How to manage health anxiety in a patient?

Managing Health Anxiety in Patients

Cognitive behavioral therapy (CBT) should be the first-line treatment for patients with health anxiety, as it has demonstrated large effect sizes (g = 0.79) with sustained benefits 12-18 months after treatment and response rates of 66%. 1

Assessment and Initial Approach

When a patient presents with health anxiety, follow this structured approach:

1. Normalize anxiety: Explain that anxiety about health is common, especially in the context of medical conditions or stressors 2
2. Validate concerns: Acknowledge the patient's distress while avoiding excessive reassurance that can reinforce anxiety
3. Assess severity: Determine if symptoms are mild/situational or meet criteria for a disorder requiring more intensive intervention
4. Screen for comorbidities: Check for depression, other anxiety disorders, or medical conditions that may complicate treatment

Evidence-Based Treatment Options

First-Line Treatments

1. Cognitive Behavioral Therapy (CBT)

   • Most effective psychological intervention with large effect sizes (d = 1.01) 3
   • Focuses on identifying and challenging catastrophic misinterpretations of bodily sensations
   • Components include:
     • Education about anxiety and bodily sensations
     • Cognitive restructuring of health-related fears
     • Exposure to feared bodily sensations
     • Reduction of safety behaviors and reassurance-seeking

2. Delivery Options for CBT

   • Individual face-to-face therapy (traditional approach)
   • Group therapy (cost-effective alternative)
   • Internet-delivered CBT (ICBT) has comparable effects to face-to-face CBT 1
   • Brief interventions delivered in primary care settings 4

Additional Evidence-Based Approaches

• Acceptance and Commitment Therapy (ACT) 2

  • Focuses on psychological flexibility and values-based action despite health worries

• Behavioral Activation

  • Encourages engagement in meaningful activities despite health concerns 2

• Structured Physical Activity/Exercise

  • Regular physical activity can reduce anxiety symptoms and improve overall wellbeing 2

• Relaxation Techniques

  • Progressive muscle relaxation
  • Diaphragmatic breathing
  • Mindfulness practices

Stepped Care Approach

For efficient use of resources, implement a stepped care model 2:

1. Step 1 (Mild Symptoms)

   • Provide education and self-help materials
   • Teach basic relaxation techniques
   • Recommend structured physical activity

2. Step 2 (Moderate Symptoms)

   • Brief CBT interventions (4-6 sessions)
   • Internet-delivered CBT with minimal guidance
   • Group-based interventions

3. Step 3 (Severe Symptoms)

   • Individual CBT with a mental health professional (8-12 sessions)
   • Consider medication if significant distress or functional impairment
   • Regular monitoring and follow-up

Pharmacological Options

While psychological interventions are preferred, medication may be considered in certain situations:

• First-line pharmacological options (if needed):

  • Selective Serotonin Reuptake Inhibitors (SSRIs)
  • Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) 5

• Benzodiazepines:

  • Not recommended for routine use due to dependency risk 5
  • May be considered for short-term management of acute anxiety symptoms 2

Common Pitfalls and How to Avoid Them

1. Excessive medical testing

   • Avoid unnecessary tests that reinforce anxiety
   • Establish regular, scheduled follow-ups instead of symptom-driven appointments

2. Repeated reassurance

   • Recognize that reassurance provides only temporary relief and can strengthen anxiety cycle
   • Instead, help patient develop skills to manage uncertainty

3. Dismissing physical symptoms

   • Always conduct appropriate medical evaluation
   • Acknowledge that physical symptoms are real, even if anxiety-driven

4. Inadequate follow-up

   • Schedule regular monitoring (monthly basis until symptoms subside) 2
   • Assess treatment adherence and address barriers to engagement

Special Considerations

• Co-location of behavioral health providers in primary care settings enhances integration and improves outcomes 2

• Patient preference should be considered when selecting treatment approach, as this improves engagement and outcomes 2

• Family involvement can be beneficial, particularly to address accommodation behaviors that may reinforce health anxiety 2

• For patients resistant to psychological framing, focus initially on symptom management rather than labeling the condition as anxiety 4

By following this evidence-based approach, clinicians can effectively help patients manage health anxiety, improving both their quality of life and reducing unnecessary healthcare utilization.