Handling patients with health anxiety

A few years ago, Dr. Jabir Jassam had two patients with severe illness anxiety disorder who would repeatedly visit his clinic, as well as the emergency room and walk-in clinics.“They used to call us very often looking for urgent appointments due to their intense episodes of anxiety, secondary to minor symptoms or a family member’s illness,” said Dr. Jassam, a family physician in Ottawa.It was difficult to accommodate these patients’ frequent requests, so Dr. Jassam set short, monthly appointments with each of them. “This worked miraculously well,” he said. “They stated that having fixed, regular appointments put them at ease and made them feel safe and gave them the time to prepare their lists of anxious thoughts until the time of their appointments, which they rarely missed.”This strategy is consistent with a recommendation from a Journal of Primary Care and Community Health study into interactions with patients with health anxiety. Since reassurance-seeking through repeated medical appointments can reinforce anxiety, scheduled follow-up visits that are independent of symptoms can be helpful.The DSM-5 defines illness anxiety disorder as “a preoccupation with having or acquiring a serious illness.” A patient with the disorder may engage in excessive health-related behaviours, such as repeatedly requesting medical appointments or tests, frequently checking for signs of illness on their body or avoiding doctor appointments and hospitals.An actual symptomIllness anxiety disorder, or health anxiety, usually involves an actual symptom, such as stomach pain, a rash or feeling dizzy. Then the patient becomes excessively worried that it is the sign of something serious.It can be difficult for a doctor to manage patients with vague symptoms or those without a readily identifiable medical cause. And if the doctor indicates health anxiety, the patient may think the doctor is not taking them seriously or believes it is “all in their head.”So, what can a physician do to help patients with health anxiety?Dr. Jassam says the first step is to recognize when a patient might be struggling with the disorder.“I recognize it by looking at the overall pattern rather than any single symptom or behaviour. Patients often continue to worry about serious illness despite appropriate medical assessment and reassuring examination or test results,” he said. “They may seek repeated medical opinions, ask for further testing or spend excessive time researching their symptoms online. Often, the anxiety itself causes more distress than the physical symptom they originally experienced.”Once he determines that anxiety is the main driver, Dr. Jassam shifts the focus from the symptom to the anxiety.“My goal is not simply to reassure the patient, because reassurance often provides only temporary relief. Instead, I help them explore why the symptom feels so threatening. Is it because of a past medical experience, a family member’s illness or a fear of missing something serious?“I explain my reasoning as scientifically and transparently as possible. I only order tests when they are medically indicated. Unnecessary testing may reduce anxiety briefly, but it can reinforce the cycle of fear and repeated reassurance-seeking. The long-term goal is to help patients better understand and manage their anxiety, rather than relying on repeated investigations for reassurance.”Dr. Jassam says he explains to patients that unnecessary tests are not always helpful and that careful followup is often the safest approach. “Knowing that we are monitoring their health closely makes it much easier for patients to accept a watchful waiting plan instead of pursuing repeated investigations,” he said. “I also reassure them that if there is a genuine medical concern, I will investigate it appropriately.”Dr. Jassam helps patients understand that their symptoms are real but are often amplified by anxiety. “I explain how anxiety can heighten normal bodily sensations and make them feel more alarming, without dismissing the patient’s concerns.“When appropriate, I also recommend psychological therapy, particularly cognitive behavioural therapy (CBT), and occasionally medication if the anxiety is significantly affecting the patient’s quality of life. However, medication is not usually the first step. Building insight, establishing trust and providing consistent follow-up are often the most effective interventions.”A cautious approachDr. Mel Borins, a family physician in Toronto and associate professor in the department of family and community medicine at the University of Toronto, takes a similarly cautious approach to testing and reassurance.He tries to reassure patients with tests that are part of the Ontario screening program, such as a mammogram, HPV screening and fecal occult blood testing and offers any applicable vaccinations. He restricts testing to provincially recommended tests.He says it is helpful to examine with the patient why they feel anxiety. “Did they have a catastrophic illness? Did they have a loss in their family? Did they have a parent who was overly anxious about their own health?”The most scientifically backed treatment for health anxiety is cognitive behavioural therapy, Dr. Borins says. “This involves looking at the core beliefs about ourselves and the people around us and how those influence our automatic thoughts and how those thoughts influence our feelings and how our feelings influence our behaviour.”He recommends that patients read Mind Over Mood by Christine Padesky and Dennis Greenberger. If necessary, he refers them to a counselling provider. He also suggests physicians learn about the DSM diagnosis of illness anxiety disorder and become familiar with how CBT can help patients.Dr. Jassam continues to schedule regular monthly follow-up visits for patients whose health anxiety is severe enough to affect their daily lives. “Patients know they have dedicated time to discuss their concerns, so they are less likely to repeatedly search their symptoms online or visit the emergency department for reassurance. Many come with a written list of questions, which we address together.“These visits are more than reassurance—they are part of the treatment itself. Knowing they will be seen regularly reduces their anxiety and often reduces the intensity of the symptoms they experience.”Dr. Jassam says one of the most important factors is trust. “When patients feel their physician is knowledgeable, confident and genuinely listening, they are much more willing to engage in the discussion. While reassurance alone is often temporary, a strong therapeutic relationship makes a significant difference.”

Handling patients with health anxiety

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