Managing Health Anxiety

By Dr Hannah Davies / 12 Mar 2021

Dr Hannah Davies describes the increasingly common condition ‘health anxiety’

“I am pleased to say Mrs X, that your clinical examination is normal. There is no sign of infection, there is good blood flow to the area, and there is no sign of allergy. Your chin filler looks perfect and is healing nicely.” Mrs X had been examined on four consecutive days and given endless reassurance, not to mention prescriptions for corticosteroids, antibiotics, anti-histamines and analgesia, yet she was convinced there was a catastrophic problem with the dermal filler I had administered her.

This highlights the crux of the problem – despite how much Mrs X tries to absorb my reassurance and guidance, and how much she wants to stop worrying, she cannot. Mrs X suffers with health anxiety, and she is not alone.

This was my first experience of managing a patient with health anxiety within the realms of aesthetics, which was something I had not been fully prepared for. Upon reflection, I have acknowledged and digested the invaluable lessons it has taught me, all of which have provided the impetus for this article. Unsurprisingly, given the paucity of evidence on health anxiety in the general population, the awareness of it amongst aesthetic practitioners is lacking, and yet failure to recognise this condition may lead to psychological, physical and economical stresses for both patient and clinician.

What is health anxiety?

Health anxiety is a relatively new notion which shares overlap with both anxiety disorders (e.g. fear, hypervigilance to bodily symptoms, and avoidance) and obsessive-compulsive disorders (OCD), for example, preoccupation, rumination and repetitive behaviours.1,2 Health anxiety is largely similar to hypochondriasis; however, it differs in that somatic symptoms are not necessarily present.2,3,4 A more accurate description lies in the International Classification of Diseases (ICD)-11 categorisation, which describes it as a ‘hypervigilance to and a catastrophic misinterpretation of bodily signs and symptoms, including normal or commonplace sensations’.2,3 The ICD-11 classification also goes onto describe how the individual’s preoccupation and fear of serious illness leads to behaviours such as: information seeking, reassurance seeking and avoidance.1,3

Health anxiety is becoming increasingly common, however there is no official data on the prevalence of it in the general population.5 One Australian study comprising 8,841 participants found that it affected almost 6% of people.6 A more recent study performed at Imperial College London, comprising 28,991 participants, suggested health anxiety affected almost 20% of individuals.7

Relevance to aesthetics

The health anxious individual will return home after an aesthetic treatment and ruminate on the possible complications such as infection, hypersensitivity reactions, or vascular occlusion. They may misinterpret normal clinical signs and symptoms, for example bruising and swelling, as indicators of serious disease or plug their harmless symptoms into a search engine which leads them to a disproportionately high number of highly unlikely explanations, including life-threatening disease. In turn, this will lead to a heightened state of anxiety and they will start to fear grave complications resulting from their treatment. It is abundantly clear that they will experience great emotional distress from their symptoms.

In my experience, the result is an unremitting cycle of telephone/video/face-to-face consults, reassurance seeking, investigations and potentially unnecessary treatments, all of which fuel the anxiety further. Both health anxiety and cyberchondria culminate in excessive reassurance-seeking behaviour, which is comparable to obsessive-compulsive checking behaviour seen in OCD.8 This behaviour can be persistent, extensive and debilitating for both the patient and practitioner, particularly given that the reassurance is usually poorly absorbed or only short-lived.

In my experience, failure to recognise health anxiety can lead to a heavy investment in your time and money, over-treatment, and undue worry. Moreover, given the lack of evidence, the treatment outcomes in those with health anxiety are not defined. However, it can be expected that these patients are likely to be dissatisfied with their treatment because their aesthetic results are overshadowed by anxiety. This is comparable to studies which have shown unsatisfactory outcomes following aesthetic surgery in those suffering with severe psychological disorders such as major depression.9 As clinicians we must remember, ‘first, do no harm’. Therefore, it may be in their best interests not to undergo aesthetic treatments.

How to spot health anxiety 

Whilst aesthetic practitioners are increasingly astute to spotting more common psychological disorders, such as the aforementioned BDD, they may be less experienced in recognising health anxiety. It can be adequately screened for during the consultation process using a validated questionnaire. Three of the most widely used and validated assessment platforms for health anxiety are:

  • The Health Anxiety Inventory (HAI)
  • Illness Attitudes Scale (IAS)
  • Whiteley Index (WI) 10

All three screen screening tests have high negative predictive values (NPV), meaning you can have confidence the patient does not have health anxiety if they get a negative test result. They are all highly specific and sensitive tests.10

Whilst many argue that the HAI and IAS are superior to the WI based on their excellent psychometric properties, the WI is much shorter and therefore, more practical for use as a screening tool in an aesthetic clinic setting.

The WI is composed of 14 questions and, in my experience, takes approximately 15 minutes to complete. The WI assessment includes questions such as: ‘Do you often worry about the possibility that you have got a serious illness?’ and ‘If a disease is brought to your attention (through the radio, television, newspapers or someone you know) do you worry about getting it yourself?’11

In comparison, the HAI and IAS are composed of 64 and 29 items, respectively, and are not practical for use in aesthetics. It is essential that every aesthetic consultation involves, in some format, screening for underlying mental health diagnoses. I strongly advocate the consultation process integrates, to some degree, a screen for underlying health anxiety.

Cyberchondria, which has a positive correlation with health anxiety, can be detected using the validated Cyberchondria Severity Scale (CSS), or more simply screened for by asking patients to state how many hours they spend per day searching the internet for medical information.12,13

Management

Effective management lies within the consultation and the ability to identify at-risk individuals. The relationship between health anxiety and aesthetic treatment outcomes has not been researched. As such, patients with this condition should be managed on a case-by-case basis. Following identification of existing, or susceptibility to, health anxiety it is imperative you explore this with your patient.

From my experience as a GP registrar and an aesthetic practitioner, it is important to emphasise that proceeding with any treatments may cause them unnecessary worry, which may outweigh the benefits of having the procedure done. This can result in under-appreciation of the results and dissatisfaction. If you recognise that your patient has health anxiety, implore them to seek help from their GP. Randomised control trials have shown cognitive behavioural therapy (CBT) to be an effective treatment for health anxiety.1,15

Consider offering your patients less-invasive alternatives to treat their aesthetic concerns such as medical-grade skin products, chemical peels, or microneedling. Allow your patient time to go away and digest the information discussed. I would suggest a period of one to two weeks. If you deem your patient’s mental state stable and their anxiety not so severe to interfere with treatment or aftercare, then you may decide to proceed with treatment. In my experience, anxiety can be minimised post-procedure by adhering to a few simple rules.

Firstly, educate your patient. In the initial consultation, explain the normal healing process, aftercare advice, and describe what is to be expected over the proceeding hours, days and weeks. Describe the signs and symptoms that would warrant urgent clinic review such as pain, pallor, or paraesthesia.16 It is useful to provide written information detailing the aforementioned as a source of accurate information for the patient to refer to once home. Given that up to 80% of verbal medical information provided by practitioners is immediately forgotten, written information is extremely important and helpful.17

Secondly, I would recommend limiting the number of procedures performed per sitting to one treatment area, especially for the aesthetic-naive patient. In my clinic this has been an effective way of minimising post-treatment anxiety. Furthermore, minimising the volume of dermal filler injected in one sitting can also reduce anxiety by reducing the occurrence and severity of local side effects such as erythema, bruising and oedema, all of which are signs that could be misconceived by the health anxious as indicators of severe illness and disease. It has been suggested that limiting injections of dermal filler to 0.1ml per injection site is safest practice.18 Imperatively, your patient must have access to help and support from your clinic should they become concerned after treatment.

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