Interview conducted by April Cashin-Garbutt, BA Hons (Cantab)
How is health anxiety defined?
Health anxiety is a relatively new diagnosis and has not been adopted fully. The nearest approximation and formal classification systems is ‘illness anxiety’ as diagnosed in DSM-5, published in May 2013 (DSM-5, American Psychiatric Association, p.315).
This is given a formal diagnosis code of 300.7 and its main features are:
preoccupation with having or acquiring a serious illness in which there is
high level of anxiety about health, and affected individuals are easily alarmed about personal health status, and tend to perform excessive health related behaviours such as repeatedly checking the body for signs of illness, or exhibiting maladaptive avoidance, such as failing to keep appointments at clinics and hospitals, and
in whom the symptoms have lasted for at least six months
This is a reasonably good combination of characteristics that are present in most people with health anxiety. I think a fair summary is ‘excessive preoccupation with having or acquiring a serious illness for at least the last six months, which is associated with persistent monitoring of health through self examination and external information systems.’ When the Internet is a major component of these the condition can be described as cyberchondria.
How many people are thought to be affected by health anxiety? Has this number risen with the increasing literature that is available online?
The most recent data about the prevalence of health anxiety is from an Australian study (Sunderland M, Newby JM, & Andrews G. (2013). British Journal of Psychiatry, 202, 56-61). They found that 5.7% had the condition at some time in their lives and 3.4% were suffering from health anxiety at the time of interview.
What are the standard ways of managing health anxiety and how effective are these?
There have been several reviews of the treatment of hypochondriasis in health anxiety. These show in general that drug treatment is not appropriate because many people interpret adverse effects as signs of illness, and of the psychological treatments cognitive behaviour therapy is the most widely used, but stress management is also employed with some success.
Please can you explain what cognitive behavioural therapy (CBT) is and how it differs from other psychological therapies?
In our study we specifically used and adapted form of cognitive behaviour therapy, CBT for health anxiety, or CBT-HA.
Normal cognitive behaviour therapy for anxiety and depression examines ways of thinking again about these symptoms in a way that is more constructive. CBT-HA is specifically focused on fear of illness versus actual illness, and pointing out the advantages of having just the fear, rather than the illness itself, especially as there is treatment for the fear.
The main difficulty many people have in treating health anxiety is that patients often do not recognise the problem at first, and feel their health seeking behaviour is perfectly reasonable as it is keeping them well.
CBT HA points out that constant monitoring and checking of your body in all its forms is not actually helpful but counter-productive, and this is demonstrated by the patient keeping diaries and in other ways, recording the levels of anxiety, both during the regular monitoring of symptoms and at times when they have been told to stop monitoring altogether.
Most are quite amazed that the anxiety levels are reduced when they stop taking this excessive responsibility for their health.
Please can you outline the first large-scale trial testing the effectiveness of CBT for health anxiety that was published in The Lancet?
CHAMP (Cognitive behaviour therapy for Health Anxiety in Medical Patients was a pragmatic randomised controlled trial with two parallel arms and equal randomisation of patients with health anxiety initially to receive CBT-HA or standard care in five medical clinics (gastroenterology, cardiology, medicine, endocrinology and neurology ) provided they satisfied the inclusion criteria of being aged between 16 years and 75 years, had a stable residence in the area covered by the hospital, had sufficient understanding of English to read and complete study questionnaires, and gave written consent for the interviews, audio-taping of 50% of treatment sessions, and for access to their medical records.
The study was carried out in six general hospitals in the UK covering urban, suburban, and rural areas. We approached all patients attending clinics of the relevant consultants, apart from those specifically excluded, while they were waiting for their outpatient appointments.
After patients gave written and signed consent, they completed the short form of the Health Anxiety Inventory anxiety index (HAI), a self-rating scale of 14 questions that takes 5–10 min to complete.
We gave a brief summary of the trial and offered the opportunity of further assessment to those who scored 20 or more on the scale.
We randomised 444 patients over a 21 month period between 2008 and 2010, and followed them up for two years – we have an extension to the grant, which allows us now to continue this for five years.
All patients continued to extension to the grant, which now allows us to see the patients up to 5 years after randomisation. All patients after randomisation were free to attend clinics as their medical attendants wished, but in addition, those allocated to CBT-HA received a mean of six sessions of treatment from relatively naive therapists who were trained at two workshops before the study began.
Why was this research carried out in hospital medical clinics?
Almost all previous research on the subject has been done in primary care, or with people recruited by advertisement. But most of the people with significant health anxiety are attending medical clinics because they wish to be reassured they do not have any medical problems, so this is the obvious place for a study to be carried out.
At the same time we also have to recognise that these people are not seeking psychological treatment, and sometimes may be reluctant to have it. For this reason we think is best offered by clinicians within the services they attend in the future rather than be interviewed by external psychologists or psychiatrists.
How did this form of adaptive CBT for health anxiety differ from standard CBT?
There are a number of standard procedures involved in CBT-HA which are not commonly used in other forms of the treatment. In particular we use pie charts and pyramids to demonstrate that the serious medical conditions associated with common symptoms are in fact very rare, and also carry out behavioural experiments such as avoidance of Internet browsing and monitoring of health regularly (e.g. taking your pulse every 30 minutes).
This is a relatively simple form of treatment that does not require excessive training and is best carried out by people knowledge of medical disorders as well as psychological understanding.
What were the main findings of this research?
The main findings were that health anxiety was significantly and greatly reduced in patients treated with CBT-HA compared with those who discontinued with standard care alone. These differences began to emerge at three months and were highly significant after six, 12 and 24 months, and this maintenance of therapeutic benefit is very unusual in psychological studies as most patients in standard care tend to return to normal function if they have other anxiety disorders.
Our hypothesis explaining these findings is that those who stay in standard care alone tend to have their health anxiety reinforced by constant and inappropriate reassurance and this is the reason why they do not improve.
Our cost-effectiveness analysis showed that there were some savings made by CBT-HA but not as much, as we had expected, possibly because a small number of patients already had significant medical pathology, before randomisation, and these dominated the cost comparisons.
Nine patients died during the course of the study, six of them in the standard care group, so there was no evidence that the psychological treatment prevented the detection of serious and life-threatening diseases.
What impact do you think these results will have?
We wish to raise the profile of health anxiety in general medical and surgical settings. The main problems in these clinics are that all health professionals are blinkered by bureaucracy in being asked to focus only on the areas of clinical practice that are their specific concern - and getting into trouble if they fail to identify disease that is under their area of responsibility, and as a consequence, ignore the psychological aspects of the conditions they are reviewing.
If we can improve psychological awareness among the staff in clinics then a lot of unnecessary investigations, discomfort and dissatisfaction can be avoided.
We think this intervention is best given by nurses or other health professionals within the clinics rather than going outside the psychological services, not least as the patient concerned tend to be antipathetic towards any form of mental health intervention unless it is given by another health professional.
How do you think the future of health anxiety therapies will develop?
There is already evidence that CBT for health anxiety can be given in computerised form over the Internet, and research evidence suggests it is effective. But this treatment requires motivation on behalf of the patient, and this is often lacking in the people we see in medical settings.
If, however, we can raise general awareness of the problem, then the treatment we have introduced could be used much more widely in many different places.
Is it possible to prevent health anxiety?
Unfortunately we have no means of knowing how to prevent any form of anxiety disorder in our present state of knowledge.
Why is there a bit of schism in the liaison psychiatry world?
One group regards liaison psychiatrists as special people who will always be in short supply, and so their main function will be to assess severe cases, and allow other personnel to deal with all the rest.
The second group is more inclusive and feels that liaison psychiatry should be involved with significant mental pathology in all parts of the secondary care hospital system and so should be assisting in training and helping professionals to detect mental health problems, and treat them more effectively. We definitely belong to the second group.
Where can readers find more information?
There are several books written about self treatment of health anxiety (Young, 2007; Veale & Willson, 2009), but we also want to make practitioners in general medicine more aware of the problem and to have the confidence to treat it in practice. A book describing the treatment in medical clinics, and how to administer it, has now been published by Helen Tyrer (2013) (my wife and one of the main CHAMP investigators).
Tyrer H (2013). Tackling health anxiety: a CBT handbook. RCPsych Press, London, 2013.
Veale D & Willson R (2009) Overcominghealth anxiety. Robinson.
Young C (2007). An introduction to coping with health anxiety. Robinson.
About Professor Peter Tyrer
Peter Tyrer is Professor of Community Psychiatry in the Centre of Mental Health at Imperial College.
He has been interested in the most common mental disorders ever since medical student days and has been particularly interested in anxiety, depression and personality disorder in terms of classification and treatment ever since.
He has been especially concerned about hypochondriasis because of its generally poor response to treatment and has been working with his wife, Helen, on better ways of detecting and treating this common condition in ordinary health settings since 1999.
He is also the lead of the North London hub of the Mental Health Research Network in England and Editor of the British Journal of Psychiatry until October 2013.