In an English churchyard, Irish comedian Spike Milligan’s gravestone has a chastening message for those who knew him: “I told you I was sick.”
We can all identify with Milligan’s concerns. Who doesn’t panic-research supposed symptoms, fearing the worst? His joke speaks to our fear that legitimate health concerns will be dismissed as nothing to worry about – “Oh, that’s just hypochondria.”
But there’s a difference between the occasional appointment with Dr. Google and long-term, serious health anxiety. This persistent fear of an undiagnosed illness can lead to endless doctor visits, or the opposite: total avoidance of medical care. What if we don’t take hypochondria itself seriously enough?
This is the takeaway of a recent Swedish study who found that people with what is now called illness anxiety disorder may die earlier than others. It’s a disturbing finding that makes the disorder sound like a self-fulfilling prophecy. As one anxious observer put it: “It’s not enough to just have worries – now you have to worry about your worries.”
But that doesn’t mean those with the disorder should despair. The study has an important, and ultimately hopeful, message. “This is a serious mental disorder. It’s not a quirk or something to be scoffed at,” says its lead author, David Mataix-Cols of Sweden’s Karolinska Institute. The deaths recorded in the study were largely preventable, the researchers noted. Their findings underscore the need for diagnosis and treatment—and the good news is that treatment is highly effective.
The study, which appeared in JAMA Psychiatry, examined records of about 45,000 people and compared mortality rates among those with diagnosed hypochondriasis (about 4,000 people) with those without it (about 41,000 demographically similar individuals). They found that people with the disorder were 84% more likely to die in the study period, and died an average of five years younger than those without the diagnosis, at 70 versus 75 years of age.
This may all sound counter-intuitive: surely the people who are most concerned about their health will take good care of it? But “like all anxiety disorders and chronic stress over many years, decades, we know that this is not good for your health”, says Mataix-Cols, although he stresses that the study does not examine the reasons behind the disparity.
Subjects with the disorder died at higher rates from both natural and unnatural causes, with most of the unnatural deaths resulting from suicide. This may seem particularly surprising among people who are seen as having a great fear of death. But people with illness anxiety disorder can experience a “great deal of suffering and hopelessness,” says Mataix-Cols, including the feeling that others don’t understand them. In terms of natural causes, the researchers noted that anxiety is associated with cardiovascular disease, and Mataix-Cols says some subjects with the condition also struggled with chronic stress, as well as drugs and alcohol. (He also points out that while the disparity may seem stark, the absolute risk of death among people with health anxiety remained low.)
And then there is the lack of access to treatment. The “biggest surprise” to Mataix-Cols was how few people were actually diagnosed with the disease compared to the number known to be living with it. Studies have shown around 3-5% of people have “what we call pathological health anxiety”, says Mataix-Cols. “According to those figures, we should have found 100,000 to 200,000 people [in Sweden] with this diagnosis more than 20 years. And we only found 4,000,” meaning that the disorder is “severely underdiagnosed” and therefore undertreated.
‘We need to take stress and anxiety very seriously’
Diagnosing illness anxiety disorder requires sensitivity, especially in a world in which patients’ actual physical ailments – e.g. women’s pain – can be wrongly rejected. Ideally, doctors don’t tell patients to take comfort in the idea that “it’s all in your head”. Instead, they recognize mental health challenges as part of the bigger picture.
When doctors see a patient seeking excessive care, they may decide to refer the patient to a therapist.
Dr. Jessie Borelli, a clinical psychologist and a professor at the University of California, Irvine, says she gets these referrals “regularly.” She’s heard some “horror stories” about that handover, but she’s also seen doctors approach it cautiously. “I think the best way they do that is to talk about the stress of health care or health anxiety—how much stress and difficulty it causes, and the need for additional support to manage it,” Borelli says. “People are usually receptive to that conversation.”
Fortunately, experts say there are treatments for the disorder very effective, especially cognitive behavioral therapy. For example, therapists and patients can work together to identify behaviors rooted in anxiety and work through them through gradual exposure to the situations that worry them.
If a patient wants to get an additional medical screening, Dr. Nora Brier say “we’ll talk about it together” to determine if it’s necessary or an anxiety-based decision. If it’s the latter, “then the exposure would be not making the appointment and not Googling or double-checking, and enduring that anxiety of just sitting at home thinking ‘maybe I should have that appointment went,’” says Brier, a psychologist and assistant professor of clinical psychiatry at the University of Pennsylvania. Medications, including the antidepressants known as SSRIs, may also be helpful.
Illness anxiety patients can continue to seek physical care, but this can be done in conjunction with therapy. And not everyone comes to therapy through their doctor – for example, patients may self-refer for therapy if they are too afraid of a diagnosis to see a doctor and admit they need help dealing with that anxiety.
All of this broadly touches on the core of anxiety: the struggle to live with not knowing. “Hypochondria is in some ways a challenge to medicine’s need for certainty,” says Dr. Catherine Belling, an associate professor of medical education at Northwestern University. The best doctor in the world cannot be 100% sure that there is nothing physically wrong with a patient. Not only does the patient have to tolerate it, the doctor does too.
It requires a doctor to say, “Well, I don’t know. We have to watch and wait and see, but in the meantime we can do something about your anxiety,” adds Belling. In fact, doctors themselves are familiar with these concerns: in their first years, medical students have been known to suddenly realize they have every disorder in the book.
One major threat to people with health anxiety right now: spending hours on the Internet. Among the key elements of illness anxiety disorder is seeking reassurance, says Mataix-Cols, and with Google we’re all self-diagnosing medical students. There’s even a term for it: cyberchondria.
The pandemic has also brought health issues to the fore (though it’s too soon to say for sure that it has increased the incidence of the disease itself, says Brier). A 2021 study warned of a growing risk of excessive health anxiety amid Covid, with a very real disease constantly on our minds, and a Iranian study published last year pointed to higher health anxiety among people whose family members had Covid.
Mataix-Cols hopes that his study, which has attracted international press, will get more patients into treatment by improving diagnosis and communication between doctors and psychotherapists.
Borelli, who was not involved in the Swedish study, also sees hope in it. “In the case of something like illness anxiety, where it’s pretty clear that there isn’t an underlying serious illness, it’s also the case that worrying a lot about your health can actually cause significant health anxiety, as is evident in this study is,” she says.
“We know that we have to take stress and anxiety very seriously. And the way we take it seriously is by shining a light on it.”
