Why medically unexplained symptoms and health anxiety don’t need to make your heart sink

Cognitive behaviour therapy is an effective strategy for overcoming the challenges of health anxiety

Patients with medically unexplained symptoms commonly present in primary care, accounting for up to a fifth of general practitioner consultations.1 Medically unexplained symptoms are defined as persistent and often debilitating symptoms for which a definitive medical cause cannot be identified after appropriate clinical examination and investigation.2 Due to the complex nature of their problems and a high use of health services, such patients represent a major challenge to the medical community.3 Understandably, in their quest to find an explanation and cure for their symptoms, they keep returning to their doctor in distress or crisis, sometimes with a diagnosis in mind, and other times frightened of having an unknown life-threatening medical condition that has gone undiagnosed. They often request referrals for specialist opinions, as well as repeated investigations that can increase the risk of false-positive results.4 Patients and doctors experience consultations as frustrating and difficult, and patients can be left feeling uncertain about how serious their symptoms might be, and lose trust in modern medicine.5

A wide range of commentaries, expert opinions and narrative reviews provide recommendations to physicians about how to manage patients with medically unexplained symptoms in primary care.4 Recent publications6,7 have outlined the challenges faced by GPs in helping such patients, and ideas for their management in clinical practice. Suggested strategies — largely based on common sense — include validating the patient’s distress, acknowledging the limitations of modern medicine, establishing common goals and boundaries, coordinating care, and developing a shared explanation of a patient’s problems and symptoms. In the absence of evidence-based treatment recommendations for patient management in GP settings, doctors are left with a seat-of-the-pants treatment approach.4 A shortcoming of the suggested strategies4,6,7 is that they generally fail to recommend that medical practitioners routinely refer patients to evidence-based cognitive behaviour therapy (CBT), which has been shown to be an effective treatment for medically unexplained symptoms2 and for factors that exacerbate distress and impairment associated with persistent somatic symptoms such as health anxiety.8

This article focuses on the importance of the identification and treatment of health anxiety (previously referred to as hypochondriasis) in the context of unexplained symptoms. Health anxiety is a broad term used to describe fears of having or developing serious illnesses. Studies indicate that even after controlling for comorbid mental diagnoses, health anxiety is linked to more severe somatic symptoms, poorer perceived health, and higher health service use.9 People with health anxiety tend to be characterised by specific cognitive biases (eg, the tendency to misattribute benign bodily symptoms to serious disease, hypervigilance to bodily symptoms, maladaptive beliefs about illness and coping) and engage in a range of behaviours (eg, excessive body checking, reassurance seeking, internet searching about symptoms) that are thought to perpetuate anxiety and body preoccupation.5 Common processes, such as thinking catastrophically about bodily symptoms or repeatedly checking the body for signs and symptoms of illness, appear to contribute to and maintain distress about physical symptoms, regardless of whether an individual experiences health anxiety in the context of unexplained symptoms or well established medical conditions (eg, fear of cancer recurrence). The positive news is that such cognitions and behaviours are amenable to change using therapeutic interventions such as CBT.

CBT interventions aim to educate patients about medically unexplained symptoms and normalise uncertainties regarding health and bodily symptoms. They teach coping strategies to help patients to be less preoccupied about their health, to be better able to manage distressing emotions, to improve their functional capacity, and to increase their quality of life through engagement in meaningful, goal-directed activities. In CBT, a patient learns how misinterpretations of physical symptoms and biased thoughts and beliefs (mainly about illnesses, coping, and medical information) lead to physiological arousal and anxiety, as well as unhelpful responses such as excessive attention, vigilance and monitoring of bodily symptoms, internet searching, reassurance seeking and avoidance, which further maintain distress and body preoccupation. Through cognitive techniques such as information gathering, thought challenging and behavioural experiments, CBT aims to help patients develop alternative, less threatening explanations of their symptoms. Attention-refocusing exercises help them shift their attention from bodily symptoms to other external stimuli to reduce body preoccupation. Behavioural techniques such as graded exposure and response prevention are used to reduce excessive body checking, reassurance seeking, internet searching and avoidance, which in turn can reduce preoccupation, challenge distorted thinking patterns, and improve self-efficacy.10

CBT has been shown to improve quality of life and reduce health service use in randomised controlled trials involving patients with health anxiety,11 and presents a viable and efficacious treatment option. A large, multicentre, randomised controlled trial conducted in the United Kingdom12 showed that a brief group-based CBT program was more effective than usual care in reducing health anxiety in patients presenting to medical settings with a range of somatic symptom profiles (including neurological and gastroenterological), with benefits observed up to 2-year follow-up.

Referral to psychiatrists or psychologists is often difficult, and engagement in treatment can be challenging, because the patient may misconstrue a referral as evidence that their doctor thinks that they are malingering or that their symptoms are “all in their head”. Patients with unexplained symptoms and health anxiety fear that if they acknowledge a problem with anxiety, their doctor may view them as a hypochondriac, fail to take their problems and symptoms seriously, and miss a serious diagnosis. It is therefore important that a doctor acknowledges that the symptoms are real, even when the cause is unknown. Because patients with health anxiety are often reluctant to accept referral to psychological support services, innovative approaches are now needed to deliver CBT interventions in a context deemed acceptable to patients and their doctors.

An approach that has seen recent success is the use of the internet to deliver CBT. A Swedish study13 found strong evidence that internet CBT is an effective and cost-effective treatment for people with health anxiety, with gains maintained up to at least 1-year follow-up. An English-language internet CBT program for health anxiety is now available for general public use in Australia (https://thiswayup.org.au/how-we-can-help/courses/health-anxiety-course).

The use of internet CBT has several advantages over face-to-face treatment. It is low cost, accessible, convenient and private, can be prescribed and supervised within general and medical practice, and can be advertised to individuals who repeatedly search online to self-diagnose their symptoms. Because education and self-management tools are provided via a computer, internet CBT involves distance between the patient and practitioner, and has the potential to overcome the counter-productive reassurance seeking and disputation between patient and practitioner that can hinder progress in face-to-face consultations.

Internet CBT for patients with health anxiety represents an exciting opportunity to intervene early, and to provide education about medically unexplained symptoms and strategies to manage such symptoms. Its use may enable patients to circumvent the chronicity of health anxiety and distress associated with medically unexplained symptoms.