Before the Internet age, people with excessive and irrational worries about their health (we called them “hypochondriacs”) went to their doctors for reassurance. Today these patients still schedule appointment — often with exasperating frequency — with their primary care physicians when they’re concerned about an unusual lump or vague symptom. But most likely they’ll have first consulted WebMD or the Mayo Clinic website and come up with a differential diagnosis of their own.
In the DSM- V, the new term for “hypochondriasis” — a loaded label suggesting that those who have it, like Molière’s farcical “malade imaginaire,” don’t experience real symptoms — is “illness anxiety disorder,” which more accurately describes the condition. People with illness, or health, anxiety aren’t imagining the symptoms that distress them; they’re just hypersensitive to benign physical sensations and overestimate the likelihood of their seriousness. To further complicate matters, they often misinterpret the physical consequences of anxiety — dizziness, shortness of breath, sweating, nausea, rapid heartbeat — as evidence of a life-threatening disease.
I see many people with health anxiety in my clinical practice because I specialize in treating obsessive-compulsive disorder. Health anxiety is a variant of OCD. The obsessions are intrusive, distressing thoughts about having a serious illness — often one without obvious early signs or symptoms, such as a malignancy or a degenerative neurological disease. In the overwrought imagination of the health anxiety sufferer, heartburn signifies esophageal cancer, and lightheadedness augurs MS.
To relieve their anxiety about an imminent, painful decline and certain death (and who wouldn’t feel anxious if those outcomes were, indeed, certain, as the health-anxiety prone imagine them to be?), people with health anxiety engage in compulsive behaviors. They go to the doctor frequently (or, less commonly, avoid checkups altogether); undergo extensive diagnostic testing, often after having pressured their physicians into ordering unnecessary procedures; seek multiple opinions if findings are negative; ask family members for reassurance; research illnesses on the Internet; palpate lumps; check for blurred vision or tremors; take their pulse and blood pressure incessantly; examine moles; eliminate certain foods and eat others with alleged health-promoting powers, and so on.
Cognitive-behavioral therapy is an evidence-based treatment for health anxiety. It aims to break the debilitating cycle of obsessional worry and compulsive searching for reassurance. But its success requires the support of a trusted physician, who understands how to address the concerns of a health-anxiety patient without reinforcing the unhelpful patterns exacerbating the problem.
Here are a few guidelines for primary-care physicians to keep in mind when treating patients with health anxiety:
1. Remember to use patient-centered interviewing techniques. In the practice of medicine class I teach with an internist, we train our first-year medical students to ask open-ended questions to elicit patients’ concerns. It’s basic, and good, clinical practice. But when your schedule allots you only 10 to 15 minutes per patient, you may be tempted to take a more directive approach for the sake of efficiency. Keep in mind that the 2 to 3 extra minutes required for the patient’s narrative to unfold will serve you well by building trust and fostering collaboration, especially since patients with health anxiety are often very mistrustful of doctors.
2. Consider scheduling longer visits with an established patient who has health anxiety. The added time in the office will pay off over time with fewer calls and emails between appointments.
3. Schedule frequent follow-up appointments on a mutually agreed upon timetable. People with health anxiety often believe they need to investigate every new symptom for fear of being irresponsible or missing an opportunity to catch a problem before it becomes critical. Someone with a high level of anxiety might initially need to come to the office one a month or every six weeks to address their concerns. Between appointments, their goal should be to avoid Internet research and refrain from contacting you about a new complaint (unless, of course, it is an obvious emergency such as a broken limb, head injury, or high fever lasting more than 72 hours, rather than a vague worry). Over time, as the patient become more able to tolerate waiting, the frequency of the appointments can decrease.
4. Order diagnostic procedures and make referrals to specialists only when clinically indicated, not in response to an anxious patient’s demands. Health anxiety consumes unnecessary medical resources and often also leads to complications from invasive procedures. Have the patient return in a month for a follow-up visit if doubts about a condition persist.
5. Explain why you don’t think a finding warrants concern. Laypeople don’t have the training to assess whether a symptom, such as an enlarged lymph node or a headache, fits the pattern of a serious disease process. So in a Google search of “headache,” those with health anxiety are more likely to fixate on “brain tumor” than “eyestrain” as a potential cause.
6. Have the patient come into the office to discuss test results or medication with you. Using an staff member (who may not be fully aware of the patient’s anxiety) or an online patient portal to communicate may prompt the patient to do more Internet research if the information seems ambiguous.
7. But take the patient’s concerns seriously. As Joseph Heller said in Catch 22, “Just because you’re paranoid doesn’t mean they’re not after you.” Even people who overreact to health concerns can have life-threatening conditions.
Coping with health anxiety can be draining for both the patient and physician. But if you keep these tips in mind, you can avoid frustration and fulfill an important therapeutic role as a source of reliable medical information and the patient’s key ally in the treatment of this debilitating psychological disorder.
Lynne S. Gots is a psychologist and an assistant clinical professor of psychiatry and behavioral science, George Washington University School of Medicine, Washington, DC. She blogs at Cognitive Behavioral Strategies.