How to manage a patient with health anxiety?

Managing Health Anxiety in Patients

Cognitive behavioral therapy (CBT) is the most effective treatment for health anxiety and should be the first-line intervention, as it provides sustained benefits for reducing anxiety symptoms and improving quality of life.

Assessment and Diagnosis

• Use validated screening tools to assess severity of health anxiety symptoms, such as the Hospital Anxiety and Depression Scale (HADS) with a score ≥8 indicating significant anxiety, or the Penn State Worry Questionnaire (PSWQ) to evaluate worry severity 1
• Identify signs and symptoms of anxiety including panic attacks, trembling, sweating, tachycardia, palpitations, and sweaty palms 1
• Assess severity of symptoms, possible stressors, risk factors, and explore underlying problems/causes 1
• Rule out medical causes of anxiety symptoms (e.g., unrelieved pain, fatigue, endocrine disorders) before confirming a diagnosis of health anxiety 1, 2

Treatment Approach: Stepped Care Model

Step 1: Mild Health Anxiety

• Provide education and information to patients and families about health anxiety, including:
  • Normalcy of health-related concerns and anxiety 1
  • Specific stress reduction strategies (e.g., progressive muscle relaxation) 1
  • Information about signs and symptoms of anxiety and their treatment 1
  • Information on sleep hygiene and self-management of fatigue 1

Step 2: Moderate Health Anxiety

• Offer cognitive behavioral therapy (CBT), which has shown the strongest evidence for long-term effectiveness with a large effect size (g = 0.79) compared to control conditions 3
• CBT for health anxiety has demonstrated sustained benefits for up to 8 years after treatment, with significant improvements in health anxiety scores and depression symptoms 4
• Consider therapist-guided Internet-delivered CBT (ICBT) which has comparable effects to face-to-face CBT and may improve accessibility 3
• Psychological interventions should be derived from empirically supported treatment manuals that specify content and structure 1

Step 3: Severe Health Anxiety

• For severe symptoms, combine psychological and pharmacological approaches 1
• First-line pharmacotherapy includes:
  • Selective serotonin reuptake inhibitors (SSRIs) such as sertraline, which show small to medium effect sizes compared to placebo 5
  • Serotonin-norepinephrine reuptake inhibitors (SNRIs) such as venlafaxine extended-release 5
• When selecting medication, consider:
  • Adverse effect profiles
  • Potential drug interactions
  • Response to prior treatment
  • Patient preference 1

Implementation Considerations

• Follow-up is crucial as patients with anxiety often avoid treatment; assess compliance with referrals and treatment monthly until symptoms subside 1
• If symptoms persist after 8 weeks of treatment despite good compliance, modify the treatment approach (e.g., add psychological intervention if using medication alone, change medication, or switch from group to individual therapy) 1
• Use outcome measures routinely (pre- and post-treatment) to gauge treatment efficacy, monitor adherence, and evaluate practitioner competence 1

Special Considerations

• Caution with benzodiazepines: While effective for short-term anxiety relief, these medications carry increased risk of abuse and dependence and are associated with cognitive impairment; use should be time-limited according to psychiatric guidelines 1
• Health anxiety is particularly common in hospital and medical settings, where it often goes unrecognized and untreated 6
• A stepped care approach where physicians and nurses are trained to identify health anxiety and provide initial interventions can be effective in secondary care settings 6
• CBT for health anxiety is likely cost-effective, though its effect on quality of life may be limited 3

Common Pitfalls to Avoid

• Failing to recognize health anxiety in medical settings, leading to unnecessary investigations and reinforcement of anxiety 6
• Not addressing comorbid conditions, particularly depression, which is common in patients with health anxiety 4
• Dismissing patient concerns, which can increase anxiety and reduce trust in healthcare providers 1
• Providing reassurance without addressing underlying anxiety mechanisms, which can reinforce anxiety patterns 4