Bad Medicine: The worried hell

Des Spence

doi:10.3399/bjgp16X687361

The ‘worried well’. I can’t quite remember when I heard this expression, nor who might have coined it. But it is common parlance in medicine and all GPs understand its meaning implicitly. I know that we shouldn’t use stereotypes, but where is the fun in that? The worried well are educated patients, perhaps with too much time on their hands, who repeatedly attend the surgery with reams of internet pages. Dr Google always diagnoses possible cancer or an appalling life-shortening degenerative condition, catastrophising all symptoms, irrespective of the probability. And the worried well reflect the general levels of high anxiety paralysing one in four of us a year. Is this the new norm, the consequence of wealth and free time, where ‘the worst case scenarios’ pervade thinking in all things? Anxiety is the biggest public health issue of our time.

It seems to start with parents. In pregnancy there is paranoia about foods, alcohol, medications, weight, scans, and a birth plan that always becomes the complete opposite. Then there are special care baby units, the breastfeeding police, weaning, allergies, the dangers of vaccination, delayed development, gluten, endless contradictory specialist advice, and a swathe of poisoning self-help books. Anxiety is heaped on anxiety. Then there’s choosing the best school, tutoring, exam stress, self-harm, gender issues, Photoshop celebs, gluten, peanuts, piano lessons, the Duke of Edinburgh Award, sexualisation, eating disorders, Facebook, sexting, cyber-bullying and just ever-escalating anxiety. There is no place today for the half-baked-just-about-adequate parenting of the past. Instead, it is parenting seen through a prism of potential illness and risk, a head-spinning cocktail of concern. Seemingly well-intentioned guidelines have become confining and limiting like never before. Our society, which is driven by wealth, individualism, and perfectionism, leaves many riven with introspection, indecision, and full of unrealistic and unobtainable expectations. Modern life seems little more than a gilded cage for many, with anxiety hardwired in utero. This is important to medicine because much of our work is spent dealing with anxiety. And what do we offer? Psychoactive medications, sedatives, and antidepressants. Or the latest faddish counselling intervention. These haven’t worked and won’t work.

Specifically, the worried well are anxious about their health, unwilling to accept reassurance, demanding investigation and referrals. They then suffer unnecessary intervention and overtreatment with real lasting harm. The recent explosion in medically unexplained symptoms simply reflects the rise and rise of health anxiety. Also, the health anxious vocally promote screening despite its severe limitations and dangers. For example, the current calls for dementia screening, which lacks specificity, will see overdiagnosis and the loss of wellbeing for many with health anxiety. Finally, the health anxious are high achieving and are entering medicine, projecting disproportionate anxieties and health beliefs onto patients, a perfect storm of health anxiety. All this clogs access and drives costs in the NHS.

Currently our healthcare system wrings it hands over the ‘unworried unwell’, who are seemingly impervious to all health promotion: defaulting clinics, non-compliant with medication, and spurning all screening. Yet the unworried unwell are free from anxiety and spared of much iatrogenic harm.

We cannot underestimate the burden of chronic mental health problems and the loss of wellbeing suffered by the worried well. We need to refocus our concern on the ‘worried well’ for they are sick and at risk. But there is no research, no task force, no tsar, no professors or academic departments seeking to find solutions. Doctors have a duty to the sick, but an even greater duty to protect the well, and we are currently failing in this duty. For life without being a bon-viveur ain’t no life at all.