Over several decades, what we now describe as health anxiety was termed hypochondriasis in several editions of the DSM (initially classified as a neurosis in early editions of DSM, in later editions up to 2013, and later issues classified under Somatoform Disorder). Also, this term is used in the common language. What comes to mind when people hear this word? Probably someone who always claims there is something wrong with them medically when there isn’t. The term is often used pejoratively by people, as in “She is now worried about having cancer, there is always something terribly wrong with her, she is such a hypochondriac”.
In the DSM-5 (2013), the term Illness Anxiety Disorder was introduced, which improved matters. No assumptions are made in this term about the mental health of these individuals, but it indicates that they are markedly anxious about having an illness. Some of these individuals may have a mild medical condition or have had one previously and are excessively anxious about it or a recurrence. The broader term, health anxiety, could describe a large number of people at certain times and under certain conditions. All of us could potentially have periods of health anxiety. Think of a time when someone has had a lab result come back in the significant range (for example; low creatinine levels) and they immediately went to the worst case scenario (incurable kidney disease) or had a highly unexpected symptom (hands shaking) and, because this can be associated with a serious condition (Parkinsons Disease), they already diagnosed themselves and become very anxious.
This is a common phenomenon, as I can attest to. A good friend of mine died of pancreatic cancer two years ago. Sometime later, I had persistent pain on my left side (the location of the pancreas) and found myself thinking the worst, even though I knew rationally (using my self-directed CBT) that it was highly unlikely. Now imagine doing this repeatedly for different bodily sensations/symptoms and think about what it would be like to live that way. So, we might increase our empathy for these individuals by noting that health anxiety can be experienced by anyone under certain conditions. It becomes a clinical problem (roughly 2-10% of the population at some point in their lives) when unlike the situational health anxiety, which occurs when waiting for test results, for example, usually goes away after the results show nothing abnormal, this anxiety persists despite reassurance or test results and can cause significant longer-term distress. In addition, in these individuals, there may be a transfer to other fears from the initial one (a brain tumor to cancer to a heart condition). At this point, the person may engage in checking behavior (taking their blood pressure or temperature frequently), seeking reassurance (internet searches or asking others), or excessive use of medical services. Alternatively, he/she might avoid any situation that brings on this worry (news stories about cancer or even going for a medical check-up).
This is when it becomes an impairing and disabling condition.
Approximately 5% of medical visits are due to due to this condition, and up to 20% of medical patients have significant health anxiety. Unfortunately, such patients are seldom referred to therapists and are treated by physicians first with reassurance but later with a dismissive attitude. Patients with a history of health anxiety may be undertreated medically compared to patients without health anxiety (tests are not ordered, or it is all put down to ‘anxiety'). In addition, although many of these clients may engage in ‘doctor-shopping’ (overutilization of costly medical services) to obtain reassurance, a percentage do the opposite and avoid doctors due to fear and subsequently end up with preventable serious illnesses, which are also costly. The bigger cost is how much emotional disturbance these clients go through as they experience significant anxiety, depression, frustration, and anger. The compulsive behavior associated with this condition can be very time-consuming, tends to prevent enjoyment of activities, and can be very impairing in terms of relationships and work.
Since we can all have health anxiety temporarily and in certain situations, why do some people’s fears go away, and some don’t? Research suggests that some people react to their bodies and bodily changes or symptoms with frightening thoughts (“Maybe this means I have cancer”), and anyone who has had these thoughts would be anxious. When they persist and are strongly believed to be true, the anxiety also persists at a high level. These beliefs persist by a combination of factors such as:
- Being over-vigilant and noticing every bodily change, however small.
- Interpreting every change as being a sign of something serious or dangerous rather than normal or benign.
- Getting some immediate relief by seeking reassurance (family, friend, doctor) or checking (pulse, blood pressure), but later questioning if this can be trusted with a return of health anxiety.
- Avoiding actions that might disconfirm the anxious thoughts by providing evidence against the idea (getting a medical examination).
Since a combination of these factors may be involved in keeping anxiety and fearful thoughts going, CBT can help modify these patterns by helping clients reduce anxiety about health in several important ways.
Some important points to remember in doing therapy with clients with significant health anxiety:
- Since these clients often feel invalidated, the therapist needs to let them know that the distress they experience and the bodily sensations they are reacting to are absolutely real, and in therapy, the focus is on whether the problem is fundamentally an illness, or anxiety about an illness, or both. This therapeutic open-mindedness is important. A very helpful self-help book entitled It Is Not All In Your Head by Gordon Asmundsen and Steven Taylor makes a very valid point in the title of the book
- Often, these clients feel they should be seeing a medical specialist and not a counselor, so we need to be very collaborative and make every attempt to validate their distress.
- A therapist should never be perceived to be trying to argue this kind of client out of believing something is wrong, but guide them to explore alternate explanations or what they are feeling in an open-minded way. Medical explanations should not be preemptively dismissed but reviewed, as well as the role of thinking patterns and anxiety.
- It should be stressed that it is not a form of mental illness but rather a special type of anxiety which is treatable by CBT and other approaches.
- These clients have often been told by specialists and doctors what is not wrong with them (what tests or examinations have ruled out), but nobody has explained what is wrong and why they feel the way they do. This is what we should help them with: give them an understanding of what this is and, more importantly, what can be done to alleviate it.
A great resource for therapists showing how CBT can be used to help these clients is CBT for Health Anxiety, written by Steven Taylor and Gordon Asmundsen (Guilford Press, 2004). An excellent CBT-based self-help book by the same authors is It’s Not All in Your Head ( Guilford Press, 2004).
