Q: I think my wife is a hypochondriac. I get the sense that our GP is sick of seeing her as she is there almost every month with a new set of symptoms. There are always tests and they are always clear. It is costing us a fortune. She does suffer from headaches and pains but I think that she is making herself sick with all her worries. I am losing patience with her and I was wondering if you had any advice as to how I could help her manage her anxiety around her health and get her to see a psychologist. The GP suggested this, but it just made my wife angry. Do you have any advice?
Dr Grant replies: It’s fair to say that a little bit of anxiety is often no harm, as it can drive us to perform better, achieve things that we never thought we would and in terms of our health, to get symptoms checked. However, it’s all about getting the correct balance.
Illness anxiety disorder (IAD) is a spectrum of disease — previously known as hypochondriasis — ranging from mild, moderate to severe.
Even mild illness anxiety can be difficult to manage but with the right support and a better focus around your wife and her health complaints, she should be able to move on with her life. Clearly, her persistent health fears are interfering with your relationship.
You mentioned the word ‘hypochondriac’ and I presume you were being flippant as I doubt your wife would hit the diagnostic criteria (A to F below) for an illness anxiety disorder.
The core clinical feature of IAD is persistent preoccupation with having a serious medical illness despite appropriate medical evaluation and reassurance from doctors. The DSM-5 Diagnostic and Statistical Manual of Mental Disorders by the American Psychiatric Association states it as:
A) Preoccupation with fears of having, or the idea that one has, a serious disease based on the person’s misinterpretation of bodily symptoms;
B) The preoccupation persists despite appropriate medical evaluation and reassurance;
C) The belief in criterion A is not of delusional intensity (as in delusional disorder, somatic type) and is not restricted to a circumscribed concern about appearance (as in body dysmorphic disorder);
D) The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning;
E) The duration of the disturbance is at least six months;
F) The preoccupation is not better accounted for by generalised anxiety disorder, obsessive-compulsive disorder, panic disorder, a major depressive episode, separation anxiety, or another somatoform disorder.
The quality of the doctor-patient rapport has been studied in patients with IAD. Obviously, the stronger the relationship, the better the outcomes for the patient.
Within this relationship exists another delicate balance, as the doctor cannot be overly reassuring because the patient may feel his/her physical complaints were not taken seriously.
Sometimes it is best for both parties involved to ask for a change of doctor. The same applies for the psychotherapist. A new fresh look at the patient by another trained professional may result in a better outcome. Many patients will resist or decline the offer to refer on to mental health services.
But if it is presented in the correct manner, as a means to help to improve coping with health fears rather than eliminate them, the patient is more likely to engage.
Furthermore, the patient has to feel they will not be discarded or abandoned by the medical doctor, who will still be available to listen to their concerns and arrange appropriate evaluation when necessary. One technique used by some doctors is scheduling regular appointment intervals with the patient. This can help alleviate their fears and it can also establish a collaborative therapeutic alliance.
Psychotherapy is first line in the treatment of IAD with cognitive behavioural therapy (CBT) conferring the most efficacy and other adjunctive therapies such as behavioural stress management and psychoeducation often coming into the fold.
Occasionally, antidepressant medication can help, particularly when there is an element of co-existing generalised anxiety disorder or depression, and when access to CBT is delayed or difficult to access.
Dr Jennifer Grant is a GP with Beacon HealthCheck