They're worried sick

Hypochondriacs used to be seen as a nuisance. Now doctors recognise health anxiety as a real illness - that can be treated. Hugh Wilson reports

Ryan Smith thinks he has worried about his health for a long time, perhaps since childhood. But in 2002, health anxiety took over his life. "My anxiety went through the roof. I found out someone I'd known had died of Aids. I developed an immense fear of contracting HIV, to the extent that I would avoid all situations where there might be the slightest risk. I would avoid a whole circle of friends. I had no sex life whatsoever. I wouldn't even kiss anyone."

Smith's GP referred him to a psychiatrist, who advised him to wear an elastic band round his wrist, and twang it whenever he felt his fears were getting out of hand. "I didn't even try it," he says. "I knew it would achieve nothing, apart from a nasty sore." Instead, he found one of the few private therapists to specialise in treating severe health anxiety - better known as hypochondria - with cognitive behavioural therapy (CBT).

"The treatment was highly effective," he says. "I have a sex life again. I don't avoid anyone. I'm not fully cured and I'm not sure I ever will be, but I've learned to live with my condition. I have some control back."

Ryan's experience hints at something that the majority of health anxiety sufferers - and many GPs - still don't know: that an effective treatment exists. In 2004, a large-scale trial by doctors at the Brigham and Women's Hospital in Boston - the first of its kind in the US to look at potential hypochondria treaments - found that psychological intervention, and specifically CBT, significantly improved symptoms. Another recent study in Australia showed that attention-training techniques could be used whenever a fear of illness threatened to dominate a patient's thoughts.

"Hypochondria is a common, chronic and debilitating condition, but no intervention has proven to be clinically effective in treating it, largely due to our lack of understanding and research," says Arthur Barsky, the director of psychiatric research at the Brigham and Women's Hospital. "Our data shows that CBT is a tool physicians can use to care for patients, making a big difference in how they feel."

That conclusion comes as no surprise to Paul Salkovskis, a professor of clinical psychology at King's College London, who has been looking at CBT as a treatment for health anxious patients since the 1980s. The new studies add to a growing body of evidence that it works, he says. The problem is that very few people suffering severe health anxiety will ever see a specialist in CBT, particularly if they can't fund the treatment themselves.

"In trials, between 60 and 70 per cent of sufferers are either completely better or very much improved after a year. But there are very few people trained in it, and even we don't have the funding to deliver it. The scandal is that GPs can't access CBT so they continue to send patients for outmoded treatments that don't work. When a severely health-anxious patient is told to 'lie on the couch and tell me about your relationship with your mother', he doesn't see the relevance and he drops out."

Experts hope - perhaps forlornly - that the recent spate of research might signal a change in attitude towards hypochondriacs, who have often been regarded as nuisances to be dismissed from surgeries as quickly as manners and ethics allow. Certainly, it's no coincidence that the focus on treatments for anxious patients has come at a time when hypochondriacs consume (according to one study) over 10 times more healthcare resources than the average patient. But it might also be a belated recognition that, for sufferers, severe health anxiety is as serious a threat as physical illness and could be getting worse.

According to Professor Salkovskis, unpublished research hints at how serious that threat could be. Statistics garnered from patients diagnosed with hypochondriasis 30 years ago show that, in general, the doctor was right and the headache was just a headache. Death rates from natural causes are within the normal range, but deaths from unnatural causes (usually suicide) are way above average, and in one sub-group, 50 times higher than expected. As Professor Salkovskis says: "The needs of these patients were clearly not being met."

Suicide is the thin end of a very thick wedge. Few health anxiety sufferers are suicidal but many would recognise a vicious circle of worry, sleep disorders, depression, work problems and relationship breakdowns. Many doctors believe that health anxiety today is exacerbated by vastly increased access to information and services.Stephen Palmer, director of the Centre For Stress Management, says: "I've seen clients who have surfed the net for six hours, terrified themselves, tried to sleep, woken up exhausted and made the whole situation worse. Another factor is the rise in stress levels. We're all under more pressure, so we're more likely to experience physiological responses such as sleep disturbance and a racing heart. In people predisposed to it, that can lead to a greater chance of developing hypochondriasis."

In our tech-savvy world, the illness-obsessed no longer just put their symptoms into Google, though they certainly do that first. Patients unsatisfied with their own doctor's reassurances can ring NHS Direct, visit an NHS walk-in centre, join online news groups, consult a private doctor by e-mail at £25 a shot, arrange for expensive and usually unnecessary full-body screenings and visit a private GP. Unfortunately, none of these measures is likely to bring the reassurance they crave. New research into hypochondria comes at a time when the fear of illness - and the endless search for a diagnosis - can take over a patient's life, and finances, like never before.

CBT will not satisfy the need for reassurance either. In fact, practitioners believe that this is the last thing severely anxious patients need. "Reassurance just makes things worse," says Professor Palmer, "because the underlying anxiety is not dealt with. I won't reassure anxious clients."

Daniel Constantinou, the Harley Street therapist who treated Ryan Smith, puts it like this. "Today, sufferers will 'doctor shop', seeking out two, three or even four different opinions. But reassurance is like a drug with a hit that gets less and less effective. And sufferers know that no doctor can reassure them 100 per cent that nothing is wrong, so they always infer that something has been missed."

The aim of CBT is not to convince patients that they don't have a particular disease, but to challenge the thought patterns that always turn a racing heart into heart disease, or a headache into a brain tumour. Arthur Barsky says that severe hypochondriacs know something is wrong. The trick is not to contradict them, but to offer them an alternative explanation for their symptoms.

For example, Professor Salkovskis talks about a woman who had seen a close relative die of multiple sclerosis, and would focus on the end of her fingers for the tell-tale tingling that can be an early symptom of the disease. She invariably found it. "As soon as you focus attention on your body you'll find an ache or symptom somewhere," he says. "We got her to find out how that works by giving her exercises to make her focus on other parts of her body."

Other therapists have patients running on the spot, to show how easy it is to get a racing heart, or writing diaries of their body-checking habits so they can see how an obsession with checking for lumps in the mirror can lead to an irrational response.

Daniel Constantinou believes that a key to fighting health anxiety is teaching patients to live with uncertainty. "Clients have to realise that we can't be completely sure about anything," he says. "What's the likelihood, for example, that the hospital mixed up your results? Let's say one in 10 at worst. We ask the client, 'In other areas of life, an investment say, would you accept those odds?' The rest of us live with uncertainties, and it's something health anxiety sufferers need to learn."

Unfortunately, very few will be given the chance. Despite a growing recognition that CBT is effective, Professor Salkovskis believes that it is "not being taken seriously" by the medical community. "It's frustrating," he says. "We now know what living hell severe health anxiety can be for sufferers. We now know there is a better way to treat it. But what's really newsworthy here is that CBT is simply not being used."