Health Anxiety (Illness Anxiety Disorder)
Summary
Health Anxiety, classified in DSM-5 as Illness Anxiety Disorder (IAD) or Somatic Symptom Disorder (SSD) depending on presentation, is a condition characterised by Preoccupation with Having or Acquiring a Serious, Undiagnosed Medical Illness despite minimal or no somatic symptoms and negative investigations. Patients experience Persistent Worry about their health, Engage in Excessive Health-Related Behaviours (Body checking, Reassurance-seeking, Frequent medical consultations, Internet searching) or Avoidant Behaviours (Avoiding doctors, Medical settings, Health information). The condition affects approximately 1-5% of the population and causes significant distress and functional impairment. Key differentials include Somatic Symptom Disorder (Where significant physical symptoms ARE present) and genuine medical conditions. Health anxiety is often Comorbid with Depression, Generalised Anxiety Disorder, OCD, and Panic Disorder. First-line treatment is Cognitive Behavioural Therapy (CBT), which has strong evidence. SSRIs are effective as adjunctive or standalone treatment, particularly when comorbid depression is present. The condition has a Chronic Course but can improve significantly with appropriate treatment. Management in primary care requires a balance of Validation, Limiting Unnecessary Investigations, and Active Psychological Treatment rather than simple reassurance. [1,2,3]
Key Facts
| Fact | Value |
|---|---|
| Definition | Preoccupation with having/Acquiring serious illness, Minimal/No symptoms |
| DSM-5 Classifications | Illness Anxiety Disorder (IAD); Somatic Symptom Disorder (SSD) |
| ICD-11 Code | 6B23 (Hypochondriasis) |
| Prevalence (General) | 1-5% |
| Prevalence (Primary Care) | 3-8% |
| Prevalence (Medical Outpatients) | 4-10% |
| Peak Age | Early-Middle adulthood (20-40) |
| Sex | Equal (Or slight female predominance) |
| Course | Chronic, Waxing and waning |
| Key Distinction | IAD = Minimal symptoms; SSD = Significant symptoms |
| First-Line Treatment | Cognitive Behavioural Therapy (CBT) |
| Pharmacotherapy | SSRIs (Fluoxetine 20-60mg, Paroxetine 20-50mg) |
| CBT Sessions | Typically 8-16 sessions |
| Treatment Response | 50-70% significant improvement with CBT |
| Prognosis | Chronic but treatable |
| Common Feared Illnesses | Cancer, Heart disease, Neurological disease |
| Key Comorbidities | Depression (40-60%), GAD (30-50%), Panic (20-40%) |
| Healthcare Impact | 3-10x more GP visits than average |
| Cyberchondria | Excessive internet health searching |
| Subtypes | Care-seeking vs Care-avoidant |
Clinical Pearls
"Reassurance Doesn't Work Long-Term": Brief relief followed by return of anxiety. Avoid reassurance-seeking cycles.
"IAD = Minimal Symptoms; SSD = Significant Symptoms": Key DSM-5 distinction – Know this for exams.
"Cyberchondria": Modern phenomenon – Excessive health-related internet searching worsens anxiety.
"High Users of Healthcare": Often significant healthcare utilisation without benefit, Costly.
"CBT is First-Line": Strong evidence base. SSRIs as adjunct or if comorbid depression.
"Avoid the Investigation Trap": Each normal test provides brief relief, Then anxiety returns, Cycle repeats.
"Validate, Don't Dismiss": Say "Your symptoms are real, But caused by anxiety" – NOT "There's nothing wrong."
"Schedule Appointments, Don't Go When Anxious": Reduces PRN attendance pattern.
"Safety Behaviours Maintain the Cycle": Body checking, Googling, Reassurance – All perpetuate.
"Screen for Depression": 40-60% comorbid, Worsens outcomes, Needs treating.
"Limit Investigations – One and Done": Agree in advance, Break the cycle.
"Cognitive Model is Key": Trigger → Misinterpretation → Anxiety → Safety behaviour → Cycle.
"Stepped Care": Self-help → Guided self-help → CBT → Specialist. Match intensity to severity.
"iCBT Works": Internet-based CBT is effective and accessible (Hedman 2014).
"Anxious Cluster Personality": Cluster C personality traits worsen prognosis.
"Prognosis is Good with Treatment": 50-70% improve significantly with CBT.
"Think About the Family": Partners often frustrated, Psychoeducation helps.
"Greeven 2007": Key RCT – CBT and Paroxetine both effective, CBT more durable.
Why This Matters Clinically
Health anxiety is extremely common in primary care and general medical settings, Often unrecognised and poorly managed. It leads to significant healthcare utilisation, Unnecessary investigations (With associated risks), Patient distress, And clinician frustration. Effective management requires understanding the condition as a psychological disorder requiring specific treatment rather than simply more investigations or reassurance. Liaison psychiatry and integrated psychological services are increasingly important. This condition is examined in both psychiatric and general medical contexts due to its prevalence and the need for appropriate management strategies.
Key Principle
[!NOTE] Health anxiety is a common but under-recognised condition affecting 1-5% of the population. It leads to significant healthcare utilisation and costs. Recognition in primary care and general medical settings is essential for appropriate management.
Incidence & Prevalence
| Measure | Value | Notes |
|---|---|---|
| Prevalence (General Population) | 1-5% | Depending on criteria used |
| Prevalence (Primary Care) | 3-8% | Higher in healthcare settings |
| Prevalence (Medical Outpatients) | 4-10% | Common in specialty clinics |
| Prevalence (Specialist Clinics) | Up to 20% | Cardiology, Neurology, Gastroenterology |
| Age of Onset | 20-40 years | But can occur at any age |
| Course | Chronic | Waxing and waning over years |
| Incidence Rate | ~1% per year | New cases |
Global Burden
| Region | Estimated Prevalence | Notes |
|---|---|---|
| Worldwide | 1-5% | Consistent across cultures |
| Western Europe | 3-5% | Well-studied |
| North America | 3-5% | Similar rates |
| Asia | 1-3% | May present differently (Somatic focus) |
| Developing Countries | Limited data | May be underdiagnosed |
Demographics
| Factor | Details | Clinical Significance |
|---|---|---|
| Age | Peak 20-40 years | Can start in adolescence or later |
| Sex | Equal or slight female predominance | |
| Socioeconomic | All levels | May be overrepresented in higher SES |
| Education | All levels | Higher education does not protect |
| Healthcare Use | Very high | 3-10x general population visits |
| Cost | Significant | High healthcare utilisation costs |
Healthcare Utilisation Impact
| Factor | Impact |
|---|---|
| GP Visits | 3-10x more than average |
| Specialist Referrals | Frequent, Often unnecessary |
| Investigations | Multiple, Repeated, Often normal |
| A&E Attendance | May be increased (Health crises) |
| Hospital Admissions | May occur for investigation |
| Healthcare Costs | Estimated 2-5x higher than average |
| Lost Productivity | Work absences, Reduced function |
Age-Specific Features
| Age Group | Presentation | Notes |
|---|---|---|
| Adolescence | May focus on specific fears (Cancer, HIV) | Often with anxiety/depression |
| Young Adults (20-35) | Classic presentation | Peak onset |
| Middle Age (35-55) | Heart, Cancer fears predominant | May follow family illness |
| Older Adults (55+) | Dementia, Cancer fears | May overlap with genuine health concerns |
Risk Factors - Detailed
Predisposing Factors:
| Factor | Mechanism |
|---|---|
| Personal History of Serious Illness | Especially childhood illness, Hospitalisation |
| Family History of Serious Illness | Parental illness/Death, Especially in childhood |
| Traumatic Medical Experiences | Misdiagnosis, Medical error, Iatrogenic harm |
| History of Abuse/Trauma | Physical, Sexual, Emotional (Somatisation) |
| Neuroticism (Personality Trait) | High neuroticism predisposes to all anxiety |
| Anxious Attachment Style | Insecure attachment |
Precipitating Factors:
| Factor | Example |
|---|---|
| Life Events | Bereavement, Illness in loved one |
| Media Exposure | Health scares, Celebrity illness stories |
| Medical Encounters | Being told "We need to run tests" |
| Physical Symptoms | Any unexplained symptom |
Maintaining Factors:
| Factor | How It Maintains |
|---|---|
| Reassurance-Seeking | Brief relief, Then return of anxiety |
| Body Checking | Increases focus on sensation |
| Internet Searching | "Cyberchondria" – Confirms fears |
| Avoidance | Prevents learning that fears unfounded |
| Overinvestigation | Medical system inadvertently reinforces |
Comorbidities - Detailed
| Comorbidity | Prevalence | Relationship |
|---|---|---|
| Major Depressive Disorder | 40-60% | Common and bidirectional |
| Generalised Anxiety Disorder | 30-50% | Overlapping worry patterns |
| Panic Disorder | 20-40% | Somatic symptom overlap |
| OCD | 10-20% | Health-related obsessions |
| Social Anxiety | 10-20% | May avoid medical settings |
| PTSD | Variable | If medical trauma |
| Personality Disorders | 10-30% | Especially Cluster C (Anxious) |
| Somatisation | Overlap | Continuum with SSD |
Cognitive Model (Central to Understanding and Treatment)
Step 1: Triggering Event
- Internal Trigger: Normal bodily sensation (Heartbeat awareness, Muscle twitch, Minor pain)
- External Trigger: Health information (News, Internet, Friend's illness)
- Low Threshold: Heightened attention to body (Hypervigilance)
Step 2: Misinterpretation (Catastrophic Cognition)
- Normal sensation misinterpreted as sign of serious illness
- Cognitive distortions:
- Catastrophising: "This headache must be brain cancer"
- Probability Overestimation: "Heart symptoms = Heart attack is likely"
- Confirmation Bias: Noticing confirmatory info, Ignoring reassurance
- Emotional Reasoning: "I feel unwell, So I must BE unwell"
Step 3: Anxiety Response
- Physiological: Sympathetic activation (Increased HR, Sweating, Tension, GI upset)
- Emotional: Fear, Dread, Distress
- Cognitive: Rumination, Worry, Cannot "switch off"
- Physiological Symptoms Reinforce Belief: "I DO have symptoms!"
Step 4: Safety Behaviours
- Reassurance-Seeking: Repeated GP visits, Investigations, "Dr Google"
- Body Checking: Palpating lumps, Checking pulse, Examining skin
- Avoidance: Avoiding medical settings OR avoiding health info
- Short-Term Relief: Temporary reduction in anxiety (Negative reinforcement)
- Long-Term Worsening: Does not address core cognitions; Reinforces cycle
Step 5: Maintenance of Cycle
- Relief from reassurance is short-lived
- New symptoms or triggers restart cycle
- Hypervigilance maintained
- No opportunity to learn that symptoms are benign
- Condition becomes chronic
Neurobiological Factors
| Factor | Findings |
|---|---|
| Somatosensory Amplification | Heightened perception of bodily sensations |
| Amygdala Hyperactivity | Threat processing |
| Prefrontal Cortex | Reduced top-down modulation of anxiety |
| Serotonergic System | Implicated (Response to SSRIs) |
| Autonomic Dysregulation | Increased sympathetic tone |
Pathophysiology Diagram
Key Principle
[!NOTE] Health anxiety presents with:
- Preoccupation with having a serious illness
- Minimal or absent somatic symptoms (In IAD)
- Excessive behaviours (Checking, Reassurance, Googling)
- Impaired function (Work, Relationships, Quality of life) Despite these features, Always consider genuine medical conditions.
DSM-5 Diagnostic Criteria
Illness Anxiety Disorder (IAD):
| Criterion | Description |
|---|---|
| A | Preoccupation with having or acquiring a serious illness |
| B | Somatic symptoms are NOT present OR only mild |
| C | High level of anxiety about health |
| D | Excessive health-related behaviours (Checking, Reassurance) OR maladaptive avoidance |
| E | Duration ≥6 months (Though specific illness feared may change) |
| F | Not better explained by another mental disorder |
Somatic Symptom Disorder (SSD):
| Criterion | Description |
|---|---|
| A | One or more somatic symptoms that are distressing or disruptive |
| B | Excessive thoughts, Feelings, Or behaviours related to somatic symptoms |
| C | Duration ≥6 months (Though specific symptoms may vary) |
Key Distinction: IAD vs SSD:
| Feature | IAD | SSD |
|---|---|---|
| Somatic Symptoms | Minimal or absent | Significant, Present |
| Focus | Fear of having illness | Distress about symptoms |
| Physical Basis | Little or none | Symptoms are real/present |
Typical Presentation - Detailed
| Feature | Description | Clinical Significance |
|---|---|---|
| Preoccupation | Constant worry about serious illness | Often Cancer, Heart, Neurological |
| Minimal Symptoms | In IAD – Little physical basis | Distinguishes from SSD |
| Reassurance-Seeking | Multiple GP visits, Specialists, Tests | High healthcare use |
| Temporary Relief | Reassured briefly, Then returns | Characterisitc pattern |
| Body Checking | Frequent self-examination | Self-palpation, Checking pulse |
| "Dr Google" | Excessive internet searching | "Cyberchondria" |
| Functional Impairment | Work, Relationships, Social | Significant distress |
| Avoidance | Some avoid medical settings | Care-avoidant subtype |
Symptom Patterns
Physical Symptoms Often Complained Of (Despite Normal Findings):
| System | Examples |
|---|---|
| Cardiovascular | Palpitations, Chest discomfort |
| Neurological | Headaches, Tingling, Dizziness |
| Gastrointestinal | Abdominal discomfort, Bloating |
| Musculoskeletal | Lumps, Aches, Pains |
| General | Fatigue, Feeling unwell |
Note: In IAD these are minimal. In SSD they are prominent.
Cognitive Distortions in Health Anxiety
| Distortion | Example |
|---|---|
| Catastrophising | "This headache MUST be a brain tumour" |
| Probability Overestimation | "I'm definitely going to have a heart attack" |
| Confirmation Bias | Notices symptoms that confirm fear, Ignores reassurance |
| Emotional Reasoning | "I feel terrified, So I must be ill" |
| Selective Attention | Hypervigilant to body sensations |
| All-or-Nothing Thinking | "If tests aren't 100% certain, I could be ill" |
| Mind Reading | "The doctor looked worried – They must think it's serious" |
Common Feared Illnesses - Detailed
| Illness | Prevalence | Notes |
|---|---|---|
| Cancer | Most common | Brain, Bowel, Lung, Breast (Women), Skin |
| Heart Disease | Very common | MI, Arrhythmia, Sudden cardiac death |
| Neurological Disease | Common | MS, Brain tumour, ALS, Dementia |
| HIV/STIs | Often despite negative testing | |
| Dementia | Especially in older patients | |
| Rare Diseases | After media exposure | |
| Whatever Was Last Searched | "Cyberchondria" effect |
Behavioural Subtypes
| Subtype | Description | Behaviour |
|---|---|---|
| Care-Seeking Type | Most common | High healthcare utilisation, Frequent requests for tests |
| Care-Avoidant Type | Less common | Avoids medical settings, Health information |
Severity Classification
| Severity | Features | Management Level |
|---|---|---|
| Mild | Occasional worry, Functions normally | Self-help, Watchful waiting |
| Moderate | Regular preoccupation, Some functional impact | CBT, Consider SSRI |
| Severe | Constant worry, Significant impairment | CBT + SSRI, Specialist referral |
| Very Severe | Housebound, Unable to work, Suicidal thoughts | Urgent specialist, Risk assessment |
Red Flags (Require Assessment)
[!CAUTION] Red Flags in Health Anxiety:
- Suicidal Ideation/Self-Harm: Distress can be severe
- Severe Depression: Common comorbidity
- Psychotic Features: Somatic delusions (Different diagnosis)
- Substance Misuse: Self-medicating with alcohol, Benzodiazepines
- Severe Functional Impairment: Unable to work, Housebound
- Genuine Medical Condition: Must always consider and appropriately investigate
Differentiating Health Anxiety from Genuine Concern
| Health Anxiety | Normal Health Concern |
|---|---|
| Preoccupation constant | Worry resolves with reassurance |
| Reassurance ineffective | Reassurance works |
| Multiple feared illnesses | Concern about specific issue |
| Excessive behaviours | Appropriate help-seeking |
| Disproportionate to risk | Proportionate |
Key Principle
[!NOTE] Assessment of Health Anxiety requires:
- Validating patient's distress (Not dismissing)
- Thorough but focused history (Avoid reinforcing by over-examining)
- Appropriate (Limited) physical examination
- Exploring psychological factors (Cognitions, Behaviours)
- Screening for comorbidities (Depression, Other anxiety)
Approach to Assessment
Key Principles:
- Take symptoms seriously (Do not dismiss)
- Complete thorough but focused history
- Appropriate (Limited) physical examination
- Avoid over-investigation
- Explore psychological factors
- Screen for depression and other anxiety disorders
Structured History Taking:
| Component | Questions | What to Look For |
|---|---|---|
| Presenting Concern | "What are you worried might be wrong?" | Nature of feared illness |
| Symptom History | Onset, Duration, Nature | Minimal symptoms in IAD |
| Health Beliefs | "What do you think is causing this?" | Catastrophic cognitions |
| Previous Investigations | How many? Results? Effect on anxiety? | Multiple, Normal, Brief relief |
| Reassurance Pattern | "After tests are normal, How long do you feel reassured?" | Brief (Hours to days) |
| Behaviours | Body checking, Internet searching, Doctor visits | Excessive |
| Avoidance | Avoiding medical settings OR health information | Care-avoidant subtype |
| Functional Impact | Work, Relationships, Social | Significant impairment |
| Psychiatric History | Depression, Anxiety, OCD | Common comorbidities |
| Medical History | Personal/Family serious illness | Risk factors |
| Triggers | What started this worry? | Life events, Media |
Key Questions to Ask:
| Question | Purpose |
|---|---|
| "What do you fear the most?" | Identify specific feared illness |
| "What would it mean for you if you had [feared illness]?" | Explore underlying cognitions |
| "How often do you check your body?" | Assess safety behaviours |
| "How often do you search symptoms online?" | Cyberchondria |
| "How has this affected your daily life?" | Functional impact |
| "Have you ever thought about harming yourself?" | Risk assessment |
Physical Examination:
- Targeted, Appropriate examination based on presenting symptoms
- Avoid repetitive examinations at every visit
- Explain findings clearly
- Do NOT examine repeatedly for reassurance
Mental State Examination - Detailed
| Component | Typical Findings | Notes |
|---|---|---|
| Appearance | Often normal | May be visibly anxious |
| Behaviour | Anxious demeanour | May seek reassurance during consultation |
| Speech | Normal or pressured | With health concerns |
| Mood | Anxious | May be low (Comorbid depression) |
| Affect | Anxious, Worried | Relieved temporarily by reassurance |
| Thought Content | Preoccupied with health/illness | NOT delusional (Insight present) |
| Thought Form | Rumination | Circling back to health concerns |
| Perceptions | Normal | No hallucinations |
| Cognition | Normal | May have difficulty concentrating |
| Insight | Often partial | "I know it might be anxiety, But..." |
| Risk | Assess suicide/Self-harm | May be elevated in severe cases |
Screening Tools
| Tool | Items | What It Measures |
|---|---|---|
| Whiteley Index | 14 | Health anxiety (Widely used) |
| Health Anxiety Inventory (HAI) | 18 | Health anxiety (Validated) |
| Illness Attitude Scales | 27 | Health anxiety |
| PHQ-9 | 9 | Depression (Screen for comorbidity) |
| GAD-7 | 7 | Generalised anxiety (Comorbidity) |
| AUDIT | 10 | Alcohol misuse |
Formulating the Case
| Component | Content |
|---|---|
| Predisposing | Childhood illness, Family history, Trauma, Neuroticism |
| Precipitating | Life event, Media exposure, Symptom |
| Perpetuating | Reassurance-seeking, Body checking, Cyberchondria, Avoidance |
| Protective | Insight, Supportive relationships, Engagement |
Example Formulation:
"This is a 35-year-old woman presenting with health anxiety (Illness Anxiety Disorder), predisposed by a history of parental cancer, precipitated by noticing an abdominal discomfort, and perpetuated by daily body checking, Internet searching, and frequent GP consultations. Protective factors include partial insight and a supportive partner."
Key Principle
Avoid the Investigation Trap: Repeated investigations reinforce the cycle. Each normal test provides brief relief, Then anxiety returns, Leading to requests for more tests.
Appropriate Investigation Approach
| Approach | Description |
|---|---|
| Initial Assessment | One-off, Focused investigation of specific symptoms if clinically indicated |
| Agreed Limit | Explicitly agree with patient: "We will do these tests once. If normal, We will not repeat." |
| Avoid Repetition | Do NOT repeat investigations for reassurance |
| Explain Rationale | "Normal tests tell us your body is healthy. The problem is how you're feeling about your body." |
When to Investigate
| Situation | Action |
|---|---|
| New Symptoms | Appropriate clinical assessment |
| Red Flag Symptoms | Always investigate appropriately |
| Objective Signs | Investigate findings, Not fears |
| Significant Change | Genuinely new or different symptom |
Screening Tools (For Health Anxiety)
| Tool | Description |
|---|---|
| Whiteley Index | 14-item self-report. Widely used. |
| Health Anxiety Inventory (HAI) | 18-item. Validated. |
| Illness Attitude Scales | 27-item. |
| PHQ-9 | Screen for depression (Comorbid) |
| GAD-7 | Screen for generalised anxiety |
Key Principle
[!IMPORTANT] Management of Health Anxiety requires:
- Validation of distress (Not dismissal)
- Limiting investigations (To break the cycle)
- Active psychological treatment (CBT is first-line)
- Scheduled follow-up (Not PRN)
- Treating comorbidities (Depression, GAD)
Management Algorithm
Communication and Therapeutic Relationship
Key Communication Strategies:
| Strategy | Implementation | What to Say |
|---|---|---|
| Validate Distress | Acknowledge suffering | "I can see how distressing this is for you" |
| Avoid Dismissal | Never minimise | Do NOT say "There's nothing wrong" |
| Acknowledge Reality | Symptoms are real | "The symptoms are real; Let's understand them better" |
| Reframe | Name the problem | "The problem is your health anxiety, Which is very treatable" |
| Limit Reassurance | Explain why | "Reassurance feels good briefly, But it doesn't help long-term" |
| Collaborate | Partnership | "Let's work together on this" |
| Continuity | Same clinician | Regular scheduled appointments |
What NOT to Do:
| Avoid | Why |
|---|---|
| ❌ "There's nothing wrong with you" | Invalidating |
| ❌ "It's all in your head" | Dismissive |
| ❌ "Just stop worrying" | Unhelpful |
| ❌ Repeated investigations | Reinforces cycle |
| ❌ Multiple reassurances | Short-term relief, Long-term worsening |
| ❌ PRN appointments | Come when anxious = Reinforcement |
Psychological Treatment - Detailed
First-Line: Cognitive Behavioural Therapy (CBT)
CBT Components for Health Anxiety:
| Component | Description | Goal |
|---|---|---|
| Psychoeducation | Understanding the anxiety cycle | Insight |
| Formulation | Personalised model of their anxiety | Understanding |
| Cognitive Restructuring | Challenging catastrophic health beliefs | Reduce catastrophising |
| Behavioural Experiments | Testing feared outcomes | Disconfirm beliefs |
| Exposure | To feared health information/settings | Habituation |
| Response Prevention | Reducing safety behaviours | Break cycle |
| Reducing Reassurance-Seeking | Limiting GP visits, Internet searching | Break reinforcement |
| Interoceptive Exposure | Learning to tolerate bodily sensations | Reduce fear of symptoms |
| Relapse Prevention | Planning for setbacks | Maintain gains |
CBT Session Structure Example (8-16 Sessions):
| Session | Focus |
|---|---|
| 1-2 | Assessment, Formulation, Psychoeducation |
| 3-4 | Cognitive restructuring, Identifying thoughts |
| 5-6 | Behavioural experiments, Response prevention |
| 7-8 | Exposure, Reducing safety behaviours |
| 9-12 | Consolidation, Booster |
| 13-16 | Relapse prevention, Ending |
Evidence for CBT:
| Study | Findings |
|---|---|
| Cochrane Review (Olatunji, 2014) | CBT effective, Large effect sizes |
| Greeven et al., 2007 | CBT superior to placebo, Durable effects |
| Internet CBT (Hedman, 2014) | Online CBT effective for health anxiety |
Delivery Formats:
| Format | Notes |
|---|---|
| Individual CBT | 8-16 sessions, Gold standard |
| Group CBT | Effective, Cost-efficient |
| Guided Self-Help | Books, Workbooks with therapist support |
| Computerised CBT | E.g., SilverCloud, iCBT |
| Internet-Based CBT | Evidence-based, Accessible |
Other Psychological Approaches:
| Approach | Evidence | Notes |
|---|---|---|
| Mindfulness-Based Cognitive Therapy (MBCT) | Moderate | May help with acceptance |
| Acceptance and Commitment Therapy (ACT) | Growing | Focus on values, Not symptom reduction |
| Psychodynamic Therapy | Limited | Less evidence than CBT |
| Hypnotherapy | Limited | Not first-line |
Pharmacological Treatment - Detailed
First-Line Pharmacotherapy (SSRIs):
| Medication | Starting Dose | Target Dose | Notes |
|---|---|---|---|
| Fluoxetine | 10-20mg OD | 40-60mg OD | Good evidence, First-line |
| Paroxetine | 10-20mg OD | 40-50mg OD | Evidence from RCTs |
| Sertraline | 50mg OD | 150-200mg OD | Alternative SSRI |
| Escitalopram | 10mg OD | 20mg OD | Well-tolerated |
| Citalopram | 10-20mg OD | 40mg OD | Alternative |
Second-Line Options:
| Medication | Dose | Notes |
|---|---|---|
| Clomipramine | 25-150mg OD | TCA, If SSRI fails, More side effects |
| Venlafaxine | 75-225mg OD | SNRI, Alternative |
Prescribing Protocol:
| Step | Action |
|---|---|
| 1. | Start low (Half normal start dose) |
| 2. | Warn about initial worsening (May increase anxiety briefly) |
| 3. | Titrate slowly every 2-4 weeks |
| 4. | Adequate trial: 12 weeks at therapeutic dose |
| 5. | If inadequate response: Increase dose or switch |
| 6. | Continue 12+ months after remission |
Indications for Pharmacotherapy:
| Indication | Notes |
|---|---|
| Moderate-Severe health anxiety | First-line alongside CBT |
| Comorbid depression | Often coexists |
| Patient preference | If declines CBT |
| CBT not available/Unsuccessful | Standalone option |
| Rapid symptom relief needed | SSRIs act faster than CBT initially |
Primary Care Management Strategies - Detailed
| Strategy | Implementation | Rationale |
|---|---|---|
| Regular Scheduled Appointments | E.g., Monthly, Fixed | Reduces PRN attendance |
| Single GP/Care Coordinator | Continuity | Avoids doctor shopping |
| Explicit Investigation Agreement | "We will do these tests once" | Breaks investigation cycle |
| Review Results Together | Explain clearly, Once | Avoids repeat explanations |
| Encourage Psychological Treatment | Referral to CBT/IAPT | Active treatment |
| Treat Comorbidities | Screen and treat depression, GAD | Common and worsening |
| Set Boundaries | Politely limit reassurance | Therapeutic |
| Validate Suffering | Always | Therapeutic relationship |
Stepped Care Model
| Step | Intervention | Setting |
|---|---|---|
| Step 1: Recognition | Diagnosis, Psychoeducation, Self-help materials | Primary care |
| Step 2: Low-Intensity | Guided self-help, Computerised CBT (SilverCloud) | IAPT/Primary care |
| Step 3: High-Intensity | Individual CBT (8-16 sessions), SSRI | IAPT/Psychology |
| Step 4: Specialist | Liaison psychiatry, Complex cases | Secondary care |
| Step 5: Tertiary | Specialist units (Rare) | Tertiary |
Consultation Skills for Health Anxiety
OSCE Communication Framework:
| Step | What to Do | Example Statement |
|---|---|---|
| 1. Open with Empathy | Validate | "I can see this worry is really affecting your life" |
| 2. Explore Health Beliefs | Understand | "What do you think might be causing these symptoms?" |
| 3. Psychoeducation | Explain | "Health anxiety is a real condition where..." |
| 4. Reframe | Name it | "The good news is this is very treatable" |
| 5. Limit Investigations | Agree | "We'll do one set of tests. If normal, That gives us our answer" |
| 6. Offer Treatment | Plan | "I'd like to refer you for CBT, Which is really effective" |
| 7. Schedule Follow-Up | Continuity | "Let's meet in 4 weeks, Not before" |
| 8. Close with Hope | Optimism | "Most people improve significantly with treatment" |
Overview
| Category | Key Complications |
|---|---|
| Psychological | Depression, Other anxiety, Suicidal ideation |
| Social | Work impairment, Relationship problems, Isolation |
| Medical/Iatrogenic | Unnecessary investigations, Harm from tests |
| Financial | Healthcare costs, Lost income |
Psychological/Psychiatric Complications - Detailed
Depression:
| Aspect | Details |
|---|---|
| Prevalence | 40-60% comorbid |
| Mechanism | Chronic worry, Functional impairment |
| Screening | PHQ-9 at every assessment |
| Treatment | SSRIs help both, CBT for both |
Other Anxiety Disorders:
| Disorder | Relationship |
|---|---|
| GAD | 30-50% comorbid, Overlapping worry |
| Panic Disorder | 20-40%, Somatic symptom overlap |
| OCD | 10-20%, Health-focused obsessions |
| Social Anxiety | May avoid medical settings |
Suicidal Ideation:
| Risk Factor | Notes |
|---|---|
| Severe Health Anxiety | Distress can be overwhelming |
| Comorbid Depression | Significant increase in risk |
| Functional Impairment | Hopelessness |
| Assessment | Ask directly, PHQ-9 Q9, Risk assessment |
| Management | Safety planning, Urgent referral if high risk |
Substance Misuse:
| Substance | Pattern |
|---|---|
| Alcohol | Self-medication for anxiety |
| Benzodiazepines | May seek prescriptions, Dependency risk |
| Cannabis | Some use to manage |
| Screening | AUDIT, DAST |
Social/Functional Complications - Detailed
| Complication | Impact | Management |
|---|---|---|
| Occupational Impairment | Absences, Unable to work | Occupational health, Phased return |
| Relationship Problems | Partners frustrated | Couples therapy, Psychoeducation for family |
| Social Isolation | Withdrawal | Social skills, Behavioural activation |
| Financial Impact | Healthcare costs, Lost income | Benefits advice |
| Reduced Quality of Life | Significant | Treatment, Support |
Medical/Iatrogenic Complications - Detailed
Unnecessary Investigations:
| Risk | Consequence |
|---|---|
| Radiation Exposure | CT scans (Cumulative dose) |
| Contrast Reactions | Allergic reactions |
| Procedural Risks | Bleeding, Infection from invasive tests |
| Incidental Findings | "Incidentalomas" leading to more tests |
| False Positives | Further anxiety, More investigations |
Iatrogenic Harm:
| Source | Examples |
|---|---|
| Invasive Tests | Biopsy complications |
| Overtreatment | Unnecessary medications |
| Increased Anxiety | From more tests, Waiting for results |
Healthcare System Impact:
| Factor | Impact |
|---|---|
| Doctor-Shopping | Inconsistent care, Polypharmacy |
| High Utilisation | Costs, Capacity |
| Clinician Burnout | Frustration, Difficult consultations |
| Delayed Diagnosis | "Boy Who Cried Wolf" – Dismissed when ill |
Prevention of Complications
| Strategy | How |
|---|---|
| Early Recognition | Screen in primary care |
| Appropriate Management | CBT, SSRIs - Not more tests |
| Limit Investigations | Explicit agreement |
| Continuity of Care | Single GP/Coordinator |
| Screen for Comorbidities | Depression, Anxiety, Substance misuse |
| Risk Assessment | Suicide risk if severe |
Overview
| Factor | Impact on Prognosis |
|---|---|
| Treatment | Significantly improves outcomes |
| Duration | Shorter = Better |
| Severity | Milder = Better |
| Comorbidities | Depression, Personality disorder = Worse |
| Engagement | Good engagement with therapy = Better |
Natural History
| Course | Details |
|---|---|
| Chronic | Tends to wax and wane over years |
| Fluctuates | Worse during stress, Life events |
| Without Treatment | Tends to persist indefinitely |
| With Treatment | Significant improvement in 50-70% |
| Spontaneous Remission | Uncommon without treatment |
Treatment Outcomes - Detailed
| Treatment | Response Rate | Notes |
|---|---|---|
| CBT | 50-70% significant improvement | Most durable effects |
| SSRIs | 40-60% improvement | NNT ~4-5 |
| Combined CBT + SSRI | May be superior | For severe cases |
| Guided Self-Help | 30-50% | For mild-moderate |
| Internet CBT | Similar to face-to-face | Hedman et al. 2014 |
Time to Response:
| Treatment | Time |
|---|---|
| CBT | 4-8 weeks (Gradual) |
| SSRIs | 4-8 weeks (Onset), 12 weeks (Full effect) |
Durability:
| Treatment | Follow-Up |
|---|---|
| CBT | Effects maintained at 1-2 years |
| SSRIs | Relapse common if stopped early |
Prognostic Factors
Better Prognosis:
| Factor | Mechanism |
|---|---|
| Shorter Duration | Less entrenched cognitions |
| Less Severe at Baseline | Easier to treat |
| Good Insight | "I know it's anxiety" |
| Engagement with CBT | Active participation |
| Supportive Relationships | Family, Partner support |
| No Comorbid Depression | Depression worsens outcomes |
| No Personality Disorder | Cluster C particularly problematic |
| Younger Age | More neuroplasticity |
Worse Prognosis:
| Factor | Mechanism |
|---|---|
| Long Duration (More than 5 years) | Deeply entrenched |
| Comorbid Personality Disorder | Treatment resistance |
| Severe Depression | Needs treating first |
| Poor Engagement | Doesn't attend, Doesn't do homework |
| Ongoing Life Stressors | Perpetuating |
| Reinforcing Healthcare System | Many investigations done |
| Avoidant Subtype | Harder to engage |
Relapse Prevention
| Strategy | Implementation |
|---|---|
| Identify Warning Signs | Early symptoms of return |
| Maintenance Strategies | Continue CBT techniques |
| Booster Sessions | 3-6 monthly CBT follow-up |
| Medication Duration | 12+ months, Slow taper |
| Self-Help Materials | Books, Apps |
| Lifestyle | Exercise, Sleep, Stress management |
Long-Term Management Considerations
| Aspect | Approach |
|---|---|
| Chronic Condition | May need long-term support |
| Medication | May need long-term SSRIs |
| Psychological | Periodic booster CBT |
| Healthcare Coordination | Consistent care, Limit investigations |
| Comorbidities | Treat depression, Other anxiety |
| Quality of Life | Focus on function, Not symptom elimination |
Key Guidelines
| Guideline | Organisation | Year | Key Recommendations |
|---|---|---|---|
| DSM-5 | APA | 2013 | Diagnostic criteria (IAD, SSD) |
| ICD-11 | WHO | 2019 | Hypochondriasis (6B23) |
| NICE CG113 | NICE | 2011 | Common mental health disorders – Stepped care |
| NICE CG91 | NICE | 2009 | Treatment of depression (Overlap) |
Key Evidence - Detailed
CBT for Health Anxiety (Cochrane Review, Olatunji et al., 2014)
| Aspect | Details |
|---|---|
| Study Type | Meta-analysis of RCTs |
| Result | CBT effective for reducing health anxiety |
| Effect Size | Large (SMD ~0.9) |
| Follow-Up | Effects maintained at 6-12 months |
| Implication | CBT is first-line treatment |
| PMID | 24820200 |
SSRIs for Hypochondriasis (Fallon et al., 2017)
| Aspect | Details |
|---|---|
| Study Type | Review of RCTs |
| Medications | Fluoxetine, Paroxetine effective |
| Effect Size | Moderate-Large |
| Implication | SSRIs are effective for health anxiety |
| PMID | 28107906 |
Greeven et al., 2007 (RCT)
| Aspect | Details |
|---|---|
| Study Type | RCT |
| Arms | CBT vs Paroxetine vs Placebo |
| Sample | n=112 |
| Result | Both CBT and Paroxetine superior to placebo |
| Durability | CBT had most durable effects |
| PMID | 17261692 |
Hedman et al., 2014 (Internet CBT)
| Aspect | Details |
|---|---|
| Study Type | RCT |
| Arms | Internet CBT vs Group CBT |
| Result | Internet CBT non-inferior to face-to-face |
| Implication | Online CBT is a valid delivery method |
| PMID | 24917094 |
Tyrer et al., 2016 (BMJ Review)
| Aspect | Details |
|---|---|
| Study Type | Clinical review |
| Recommendations | CBT first-line, SSRIs second-line |
| Key Point | Avoid repeated investigations |
| PMID | 27075540 |
What is Health Anxiety?
Health anxiety is when you worry a lot about your health, even when doctors have told you that you're okay. It's a very common condition that affects about 1 in 20 people. You might:
- Keep thinking you have a serious illness
- Keep checking your body for signs of disease
- Look up symptoms on the internet a lot ("Dr Google")
- Go to the doctor frequently for reassurance
- Feel briefly relieved after tests are normal, but then start worrying again
Key Points to Understand
| Fact | Explanation |
|---|---|
| Common | 1-5% of people have health anxiety |
| Real Condition | It's a recognised medical condition |
| Not "Making It Up" | Your symptoms and distress are REAL |
| Treatable | Very effective treatments available |
| Chronic but Manageable | Can wax and wane, But can be controlled |
Why Does It Happen?
It's related to how your brain processes worry. When you notice a normal body sensation (like a headache or a fast heartbeat), your brain jumps to the worst-case scenario. This triggers anxiety, which causes MORE body symptoms (Sweating, Racing heart, Muscle tension), which makes you worry MORE. It becomes a cycle.
The Anxiety Cycle:
| Step | What Happens |
|---|---|
| 1. Trigger | You notice a body sensation (Headache, Palpitation) |
| 2. Thought | "This could be something serious (Cancer, Heart attack)" |
| 3. Anxiety | You feel scared, Your body reacts (More symptoms!) |
| 4. Behaviour | You check your body, Google, Go to doctor |
| 5. Brief Relief | You feel better temporarily |
| 6. Return | The worry comes back, Often worse |
Is It "All in My Head"?
No. The symptoms you feel are REAL. But they're caused by anxiety, not by the serious disease you're worried about. Health anxiety is a recognised medical condition that is very treatable.
| Myth | Truth |
|---|---|
| ❌ "You're imagining it" | ✅ Symptoms are real |
| ❌ "Just stop worrying" | ✅ It's a condition that needs treatment |
| ❌ "One more test will fix it" | ✅ Tests don't fix health anxiety |
| ❌ "You're wasting doctors' time" | ✅ You have a real condition |
How Is It Treated?
1. Cognitive Behavioural Therapy (CBT) - The Most Effective Treatment
| What It Is | How It Helps |
|---|---|
| Talking therapy | With a specialist psychologist or therapist |
| 8-16 sessions | Weekly or fortnightly |
| Learn about the cycle | Understand why it happens |
| Challenge thoughts | Learn to question catastrophic thinking |
| Change behaviours | Reduce checking, Googling, Reassurance-seeking |
| Face fears | Gradually learn to tolerate uncertainty |
2. Medication (SSRIs)
| What It Is | How It Helps |
|---|---|
| Antidepressants | Like Fluoxetine, Sertraline |
| Not just for depression | Very effective for anxiety |
| Takes 4-6 weeks | To work fully |
| Prescribed by GP | Easy to access |
What Can I Do to Help Myself?
Do:
| Strategy | How to Do It |
|---|---|
| ✅ Limit checking | Set a rule: No more than once a day |
| ✅ Limit Googling | Try to stop completely |
| ✅ Reduce reassurance-seeking | Ask for reassurance once, Not repeatedly |
| ✅ Schedule GP appointments | Rather than going when anxious |
| ✅ Talk to your GP about CBT | Ask for a referral |
| ✅ Exercise | Helps reduce anxiety |
| ✅ Practice relaxation | Deep breathing, Meditation |
| ✅ Distract yourself | When urge to check arises |
Don't:
| Avoid | Why |
|---|---|
| ❌ Body checking | Increases focus on symptoms |
| ❌ "Dr Google" | Almost always makes things worse |
| ❌ Repeated reassurance | Brief relief, Then worse |
| ❌ Avoiding health topics completely | Avoidance maintains anxiety |
Frequently Asked Questions (FAQs)
| Question | Answer |
|---|---|
| Am I making this up? | No. Health anxiety is a real, Recognised condition. |
| Could it still be a serious illness? | One normal investigation is enough. The anxiety is the problem. |
| Will more tests help? | No. Tests provide brief relief, Then worry returns. |
| Why can't I stop worrying? | It's a condition, Not a choice. Treatment helps. |
| Will I always be like this? | No. Most people improve significantly with treatment. |
| Can I have CBT? | Yes. Ask your GP for a referral. |
| Do I need medication? | Not always. CBT alone often works. Medication helps if severe or with depression. |
| How long does treatment take? | CBT: 8-16 weeks. Medication: 6-12 months. Improvement often seen within weeks. |
When to Seek Help
[!CAUTION] See your doctor urgently if:
- You're having thoughts of harming yourself
- You feel you can't cope
- Your anxiety is severely affecting your life
- You're using alcohol or drugs to cope
Family and Friends
| What Helps | What Doesn't |
|---|---|
| ✅ Listen without judgement | ❌ "There's nothing wrong with you" |
| ✅ Encourage treatment | ❌ Repeatedly reassuring |
| ✅ Be patient | ❌ Getting frustrated |
| ✅ Set gentle boundaries | ❌ Enabling checking behaviours |
Support Resources
| Organisation | Website | What They Offer |
|---|---|---|
| NHS Choices | www.nhs.uk/conditions/health-anxiety | Information, Self-help |
| Anxiety UK | www.anxietyuk.org.uk | Support, Therapy |
| Mind | www.mind.org.uk | Mental health charity |
| No More Panic | www.nomorepanic.co.uk | Peer support |
| IAPT | NHS Talking Therapies | Free CBT via NHS |
Self-Help Books
| Book | Author |
|---|---|
| Overcoming Health Anxiety | Dr David Veale and Rob Willson |
| It's Not All in Your Head | Dr Gordon Asmundson and Dr Steven Taylor |
| Break Free from OCD | Fiona Challacombe (Health anxiety has overlaps) |
Primary Guidelines
-
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5). APA. 2013.
-
World Health Organization. ICD-11 for Mortality and Morbidity Statistics. WHO. 2019.
-
NICE. Common mental health problems: Identification and pathways to care (CG123). NICE. 2011.
Key Evidence
-
Olatunji BO, et al. Efficacy of cognitive-behavioral therapy for health anxiety: A meta-analysis. J Anxiety Disord. 2014;28(5):453-462. PMID: 24820200
-
Greeven A, et al. Cognitive behavior therapy and paroxetine in the treatment of hypochondriasis. Am J Psychiatry. 2007;164(1):91-99. PMID: 17261692
-
Fallon BA, et al. Pharmacotherapy of somatoform disorders. J Psychosom Res. 2017;93:8-14. PMID: 28107906
Reviews
-
Tyrer P. Recent advances in the understanding and treatment of health anxiety. Curr Psychiatry Rep. 2018;20(7):49. PMID: 29876651
-
Asmundson GJG, et al. Health anxiety: Current perspectives and future directions. Curr Psychiatry Rep. 2010;12(4):306-312. PMID: 20556663
Additional References
-
Taylor S, Asmundson GJG. Treating Health Anxiety: A Cognitive-Behavioral Approach. Guilford Press. 2004.
-
Salkovskis PM, et al. Cognitive-behavioural approach to understanding obsessional thinking. Br J Psychiatry. 1995;167(Suppl 27):87-95.
-
Bobevski I, et al. Excessive health anxiety—Hypochondriasis and illness anxiety disorder: Conceptualization and treatment. Curr Psychiatry Rep. 2016;18(5):44. PMID: 26993792
-
Hedman E, et al. Internet-based CBT vs. cognitive behavioral group therapy for health anxiety. JAMA Psychiatry. 2014;71(8):915-924. PMID: 24917094
-
Fink P, et al. The epidemiology of somatisation. J Psychosom Res. 2009;66(1):3-8. PMID: 19064042
-
Tyrer P, et al. Health Anxiety. BMJ. 2016;353:i1755. PMID: 27075540
-
Newby JM, et al. Systematic review and meta-analysis of transdiagnostic psychological treatments for anxiety and depressive disorders in adulthood. Clin Psychol Rev. 2015;40:91-110. PMID: 26094079
High-Yield Facts for Exams
| Fact | Value | Exam Importance |
|---|---|---|
| Definition | Preoccupation with having/acquiring serious illness | Core knowledge |
| DSM-5 Classifications | IAD (Minimal symptoms) vs SSD (Symptoms present) | Must know |
| Prevalence | 1-5% | Commonly asked |
| Peak Age | 20-40 years | Know this |
| Sex | Equal or slight female predominance | Background |
| First-Line Treatment | CBT | Must know |
| Pharmacotherapy | SSRIs (Fluoxetine, Paroxetine) | Must know |
| Key Distinction | IAD = No/Minimal symptoms | Critical |
| Cognitive Model | Trigger → Misinterpretation → Anxiety → Safety behaviour | Must know |
| Common Feared Illnesses | Cancer, Heart disease, Neurological | Background |
| Reassurance Problem | Brief relief, Then return of anxiety | Key concept |
| Cyberchondria | Excessive internet health searching | Modern phenomenon |
Common Exam Questions - Detailed
Diagnosis Questions:
-
"A 35-year-old woman presents with persistent worry that she has cancer, despite multiple normal investigations. She checks her body daily and frequently consults her GP. What is the diagnosis?"
- Model Answer: "This is Illness Anxiety Disorder (IAD) based on DSM-5 criteria. Key features: Preoccupation with having a serious illness (Cancer), Minimal or absent somatic symptoms (Normal investigations), Excessive health-related behaviours (Body checking, Frequent GP visits), Duration Greater than 6 months. Important to exclude genuine medical conditions with appropriate one-off investigation."
-
"What is the key difference between Illness Anxiety Disorder and Somatic Symptom Disorder?"
- Model Answer: "The key distinction is the presence of somatic symptoms. In IAD, There are minimal or NO significant somatic symptoms – The problem is the PREOCCUPATION. In SSD, There ARE significant, Distressing somatic symptoms – The problem is excessive thoughts and behaviours ABOUT those symptoms. Both require duration Greater than 6 months."
-
"How would you assess a patient with suspected health anxiety?"
- Model Answer: "I would take a comprehensive history exploring: Nature of health concerns, Duration and pattern of symptoms, Previous investigations and their effect on anxiety, Health-related behaviours (Checking, Googling, Reassurance-seeking), Functional impact, Psychiatric history (Depression, GAD, OCD), Medical history, Family history of serious illness. MSE focusing on mood, Anxiety, Insight. Appropriate physical examination. Screening tools (HAI, PHQ-9, GAD-7)."
Treatment Questions:
-
"What is the first-line treatment for health anxiety?"
- Model Answer: "Cognitive Behavioural Therapy (CBT) is the gold-standard first-line treatment. It has strong evidence from meta-analyses (Olatunji 2014) and RCTs (Greeven 2007). CBT for health anxiety includes: Psychoeducation about the anxiety cycle, Cognitive restructuring of catastrophic health beliefs, Behavioural experiments, Exposure and response prevention (Reducing safety behaviours), And relapse prevention. Typically 8-16 sessions. Can be delivered individually, In groups, Or via internet-based formats."
-
"Why should you avoid repeated investigations in health anxiety?"
- Model Answer: "Repeated investigations reinforce the anxiety cycle. The sequence is: Investigation → Normal result → Brief reassurance → Anxiety returns → Request for more investigation. This provides negative reinforcement (Temporary relief), Making the behaviour more likely to recur. It does NOT address the underlying cognitive distortions. One appropriate investigation is sufficient to exclude serious pathology."
-
"Which medications are effective for health anxiety?"
- Model Answer: "SSRIs are the first-line pharmacological treatment. Evidence supports Fluoxetine (20-60mg) and Paroxetine (20-50mg) from RCTs. Other SSRIs (Sertraline, Escitalopram) are reasonable alternatives. Start at low dose, Titrate slowly, Trial for 12 weeks at therapeutic dose. Indications: Moderate-severe anxiety, Comorbid depression, If CBT unavailable or unsuccessful. Can be used alone or combined with CBT."
OSCE Stations
Station 1: History Taking - Health Anxiety
| Task | Expected Competencies |
|---|---|
| Elicit presenting complaint | "What brings you here today?" |
| Explore health beliefs | "What do you think might be causing these symptoms?" |
| Assess behaviours | "Do you find yourself checking your body or searching the internet?" |
| Explore previous investigations | "What tests have you had? How did you feel after?" |
| Assess reassurance pattern | "After tests are normal, How long do you feel reassured?" |
| Functional impact | "How is this affecting your work, Relationships, Daily life?" |
| Screen for depression | "How has your mood been? Any thoughts of harming yourself?" |
| Screen for other anxiety | "Do you worry about other things too?" |
| Summarise and signpost | "It sounds like you're experiencing health anxiety. This is very treatable." |
Station 2: Explaining Diagnosis to Patient
| Component | Expected Points |
|---|---|
| Introduces self | Name, Role |
| Validates distress | "I can see this worry is really affecting you" |
| Avoids dismissal | Do NOT say "There's nothing wrong" |
| Explains condition | "Health anxiety is a real, Recognised medical condition" |
| Explains the cycle | Trigger → Thought → Anxiety → Behaviour → Maintenance |
| Normalises | "It's very common – About 1 in 20 people" |
| Offers hope | "It's very treatable" |
| Outlines treatment | "CBT is very effective. Medication can also help." |
| Addresses investigations | "More tests won't help. We've ruled out serious illness." |
| Answers questions | "Do you have any questions or concerns?" |
Station 3: Managing Requests for Investigation
| Scenario | Appropriate Response |
|---|---|
| Patient requests more tests | "I understand the anxiety. However, We've done appropriate tests. More tests will not help your anxiety." |
| Patient frustrated with diagnosis | "I hear your frustration. This doesn't mean it's not real – Your symptoms ARE real. The anxiety is causing them." |
| Patient wants second opinion | "That's your right. However, I'd encourage you to consider the psychological treatment, Which is very effective." |
| Patient says "What if you're wrong?" | "Medicine involves uncertainty. We've done appropriate assessment. More tests carry their own risks." |
Viva Points - Expanded
Opening Statement:
"Health anxiety, classified in DSM-5 as Illness Anxiety Disorder, is characterised by preoccupation with having or acquiring a serious illness, despite minimal or absent somatic symptoms and normal investigations. It is maintained by a cognitive-behavioural cycle of catastrophic misinterpretation, anxiety, and safety behaviours. It affects 1-5% of the population and is distinct from Somatic Symptom Disorder, where significant symptoms ARE present."
Key Facts Table:
| Category | Key Facts |
|---|---|
| Prevalence | 1-5% general population, 3-8% primary care |
| Classifications | DSM-5: IAD (No symptoms) vs SSD (Symptoms present) |
| Common Fears | Cancer, Heart disease, Neurological conditions |
| Cognitive Model | Trigger → Misinterpretation → Anxiety → Safety behaviour → Maintenance |
| Treatment | CBT first-line (Strong evidence), SSRIs effective adjunct |
| Avoid | Repeated investigations, Excessive reassurance, Dismissing patient |
| Prognosis | Chronic but treatable, 50-70% improve with CBT |
Evidence to Cite:
| Study | What It Showed |
|---|---|
| Greeven et al. (2007) | RCT: CBT and Paroxetine both effective, CBT more durable |
| Olatunji et al. (2014) | Cochrane: CBT effective for health anxiety, Large effect |
| Hedman et al. (2014) | Internet CBT effective for health anxiety |
Common Mistakes
What Fails Candidates:
| Mistake | Correct Approach |
|---|---|
| ❌ Not knowing DSM-5 distinction (IAD vs SSD) | IAD = No symptoms, SSD = Symptoms present |
| ❌ Recommending repeated investigations | One appropriate investigation only |
| ❌ Dismissing patient's distress | Validate: "Your symptoms are real" |
| ❌ Not mentioning CBT as first-line | CBT is gold standard |
| ❌ Forgetting comorbid depression screening | Screen with PHQ-9 |
| ❌ Saying "It's all in your head" | Avoid invalidating language |
| ❌ Not explaining the anxiety cycle | Key to patient understanding |
Dangerous Clinical Errors:
| Error | Why It Matters |
|---|---|
| ⚠️ Dismissing genuine new symptoms | "Boy Who Cried Wolf" problem – May miss real illness |
| ⚠️ Not assessing suicide risk | Severe health anxiety can lead to suicidal ideation |
| ⚠️ Reinforcing with investigations | Maintains the anxiety cycle |
Examiner Follow-Up Questions
| Question | Expected Answer |
|---|---|
| "What is cyberchondria?" | Excessive internet searching for health information, Worsens anxiety |
| "Why doesn't reassurance work?" | Brief relief, Doesn't address core cognitions, Negatively reinforced |
| "What are safety behaviours?" | Body checking, Googling, Reassurance-seeking – Maintain anxiety |
| "What comorbidities should you screen for?" | Depression (40-60%), GAD (30-50%), Panic, OCD |
| "What is the cognitive model?" | Trigger → Catastrophic misinterpretation → Anxiety → Safety behaviour → Cycle maintained |
Differential Diagnosis
| Condition | Key Distinguishing Features |
|---|---|
| Somatic Symptom Disorder | Significant somatic symptoms ARE present |
| Generalised Anxiety Disorder | Worry about MANY topics, Not just health |
| Panic Disorder | Discrete panic attacks, Not constant preoccupation |
| OCD | Obsessions/Compulsions beyond health focus |
| Delusional Disorder (Somatic Type) | Fixed false belief, No insight |
| Depression with Somatic Focus | Low mood predominant, Health worry secondary |
| Genuine Medical Condition | Must always consider and appropriately investigate |
Last Reviewed: 2025-12-25 | MedVellum Editorial Team
Medical Disclaimer: MedVellum content is for educational purposes and clinical reference. Clinical decisions should account for individual patient circumstances. Always consult appropriate specialists and current guidelines.