Back in November, I wrote a blog post about the poor health outcomes for those patients who frequently miss appointments. I was therefore interested to see a recent Swedish study that looked at health outcomes for those patients who are often at the opposite end of the appointment attendance spectrum. “All-Cause and Cause-Specific Mortality Among Individuals with Hypochondriasis”, published in JAMA Psychiatry, made for sobering reading. Now I don’t know about you, but I feel a bit uncomfortable with the diagnosis of hypochondriasis. To be fair to the authors of the paper, ICD-10 included the diagnosis at the time of the study, and it continues in the 11th version released last year. However, DSM-5 has replaced the term with two diagnoses – somatic symptom disorder and illness anxiety disorder. Both of these diagnoses share high levels of health anxiety – and this feels like more familiar territory to me. Whatever terms we use, we know these conditions are associated with increased use of health services, including GP appointments.
What does the paper say about outcomes for patients with these diagnoses? Well, it’s not good – the study suggests that affected individuals have an increased risk of death from both natural and unnatural causes, particularly suicide. The all-cause mortality risk was 84% higher, with a reduction in life expectancy of 5 years. The most common causes of death were circulatory system and respiratory diseases, although the risk of neoplasms was comparable in both groups. There was a more than 4-fold higher risk of death by suicide compared to the general population. The risk was particularly high if there was a lifetime history of depression and anxiety. The authors concluded that this excess mortality is due to preventable conditions, which is perhaps where we come in.
The study says that “more should be done to reduce stigma and improve detection, diagnosis, and appropriate integrated care for these individuals.” Ironically, you could argue that avoiding the term hypochondriasis might help reduce some of that stigma, but they make a good point. We should be wary of dismissing such patients’ symptoms as somatisation. In the current Hot Topics course, we talk about the importance of retaining curiosity in our clinical work. Faced with patients who are often considered difficult, the pressures of workload and stretched appointment systems can all too often snuff that out. Perhaps it is these patients who most need us to listen to our spider sense and go digging. That increased risk of circulatory and respiratory disease should be in our minds when interpreting symptoms and considering diagnoses.
Is there anything we can do about the health anxiety itself? A Cochrane review showed that CBT, including that offered online, can be helpful, and it is worth discussing this with patients. Systemic reviews have shown that SSRIs can also be effective. An empathic response to patients’ negative emotions can reduce patient anxiety and improve communication and these top tips for enhancing empathy in the consultation are worth a read. Most of all, we should take these patients seriously and do our best to reduce the health inequalities they face.
Health Anxiety is miserable for patients and challenging for us. To help us to manage it better for our patients, it will be one of the topics in our brand-new mental health course on Saturday February 10th and subsequently available on demand.