Treating patients with health anxiety
A specially developed form of psychotherapy can effectively help patients overcome health anxiety and could prevent them from making thousands of unnecessary trips to GP surgeries and hospitals in the future, a clinical trial has found.
The study is one of the largest of its kind to show that a modified form of Cognitive Behavioural Therapy for Health Anxiety (CBT-HA) can be used to treat the condition – in which patients excessively worry about their health and frequently consult doctors and health professionals for reassurance and diagnostic tests.
Up to one in five people attending medical clinics have abnormal health anxiety, which is made worse by people researching their symptoms online, but researchers say only one in ten are diagnosed. Many may link their symptoms to previous medical problems, such as heart attacks, and are convinced they are at risk again.
Researchers estimate the annual NHS costs of untreated patients attending unnecessary tests and appointments in primary care could be as high as £56m.*
The CHAMP study, funded by the NIHR, is published in the NIHR Journals Library. It was led by Professor Peter Tyrer at Imperial College London, in collaboration with Dr Barbara Barrett and Professor Sarah Byford from King's College London's Institute of Psychiatry, Psychology & Neuroscience (IoPPN).
The study also found that the treatment could be effectively administered by supervised trainee psychiatrists and nurses – who were the best at performing in the study.
Health anxiety overlaps with hypochondria (a term which is now becoming redundant) and is characterised by patients excessively worrying about their health and fearing they may have an unrecognised disease. Symptoms include chest pains or headaches that persist despite a doctor’s reassurance that there is no physical cause of their distress.
It provides a substantial burden on health services, leading to unnecessary and expensive medical appointments and investigations. The research data from all studies suggest that a relatively simple psychological intervention would pay for itself and save thousands of pounds to the NHS in future.
Project lead, Peter Tyrer, Professor of Community Psychiatry, said: 'Patients with high health anxiety excessively worry about their health but most do not recognise its underlying cause. The condition is often triggered by some event, and the combination of greater personal vulnerability, enhanced by increased public awareness of illness, reinforces the anxiety. With the ready availability of the internet, people feel it’s their responsibility to look after their health, and indeed, public health experts encourage this.
'The problem is that the symptoms of health anxiety are misinterpreted as those of physical illness and so most sufferers attend medical practitioners in both primary and secondary care asking for help in searching for a physical diagnosis, so ignoring the mental core of the condition.
'We found health anxiety was common in those with other physical illness. So people after apparently successful treatment of heart attacks would interpret minor symptoms as warnings of further attacks, cut down on all their activities, create more suffering, and have their lives thrown into chaos and disarray.'
Of the 28,991 patients screened prior to the study - 444 were recruited for the project from cardiology, endocrinology, gastroenterology, neurology and respiratory departments at five general hospitals in England.
The patients, aged 16-75 years, had all scored more than 20 points on the Health Anxiety Inventory (HAI), indicating severe health anxiety and had satisfied diagnostic requirements for hypochondriasis. They were randomised to receive between four-10 hour-long sessions of CBT-HA, or to receive continued care in the clinic with information given to their doctors that abnormal health anxiety had been recognised. CBT-HA helps patients challenge their thoughts and recognise how their anxiety is maintained by seeking reassurance and excessive checking of their bodies and also checking their symptoms online. This is supported by behavioural experiments testing out the new ways of thinking and offering new less threatening alternatives for their worries.
Patients received an average of six sessions of treatment and all were followed up at intervals between three months and five years.
After a year the CBT-HA groups reduced their HAI scores by 2.97 points, improving their condition from severe to moderate, compared to standard care. Their symptoms of anxiety and depression also improved. This difference lessened over time but remained moderate (2.20) after five years.
Treatment given by nurses was found to be superior to standard care by 5.5 points, improving patients’ condition from severe to mild, and nurses were found to be at least as good as psychologists and other health professionals. Patients in cardiology clinics showed the greatest reduction in HAI scores compared with standard care (5.21 points) after five years.
Deaths were similar in both groups, but those allocated to standard care died earlier, suggesting that CBT-HA did not lead to failure to identify serious life-threatening disease.
The team found that the benefits of CBT-HA persisted after five years and the costs of the treatment were more than offset by the savings to health services.
Professor Tyrer said: 'CBT-HA allows therapists with no previous experience to be trained relatively easily. It therefore has the potential to be used widely in general hospital settings under appropriate supervision. We recommend that further work is needed in research to identify and treat the growing problem of health anxiety in hospitals.'
Professor Andrew Farmer, Board Chair of the NIHR Health Technology Assessment (HTA) Programme, said: 'The NIHR is proud to have supported this independent research. We hope that it will make a difference to improving the well-being of people diagnosed with health anxiety in the NHS.'
Notes to editors
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Paper reference: Tyrer, P et al. (2017) Cognitive behaviour therapy for health anxiety in medical patients (CHAMP): a randomised controlled trial with outcomes to 5 years Health Technology Assessment https://dx.doi.org/10.3310/hta21500
This article has been adapted from materials provided by the NIHR.
*The figure of £56m is estimated by Peter Tyrer following results of study in Denmark: Fink P, Ørnbøl E, & Christensen KS. The outcome of health anxiety in primary care. A two-year follow-up study on health care costs and self-rated health. PLoS One 2010 ;5: e9873.