Cooper and Crawford2011). Also, not surprisingly, these patients do not normally attend psychiatric clinics.

The common pathway for patients with health anxiety

The average patient with health anxiety has had the condition for many years before it is diagnosed (Hedman Reference Hedman, Andersson and Andersson2011). This is one of the main reasons why it is underdiagnosed. The two main groups of patients are very different: ‘avoiders’ and ‘reassurance seekers’. The avoiders do everything they can to diminish contact with doctors and with information that is concerned with illness, especially serious medical illnesses such as cancer. They do not consult any health professionals except when absolutely necessary and will, for example, avoid travelling by routes that may expose them to advertisements for cancer treatment and support (a very difficult task nowadays). Their prevalence is unknown as their consultation rates are low and they often refuse to admit that they have any difficulty.

The reassurance seekers are high consulters of medical services, tending to present early with minor problems such as spots in the skin, marks in the cheek, chest pain or trembling. Each of these is attributed a serious aetiology and the patient often asks for further tests if clinical examination reveals nothing of note. Often, patients have a series of tests of different organ systems, sometimes accentuated by a minor abnormality in one of them occurring by chance. This is becoming particularly common with magnetic resonance imaging (MRI) scans, where normal variation may be commented on as equivocal or worthy of further tests. Most of the diseases feared by those with health anxiety are medical, but psychiatric disorders such as schizophrenia and dementia sometimes become the focus of concern.

Reassurance seekers feel they have a prime responsibility to monitor their health, and often when reassured by one doctor that all is well will question this subsequently in the light of what they feel is better evidence. A comment such as ‘your chances of getting that are one in a million’ do not reassure; the sufferer immediately sees themselves as that one in a million.

Reassurance seeking often extends to families, so when then are no medical agencies available, close family members are bombarded with questions and often collude with the reassurance cycle, even though they try to resist it. With today's easy communication technology, reassurance from family and friends can include multiple texts, Facebook and links to online medical information. This can eventually lead to schisms within families.

The avoiding and reassurance strategies can also coalesce. So, for example, a patient wanted to be reassured that she was not ill, but realised that reassurance very seldom lasted for any length of time. She therefore deliberately took a very long route when shopping so that she did not go past the health centre, just in case she had the desire to rush in and make an appointment.

How to identify pathological health anxiety in practice

As the presentation of health anxiety is so variable it is difficult to give clear advice here. Those who most clearly recognise that they have health anxiety are those who present with their symptoms for treatment, and they are most obvious in the internet treatment studies of health anxiety, where patients are usually invited to take part by advertisement. Only a minority of these individuals are excluded on the grounds of misdiagnosis, so it is clear that such patients are aware of their pathology.

In psychiatric out-patient clinics health anxiety usually presents as part of an anxiety–depression syndrome and has to be teased out from the other components. It is not readily acknowledged as, because it tends to be chronic, it is not a prime complaint. It is also frequently linked to the symptoms of obsessive–compulsive disorder, and the recurrent checking and monitoring of health has influenced the decision to place the diagnosis in the obsessive–compulsive group in the forthcoming ICD-11.

In primary care and secondary medical care health anxiety is often unacknowledged or explained as secondary to other medical problems. The assumption made is that all symptoms will disappear when their ‘true’ medical cause is identified. It is not difficult to guess that a degree of probing is therefore necessary to elicit the main symptoms (Box 4).

Treatments available for health anxiety

Although health anxiety is an important diagnostic entity that has only recently received prominence, it overlaps considerably with generalised anxiety disorder and obsessive–compulsive disorder, and it might be thought that the treatments for each would overlap. This is only partly true. Although the psychological treatments for these disorders are similar in their fundamentals, the other treatments differ greatly.

Cost-effectiveness of treatment

It might be expected that successful treatment of health anxiety would lead to a great reduction in healthcare costs. This has not yet been satisfactorily proved, probably because there are deficiencies in the current way in which economic analyses are done. What is clear is that the costs of treatment are largely or completely offset by savings in reduced out-patient and accident and emergency department attendance (Seivewright Reference Seivewright, Green and Salkovskis2008; Tyrer Reference Tyrer, Cooper and Salkovskis2014b, Reference Tyrer, Salkovskis and Tyrer2017c; Hedman Reference Hedman, Axelsson and Andersson2016a), but as many people in secondary medical care have both medical disorders and superadded health anxiety the savings are difficult to identify. When patients have both medical or surgical interventions quite independently of health anxiety (e.g. hip replacement), the costs of these far outweigh the savings made by treating health anxiety. Savings are much clearer in primary care (Fink Reference Fink, Ømbol and Christensen2010).

What has become apparent in recent years is that to exclude patients with health anxiety from psychiatric treatment on the grounds that they have an existing medical illness is not justified. In fact, there is evidence that those people who are older and have health anxiety respond better to treatment than those who are younger (Tyrer Reference Tyrer, Tyrer and Morriss2017a, Reference Tyrer, Salkovskis and Tyrerc).