Pearls

Strategies for treating patients with health anxiety

Dr. Joshi is Associate Professor of Clinical Psychiatry and Associate Director, Forensic Psychiatry Fellowship, Department of Neuropsychiatry and Behavioral Science, University of South Carolina School of Medicine, Columbia, South Carolina.

Disclosure
The author reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.


 

References

Up to 20% of patients in medical settings experience health anxiety.1,2 In DSM-IV-TR, this condition was called hypochondriasis, and its core feature was having a preoccupation with fears or the idea that one has a serious disease based on a misinterpretation of ≥1 bodily signs or symptoms despite undergoing appropriate medical evaluation.3 In DSM-5, hypochondriasis was removed, and somatic symptom disorder and illness anxiety disorder were introduced.1 Approximately 75% of patients with a previous diagnosis of hypochondriasis meet the diagnostic criteria for somatic symptom disorder, and approximately 25% meet the criteria for illness anxiety disorder.1 In clinical practice, the less pejorative and more commonly used term for these conditions is “health anxiety.”

Patients with health anxiety can be challenging to treat because they persist in believing they have an illness despite appropriate medical evaluation. Clinicians’ responses to such patients can range from feeling the need to do more to alleviate their suffering to strongly disliking them. Although these patients can elicit negative countertransference, we should remember that their lives are being adversely affected due to the substantial functional impairment they experience from their health worries. As psychiatrists, we can help our patients with health anxiety by employing the following strategies.

Maintain constant communication with other clinicians who manage the patient’s medical complaints. A clear line of communication with other clinicians can help minimize inconsistent or conflicting messages and potentially reduce splitting. This also can allow other clinicians to air their concerns, and for you to emphasize to them that patients with health anxiety can have an actual medical disease.

Allow patients to discuss their symptoms without interrupting them. This will help them understand that you are listening to them and taking their worries seriously.2 Elicit further discussion by asking them about2:

  • their perception of their health
  • how frequently they worry about their health
  • fears about what could happen
  • triggers for their worries
  • how seriously they feel other clinicians regard their concerns
  • behaviors they use to subdue their worries
  • avoidance behaviors
  • the impact their worries have on their lives.

Assess patients for the presence of comorbid mental health conditions such as anxiety disorders, mood disorders, psychotic disorders, personality disorders, and substance use disorders. Treating these conditions can help reduce your patients’ health anxiety–related distress and impairment.

Acknowledge that your patients’ symptoms are real to them and genuinely experienced.2 By focusing on worry as the most important symptom and recognizing how discomforting and serious that worry can be, you can validate your patients’ feelings and increase their motivation for continuing treatment.2

Avoid reassuring patients that they are medically healthy, because any relief your patients gain from this can quickly fade, and their anxiety may worsen.2 Instead, acknowledge their concerns by saying, “It’s clear that you are worried about your health. We have ways of helping this, and this will not affect any other treatment you are receiving.”2 This could allow your patients to recognize that they have health anxiety without believing that their medical problems will be disregarded or dismissed.2

Explain to patients that their perceptions could be symptoms of anxiety instead of an actual medical illness, equating health anxiety to a false alarm.2 Ask patients to summarize any information you present to them, because misinterpreting health information is a core feature of health anxiety.2

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