شیوع مشکلات اضطراب سلامتی در کلینیک های پزشکی

Objectives To determine the prevalence of significant health anxiety (hypochondriasis) in patients aged 16–75 in cardiology, respiratory medicine, neurological, endocrine and gastrointestinal clinics in general hospitals in London, Middlesex and North Nottinghamshire. Method The Health Anxiety Inventory (HAI) (short form) was administered to patients attending the five clinics over a 21 month period and all those who scored 20 or more invited to take part in a further assessment for a randomised controlled trial. Results Of 43,205 patients attending the clinics 28,991 (67.1%) were assessed and of these, after exclusion of ineligible patients 5747 (19.8%) had significant health anxiety. 444 subsequently agreed to take part in a randomised controlled trial of treatment. The prevalence levels varied by clinic with neurology (24.7%) having the highest prevalence followed by respiratory medicine (20.9%), gastroenterology (19.5%), cardiology (19.1%), and endocrinology (17.5%). Conclusion Abnormal health anxiety is common and a significant problem in those attending medical clinics and deserves greater awareness.

Excessive health anxiety – and its older synonym, hypochondriasis – is relatively common in both primary care (between 0.8 and 3.05%) [1], [2] and [3] and some secondary medical care settings (4.2% and 10%) [4] and [5], has a generally poor outcome with less than 50% recovery [6] and also places a substantial burden on health services [7]. As many of the unnecessary investigations and tests associated with health anxiety are carried out in medical out-patients it is not surprising that there is a higher prevalence in these settings, but there is limited knowledge of the extent of this condition in general hospital settings. As an initial part of a large multi centre randomised controlled trial to determine the effectiveness of treatment of abnormal health anxiety we determined the prevalence of the condition pathological health anxiety in five types of clinic at six hospitals in London, Middlesex and North Nottinghamshire over a 21 month period.

The patients were recruited between October 2008 and July 2010. Of a total of 57,902 attendances at the clinics of 107 consultants over a 21 month period between October 2008 and July 2010, 28,991 patients were given the HAI. 5769 (19.9%) of these scored 20 or more on the Health Anxiety Inventory and so were regarded as having significant health anxiety. The prevalence rates and the results from the generalised linear model analysis are presented in Table 1. The regression analysis showed a significant difference in the prevalence rate of HAI among different clinics (χ2 = 71.26, P < .0001), with those attending neurology clinics having the highest prevalence (24.7%) and endocrinology the least (17.5%). Compared with the average prevalence rate across all clinics, those attending neurology clinics had significantly higher rate of 4.3 (95% CI: 3.12,5.64; P < 0.0001) whereas those attending endocrinology clinics had significantly lower rate of − 2.84 (95% CI: − 3.75,−1.92; P < 0.0001). People attending cardiology and gastroenterology clinics also had a lower rate of high health anxiety than the average level of all clinics. Table 1. Prevalence of significant health anxiety in cardiology, endocrine, gastrointestinal, neurology and respiratory medicine clinics. Clinic type Total assessed Number with HAI scores ≥ 20 Prevalence rate Difference and 95% CIa P-value Cardiology 6303 1206 19.13 − 1.20(− 2.10,−0.30) 0.0093 Endocrine 5637 986 17.49 − 2.84(− 3.75,−1.92) < 0.0001 Gastroenterology 8924 1737 19.46 − 0.86(− 1.67,−0.06) 0.0355 Neurology 3205 792 24.71 4.38(3.12,5.64) < 0.0001 Respiratory medicine 4922 1026 20.85 0.52(− 0.49,1.52) 0.3161 All 28,991 5747 19.82 a The difference (and its 95% CI in the prevalence rate between each clinic and average of all clinics) is estimated from a generalised linear model. Table options Discussion The results indicate that a significant, and numerically large, proportion of patients attending medical out-patient clinics have significant pathological worries about their health. The size of the study suggests that these figures are representative but they have some limitations. The numbers refer to attendances and although many patients were approached more than once and said they had already filled in the questionnaire others may have completed it twice or more. One patient who was seen nearly 12 months after completing the HAI and was randomised, on the second time was randomised again (fortunately to the same arm of the trial), and this was only identified later. The study was not a true prevalence study and as people who worry about their health may attend more often than others they would be more likely to be seen by researchers. Although the score of 20 on the Health Anxiety Inventory has been regarded as an appropriate threshold for significant health anxiety [9] it is possible that in medical settings some patients with known medical pathologies may be false positives, although in practice even with this group the threshold seems to be appropriate in terms of response to therapy [11] and [12]. A recent study of the factor structure of the HAI also showed no fundamental differences between medical and non-medical subjects [13]. The impression of the many researchers who conducted the assessment of patients in the study was that most subjects had significant health anxiety but that sometimes this was overshadowed by physical health problems (about which some worry was appropriate) and other comorbid psychiatric disorders that complicated assessment. The higher prevalence of health anxiety in neurology clinics is not unexpected as previous studies have suggested that somatisation and hypochondriasis are common in this population [14] and so many patients in these clinics are undergoing assessment rather than specific treatment. In a related study (Tyrer et al., submitted for publication) of anxiety symptoms in medical clinics those attending endocrinology clinics had the highest HAI scores and the lower rate in this study was a little surprising. However, there was great variation between the clinics and in two hospitals (St Mary's and Chelsea & Westminster Hospitals) the endocrinology consultants excluded patients attending with more complex problems, and these may have been associated with more health anxiety. Although the findings may represent a generous estimate of true prevalence, the overall prevalence of nearly one fifth is still very high, suggesting that a great deal of unnecessary anxiety is shown by a substantial minority of patients attending these clinics, and may often pass unnoticed. It is also important to note that the version of the Health Anxiety Inventory used assessed symptoms over a 6 month period and so brief symptoms and what is sometimes described as abridged hypochondriasis [15] would have been excluded. This high prevalence is likely to be associated with both considerable morbidity and greater unnecessary heath service costs. Health anxiety has a tendency to be persistent in the absence of treatment and so causes considerable long-term suffering and is accompanied by frequent attendances in both primary and secondary care as well as larger number of investigations. As most practitioners in medical settings respond to patients with high health anxiety by reassurance and support, supplemented by further investigations, all of which are likely to reinforce pathology, there is a danger of a growing gap in service provision for what may be, in a risk averse age, a growing problem.