Abstract:
Health Anxiety is a common affliction of patients seeking medical attention, yet many physicians are unaware of it.  We surveyed 222 consecutive patients in a dermatology practice in Massachusetts and found that upwards of 49% self-reported some level of health anxiety, suggersting that it appears to be pandemic in the dermatology population of patients.

Keywords: health anxiety, dermatology, Massachusetts, actinic keratoses, cryotherapy, survey,, Tyrer

Introduction
Patients see doctors with varying degrees of concern regarding their health. Some, require tests or treatments. A subset of patients have severe health anxiety (HA) and cannot be reassured by tests, procedures or pharmaceuticals but may be helped (at least temporarily) by a sympathetic listening face and reassurance.

Tyrer et al succinctly and lucidly introduced the topic of HA in a recent British Medical Journal.¹ It’s curious how this important area has remained below the radar. As patients move in and out of my exam room, I rarely considered what role HA played in their concerns.

This led to me to survey patients for a few weeks regarding their self-perceived HA.

Methods:
For a three-week period in May of 2016, all patients were given a Health Anxiety questionnaire. Information on age, sex, and whether they were new or returning patients was collected. I had contacted Dr. Peter Tyrer regarding what screening questions to ask and he kindly suggested three:

1. Are you worried a lot about a particular health problem? Y N
2. Do you tend to worry about your health in general? Y N
3. Have you ever felt that the problem is more serious than your doctors have found it to be? Y N

Results:
Two hundred and twenty-two consecutive forms were collected. Of these five were not usable. It became clear as the study progressed, that it was not well-suited for pediatric patients and we, therefore, excluded patients less than 15 years old. In addition, patients over 84 years old were excluded since a percentage of these individuals had some cognitive impairment. This left 184 usable forms.

The demographic data is presented in Table 1.

Eighty-eight patients had at least one positive response. (Table 2). This was 49% of the 184 usable questionnaires. Nine percent of patients, 16 individuals, gave positive responses to all three questions. Thirty-four (18%) of patients affirmed two of the three questions, and 38 individuals (21%) had one positive response.

A number of patients left comments on their forms. Appendix: or HA Questionnaire Comments

List of a patient with severe health anxiety

Discussion:
Forty-nine percent of my patients expressed some health anxiety. Being seen in a doctor’s office probably selects for anxious people, however some patients with severe HA are believed to stay away from physicians for a variety of reasons. I came to appreciate that some degree of HA can actually be good for one’s health. This assures that a person makes an appointment to be seen.

However, there is a subset of patients who have disabling and pathological HA. Some of this has been amplified by the prevalent direct to consumer advertising (DTCA) in the U.S., as well magazine advertisements and public service announcements in periodicals and newspapers. Today, many people spend excessive amounts of time checking disorders on the Internet and are said to suffer from cyberchondria. The World Wide Web has contributed to the rise of HA by putting all kinds of information at one’s fingertips. One need only think of Morgellon’s disease.² A number of patients in my study commented to me that the WWW was a source of their health anxiety.

My data does not demonstrate how many patients suffer because of their self-acknowledged HA; but it is clear that some do. Their HA often leads their physicians to order unnecessary tests and to prescribe sometimes expensive and/or potentially harmful treatments. Unnecessary testing can lead to the over-diagnosis and over-treatment of conditions that could be safely left alone, especially in elderly individuals.

I speculate that aggressively marketed/promoted screening leads to over-diagnosis of disorders that do not need to be treated. In dermatology, free skin screenings lead to unnecessary cryotherapy for actinic keratosis and the treatment of indolent nonmelanoma skin cancer in the very old.³ We looked at the performance of cryotherapy of actinic keratosis in a defined geographic area by six private-practice dermatologists and found that one doctor reported freezing 20,000 actinic keratosis over a year’s period and collected $228,000 from Medicare while another treated 214 keratoses and was paid $8694 during the same period..⁴ All six dermatologists served the same community. Many dermatologists tell their patients that actinic keratosis are “pre-cancers” when in reality the number that become squamous cell carcinomas are only about one in 200 or less.⁵ Treating these lesions, while lucrative for dermatologists, is a potent way to nurture HA in susceptible individuals. Benign neglect or active surveillance is not profitable, but is honest.

It’s curious how little attention HA has received in our dermatology literature. The editorial by Tyrer et. al is a useful and accessible introduction to HA and afforded me a stimulating continuous medical inspiration (CMI) opportunity; if no CME Category I credit.

It would be important to survey populations in other countries to see if the burden of HA differs significantly, especially when the public is not bombarded by self-serving advertisements and announcements from physicians, PhRMA and organizations. These investigations would be easy and cheap to perform.

References:
1. Tyrer P, Eilenberg T, Fink P3, Hedman E, Tyrer H. Health anxiety: the silent, disabling epidemic. BMJ. 2016 Apr 25;353:i2250.  Full Free Text Online.

2. Simpson L1, Baier M. Disorder or delusion? Living with Morgellons disease. Psychosoc Nurs Ment Health Serv. 2009 Aug;47(8):36-41. Abstract

3. Linos E, Parvataneni R, Stuart SE, Boscardin WJ, Landefeld CS, Chren MM. Treatment of nonfatal conditions at the end of life: nonmelanoma skin cancer. JAMA Intern Med. 2013 Jun 10;173(11):1006-12. Full Free Text Online

4. Elpern DJ, Ferrara ML: It’s Freezing in our County: Medicare Reimbursement in 2012. Online J of Community and Patient-centered Dermatol. Full Free Text.

5. Marks R, Foley P, Goodman G, Hage BH, Selwood TS. Spontaneous remission of solar keratoses: the case for conservative management. Br J Dermatol. 1986 Dec;115(6):649-55. Abstract