Health Anxiety
Health is an important source of security in life, affecting our ability to care for ourselves, our family and home, and to work. It is therefore understandable that many people experience anxiety about their health.
Health anxiety, also known as hypochondriasis, is a psychological condition that is characterised by specific worries and convictions about having or developing a serious illness and often reinforced by excessive focus of attention and reassurance seeking. The individual experiences bodily sensations, or changes, and holds the belief that they have a serious physical illness or condition (1). This belief can result in high levels of preoccupation and worry, impaired psychosocial functioning, and excessive use of healthcare services (1). An important concept in health anxiety is the unhelpful role of reassurance seeking whereby reassurance only gives temporary relief from distress and is therefore repeatedly sought, reinforcing the cycle of anxiety. This behaviour can put stress on family relationships and increase the burden on health care services. Health anxiety tends to be chronic if untreated and can often go undetected for years (2,3).
Classification of health anxiety has evolved over the past decade. The International Classification of Diseases 11th Edition (ICD-11) uses the term hypochondriasis to define health anxiety and is characterised by persistent preoccupation or fear about the possibility of having one or more serious, progressive, or life-threatening illnesses (4). It is classified as part of the obsessive-compulsive and related disorders spectrum, which may be a helpful model in terms of treatment.
The Diagnostic and Statistical Manual, 5thEdition (DSM-5) has split classification into two conditions: “Somatic Symptom Disorder” and “Illness Anxiety Disorder” (5). The distinction is based on the presence or relative absence of co-occurring physical symptoms, and these terms are still used by some physicians.
Health anxiety rates have increased over time and studies around the COVID-19 pandemic indicated rates of 12–46% of people, depending on the population studied and the method used for detection (6,7). Increased ease of access to information and advice online is thought to be a potential factor in this upward trend.
Health anxiety can have a considerable negative impact upon an individual's quality of life due to the escalating avoidance, reassurance seeking and withdrawal impacting employment, relationships and psychosocial functioning (8). In a large Australian epidemiological survey, health anxiety was associated with the frequent use of health-care services, a high disability burden, and increased health-care costs (9).
Health anxiety is often associated with other presentations with depression, the most frequent coexisting disorder, estimated to be 32.6% (10). Anxiety disorders as a group are common alongside health anxiety and include Generalised Anxiety Disorder, Panic Disorder, specific phobia, social phobia and Agoraphobia. A range of physical conditions are often seen co-morbidly in neurological settings (11)
Kellner (12) found significantly higher death anxiety amongst those with health anxiety than controls, and evidence suggests that fear of death correlates with symptom severity in health anxiety (13,14). Death anxiety is categorized as a specific phobia, and the treatment of death anxiety may increase treatment efficacy within health anxiety (15).
People with health anxiety present more frequently to physical health services than to mental health services, (11). . In addition to the personal distress health anxiety causes, people with health anxiety face a range of issues around interactions with clinicians e.g., not feeling listened to, mistrusting doctors and medical services, and not being appropriately referred to mental health services (16).
There is consistent evidence across chronic diseases (cancer, cardiac disease, Parkinson’s disease, diabetes) that health anxiety affects around 20% of people, however, there is less agreement about the distinction between the understandable commonly experienced worries about illness that a person may have and symptoms of health anxiety (18). An assessment of health anxiety should consider the degree of distress experienced, the functional impact of the symptoms and how realistic any fears and worries (e.g. fear of recurrence, symptom monitoring) are in the context of the particular diagnosis and prognosis. Although it is unclear what the prevalence of underlying illness in patients diagnosed with health anxiety is, it should be considered that bodily symptoms reported by patients may stem from organic causes and appropriate/accurate assessments made (19). Whilst there can be a risk of iatrogenic effects of exhaustive physical investigations, moving too quickly to a psychological explanation, in the absence of physical health investigations, can disrupt engagement with psychological treatment. A balanced, collaborative approach to assessment and formulation is beneficial.
There is limited data regarding prevalence of health anxiety as it has only been relatively recently classified as a distinct disorder. An Australian national survey found a lifetime prevalence of 5.7%, with 3.4% of participants meeting criteria for health anxiety at the time of interview (8). These findings were consistent with a previous study that found a prevalence rate of 7.7% but were much higher than another population-based study in Germany where prevalence was found to be 0.58% (20,21). Unsurprisingly, rates of health anxiety are higher in those attending medical facilities, with rates of around 10% of all attenders in primary care and up to 20% in medical outpatients (22,23).
Health-related worries and behaviours are common in children and young people (24-27). In one study, 15.7% of a sample of 14- to 19-year-olds reported ‘clinically significant hypochondriacal symptoms’ and in another study, the parents of 2.7% of 5- to 7-year-olds reported ‘considerable’ health anxiety symptoms in their children (24,26). Thus, even though the prevalence of health anxiety as a formally recognised disorder may not have been established, health-related worries appear to be relatively common.
Boston & Merrick found elevated health anxiety in 7.6% of a community sample of older people, which is similar to prevalence rates found among younger adults (28). This suggests that aging does not inevitably result in increased health anxiety (28,29). However, when older individuals experience increased pain, frailty, depression, trait anxiety, and emotional preoccupation, they are at increased risk of developing health anxiety (29).
It is difficult to find prevalence figures for health anxiety in people with a learning disability; however, studies indicate a generally higher rate of anxiety in this population (30).
The specific prevalence of health anxiety among minority groups in the United Kingdom is less detailed than for anxiety disorders in general (31). An international systematic review and meta-analysis identified a higher risk of health anxiety in migrants and ethnic minorities compared to the general population, though findings varied across studies (32). More needs to be understood about the nature of health anxiety across different ethnic groups and its interaction with social inequalities.
This information is for commissioners, managers, trainers, and health care practitioners to consider the evidence base for the delivery of psychological interventions for people experiencing health anxiety. This information is also for people diagnosed with health anxiety, their families, and carers.
This topic introduction page covers evidence-based psychological interventions used to treat health anxiety in children, young people, and adults, and the psychological practices and settings in which these interventions can be delivered.
Exclusions for topic: This topic does not cover pharmacological interventions or interventions which are not informed by psychological theory. There are currently no clinical guidelines (e.g. SIGN or NICE) on the management or treatment of health anxiety, despite the inclusion of health anxiety in both the ICD-11 and DSM-V classification systems.
Established treatments have been well researched in health anxiety (33). Both cognitive behavioural therapy (CBT) and serotonin reuptake inhibitors (SSRIs) have been shown to be moderately effective in the treatment of health anxiety (34). However, there are few studies from which to draw conclusions about the longer-term effectiveness of either CBT or SSRIs for treating health anxiety (35).
Further research is needed to evaluate which components of treatment lead to the most effective outcomes, and how interventions can be tailored to individual needs. This should consider the extensive comorbidity in anxiety disorders, as many people continue to show symptoms even after reportedly effective treatment (36).
Overview of Evidence for CYP
Health anxiety typically presents in early or middle adulthood (5,25). There is some evidence to suggest that health anxiety does occur in childhood and adolescence, yet studies examining the prevalence of health anxiety in children and young people suggest that few meet the full diagnostic criteria (24-27,37-39). This may be partly due to a lack of tailored, developmentally appropriate descriptions of how health anxiety presents in children and young people (25,40).
CBT is recommended for adults with health anxiety, and it’s suitability and necessary adaptations for children and young people are explored more fully in the Matrix Generalised Anxiety Disorder evidence review. This review should be read in conjunction with the Delivering Effective Psychological Therapies and Interventions to Children and Young People.
Overview of Evidence for Adults
The intervention with the strongest evidence base for treating health anxiety is CBT, which has consistent supporting evidence from trials involving people with health anxiety, with and without medical illnesses, in different settings and with evidence of longer-term benefits (34,41,42). CBT has been shown to be effective when compared with a variety of control conditions, including treatment as usual, waiting list, medication, and other psychological therapies such as exposure response prevention, problem solving approaches, short-term psychodynamic psychotherapy, and behavioural approaches (41). Effect sizes vary, with larger effect sizes for passive control conditions (34,43).
A systematic review by Axelsson & Hedman-Lagerlöf found that in relation to control conditions, CBT leads to large reductions of health anxiety (with moderate to large effect sizes) and small to moderate effects on depression, general anxiety, and physical symptoms (44).
Tyrer conducted a long term follow up of the effectiveness of CBT for health anxiety (CBT-HA) and found that eight years post-treatment, there was a significant difference in the adjusted health anxiety scores in favour of CBT-HA over standard care, with no loss of efficacy between two and eight years (45).
CBT models of health anxiety draw on CBT models of both Panic Disorder and Obsessive-Compulsive Disorder (OCD), providing a structured approach to understanding and treating the condition (15,46,47).
Alternative delivery of CBT
Morriss, Patel, Malins et. al compared the effects of remotely delivered CBT, using videoconferencing or telephone, compared to treatment as usual for health anxiety (35). The results suggested that remote CBT is effective in reducing severe health anxiety at 6 months and this is maintained at 12 month follow up. In addition, the effect of the intervention reduced comorbid generalised anxiety and depression. The researchers also concluded that remote CBT was a cost-saving method of treatment.
In a non-inferiority trial, Axelsson indicated that internet-delivered CBT appeared to be noninferior to face-to-face CBT for health anxiety and was also more cost-effective (48).
An early study of psychological treatments for health anxiety suggested stress management to be as effective as CBT, however a subsequent randomised control trial (RCT) comparing CBT and behavioural stress management, both delivered via the internet, found that CBT was more effective (49,50).
Eilenberg, in an RCT of group Acceptance and Commitment Therapy (group-ACT) found significant effects of group-ACT in comparison to waiting list control at 10 months, with large effect sizes (51). However, adherence to treatment protocol or investigation of additional interventions during treatment were not undertaken. An RCT of iACT, (a clinician-guided, self-help program consisting of seven online modules opened consecutively over 12 weeks of treatment) versus active control was an effective and acceptable intervention that improved health anxiety and overall mental health post treatment and at 6-month post treatment follow-up (51,52).
McManus conducted an RCT of mindfulness-based group cognitive therapy compared with usual services (53). Mindfulness-based CBT participants had significantly lower health anxiety than usual services participants, both immediately following the intervention and at 1-year follow-up, with small to medium effects sizes.
Acceptance and Commitment Therapy (group and iACT) and Mindfulness-based Cognitive Therapy (group) are recommended as alternative interventions due to the smaller number of clinical trials reported to date.
Overview of Evidence for Older Adults
Within older adults, evidence of efficacy for CBT in health anxiety is limited (54,55). Recommendations for adults should generally apply; however, clinicians are advised that there are differences in presentation of psychological problems in later life. For guidance on age-specific factors, clinicians are advised to consult Delivering Effective Psychological Therapies and Interventions to Older People for further information on factors relevant to practice.
Overview of Evidence for Learning Disabilities
Autism Spectrum Disorder and other neurodevelopmental conditions are associated with higher rates of anxiety, and limited research suggests that health anxiety may also occur comorbidly in this population (56).
Overview of Evidence for Harms and Adverse Effects
Like all treatments, psychological therapies also have the potential to have adverse effects. Until recently, information on potential harms and rates of adverse effects had not been gathered systematically (see information relating to safety in the delivery of psychological therapies). Although reports of adverse effects are increasingly included in research trials and gathered as part of service provision, we do not know if psychological interventions for health anxiety cause more, fewer or similar numbers of adverse effects than no treatment or another treatment, because the current evidence in this area is of very low quality at present.
| Recommendation | Who for? | List of Interventions | Type of psychological practice | Evidence | Efficacy |
| First line recommendation | CYP presenting with health anxiety (all levels of severity) |
Cognitive Behaviour Therapy
See adult evidence, Matrix GAD, Delivering Effective Psychological Therapies and Interventions CYP
|
| Recommendation | Who for? | List of Interventions | Type of psychological practice | Evidence | Efficacy |
| First line recommendation | Adults presenting with health anxiety (all levels of severity) |
Cognitive Behaviour Therapy (33,34,41-44)
Remote delivery (35)
|
Specialist |
A
A
|
Medium-large
N/a
|
| First line recommendation | Adults presenting with health anxiety (all levels of severity) |
Cognitive Behaviour Therapy (33,34,41-44)
Remote delivery (35)
|
A
A
|
Medium-large |
Advisory Group Sheraz Ahmed, Christine Ellwood, Paula Gardiner, David Gillanders, Kirsty Lingo
Technical Group Marie Claire Shankland, Paula Gardiner, with thanks to Kirsten Loy
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