Tackling the ‘worried well’ in general practice

With the rise of ‘Dr Google’, and a stream of medical horror stories at our fingertips, health anxiety is at an all time high. What can practices do to combat the real terror these patients feel whilst also relieving the huge strain health anxiety can have on surgery staff? 

We are desperately out of touch with our own states as organic beings; Matt Haig, in his remarkable book The Humans, points out that this is laced into our language.

When we are ill, he says, we reveal ourselves to be fleshy things destined to decay. We are told to ‘recover’, as if sick bodies unravel the civility we have erected around our authentic selves. To ‘re-cover’ is to re-cloak yourself in that civility; to tuck away mortality and pretend it never happened – or never will happen.

We are expected to live cleanly and politely, as if we will never die.

The result is that death and dying isn’t normalised – we are taught that it is terrible, terrifying, unjust, painful, unnatural, even. Yet, despite this everyday denial of mutability, we are constantly bombarded with devastation as it seeps onto our television screens and social media feeds.

From diet pills and facetune apps, to rare cancer cases and an ever-increasing stream of doomsday news at our fingertips, all day long – how are we supposed to protect ourselves from entering a black hole of warped medical reality, a place where cancer disproportionately thrives, where heart disease picks us off at random, and where our cells are not the facilitators of life but ticking time-bombs ready to detonate at any moment?

What happens to people when a society that shuns death constantly broadcasts it, en masse, in its most alarming forms?

The answer: an epidemic of what doctor’s dub ‘the worried well’.

‘The worried well’ – who are they?

Frankly, it’s a miracle any of us are sane – and, actually, many of us aren’t; we are in a mental health crisis, with health anxiety or ‘cyberchondria’ snaking its way through modern society.

Health anxiety, previously known as ‘hypochondria’, is the obsessive fear that you are suffering from an undiagnosed and serious disease. People with the condition might spend several hours every day checking their bodies for symptoms or signs of illness, and may repetitively seek the reassurance of loved ones.

Many take to Google, plug in their symptoms, and are greeted with thousands of worst-case-scenario results. This is how Google’s algorithms work: the scary and rare will always appear at the top of the search engine, leaving those with ‘headaches’ reeling at the possibility of ‘brain tumour’ – hence the rise of the term ‘cyberchondria’.

The health anxious will book many appointments with their GPs to discuss their symptoms. They may come armed with online information to support their terminal self-diagnosis. At the opposite end of the spectrum, health anxiety may cause a patient to avoid health professionals altogether: a strategy which, inevitably, is not good for their health in the long run.

GPs, and other health professionals, will try to allay their fears, suggesting that patient history combined with the presentation of their symptoms point to more benign causes. But reassurance from medical professionals won’t last long, and these patients will often return demanding further tests. The doctors offer more reassurance, which will pale in comparison to the huge anxiety washing over the patients. The cycle repeats. GPs begin to dread ‘the worried well’ plaguing their practices.

Why are the worried well problematic for GPs and practice staff?

It is estimated that 4-5% of patients will be suffering with health anxiety. The worried well demand lots of consultations and they may fill a significant proportion of emergency appointments. This creates more paperwork and takes up the time needed to see people with diagnosable physical health problems.

It’s easy to imagine the potential issues raised by someone with an imagined cancer taking the appointment of someone else with actual cancer it makes it harder for people with real diseases or disabilities to access their GPs.

Doctors may also feel offended by the worried well, who no longer trust their opinions despite many years of intensive training at medical school. No-one would dream of telling a lawyer how to do their job, but many, many of people feel entitled to self-diagnose without consultation with a doctor first.

But the worried well can’t help the way they feel. They aren’t deliberately disrespecting their doctors, and they don’t intend to ‘steal’ appointments away from those in need. The suffering they are experiencing is very real, and health anxiety can result in significant emotional turmoil. A person’s quality of life may diminish rapidly under the cosh of hypochondria. Performance at work and personal relationships may deteriorate as a result.

In order to relieve the burden of the worried well on both doctors and patients, those struggling with health anxiety need compassion and the right care from their GPs.

What can be done? The expert’s take

Psychotherapist John Davies, an expert in this field, can shed light on health anxiety and what can be done to tackle it.  We asked him to define the condition, outline the problems it poses to primary care and then offer some potential solutions:

Who in life has not been health anxious at some point; laid awake at night worrying about some pain, ache or blemish? However, this doesn’t, though, turn such musings into a Proustian obsession with diet, health, illness and waiting to die.

Health anxiety has different presentations. It is the misinterpretation of a symptom which is physical and real in origin, but the subsequent fear and catastrophic thoughts it evokes lead to excessive checking, reassurance-seeking and, in some cases, a complete avoidance of seeking medical assistance due to the irrational fear that there is something more behind this symptom.

Health anxieties can also arise from symptoms brought on by stress – e.g. facial pain and clenching. Commonly, patients have fears that they will be destroying their teeth, or causing damage to their temporomandibular joint, which can never be reconciled or treated. There are those patients who do have a physical complaint but there is an excessive worry, and sensitivity, which is out of proportion to the physical problem.

In more extreme cases people succumb to excessive checking behaviours. This may result in unnecessary medical interventions which, subsequently, cause other medical problems. Although these problems can be viewed as iatrogenic in origin, they have been driven by the patient’s anxiety and fear.

However, my experience of treating people with health anxieties, on the whole, has been generally positive.

The initial difficulty is primarily focused around engagement in helping the patient to understand that the symptoms they are experiencing are not wholly attributable to a physical cause, and that their origins are psychological, or mediated, by them. Therefore, the first stages of therapy are important to show the patient that there is an alternative explanation for their experiences and what is driving the present problem.

From my experience it is also important to acknowledge that the excessive reassurance-seeking, and other health anxiety behaviours, may have elicited negative responses from health professionals. It does not mean that they’re not believed, or that they may not have a real physical problem.

The impact these patients can have on GPs may be severe. The GP can be faced with a patient who has excessive anxiety and a need for reassurance; this, in turn, can cause a GP excessive anxiety. What if the symptoms are real? There is a looming threat that comes from potential patient litigation. This may not be intentional on the part of the patient, but driven by their excessive fear.

When trying to treat such patients it is helpful for GPs to aid patients in understanding how psychological processes can affect the way that they think, and impact their interpretation of physical symptoms.

Thinking with the patient, and reflecting on alternative causes for the physical symptoms and what might be an alternative explanation, is helpful. Acknowledging with the patient that their experience is undeniable and true, but that what they think and feel are also being reflected physically.

GPs should help normalise, and explain, the commonplace experience of fear and its physical presentation; the most obvious of these is that, when feeling anxious, the accompanying sickness in the pit of the stomach is real and not ‘in the head’ – but this feeling, however physical, is driven by psychological processes. The GP should value the patient’s experiences; what they describe to you is not fictitious and is very real to them.

So what can a patient do to help themselves? Self-help can come from, and be aided by, a variety of sources.

  • The book Overcoming Health Anxiety by Rob Wilson and David Veale is a helpful resource.
  • There are other online resources such as Anxiety UK (anxietyuk.org). They offer information relating to health anxiety, and anxieties in general, and also access to support groups and other helpful information.
  • Another helpful online resource is Living Life to the Full (lltf.com). They offer a variety of free, online courses which cover several topics and areas related to anxiety and common problems.
  • The NHS has its own website page explaining health anxiety.
  • There is also the NHS-run ‘improving access to psychological therapies’ programme which, dependent on the area in England, will have links to online resources, and will facilitate self-referral to groups and therapy.

Health and hope

Practice Business hopes that by illuminating the epidemic of the worried well, and by showing compassion towards these patients rather than hostility, we can all work towards a future of health and hope, as opposed to fear and frailty.

Let’s all work together to de-stigmatise health conditions and normalise both sickness and disability, so that we can all breathe a little easier. Change begins at practice level, and we challenge you to make easing the burden of health anxiety on both patients and staff a top priority in your surgery.

So, whilst living fast and furiously in our ever-changing modern world, we can all be less worried and more well.

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