The worried well: their identification and management DAVID MILLER, DCPsych(NZ), Principal Clinical Psychologist and Honorary Lecturer in Psychiatry and Genito-Urinary Medicine TIMOTHY M. G. ACTON, DCPsych, Clinical Psychologist BARBARA HEDGE, DCPsych, Clinical Psychologist University College and Middlesex School of Medicine, London here in this unfortunate extreme, if but a pimple that they have symptoms of infection associated with appears or any slight ache is felt, they distract themselves human immunodeficiency virus (HIV), the causative with terrible apprehensions And so strongly are they agent of acquired immune deficiency syndrome (AIDS), for the most part possessed with this notion that any despite remaining infection free as verified by (often honest finds it more difficult to cure practitioner generally repeated) serological testing and clinical assessment [13- the imaginary evil than the real one. 15]. As a patient group, the worried well are distinguish- Freind, 1727 [1] able from those in the general population who experience raised anxiety as a result of media coverage of HIV/ Recent surveys of psychiatric and psychological disturb- AIDS, and who may as a consequence wish to be tested ance among patients attending sexually transmitted dis- for anti-HIV, but who experience long-term reassurance ease (STD) or genito-urinary medicine (GUM) clinics and absence of inappropriate worry as a result of negative have shown rates of 20-45 per cent morbidity [2-6]. clinical and laboratory findings. This latter group may be Examples of disorders revealed in these surveys include described as those with 'AIDS anxiety'. affective and personality disorders, psychosexual dysfunc- A media-generated public anxiety related to topical tions and disorders associated with physical symptoms health concern is not a new phenomenon, although (for example, primary hypochondriasis, dysmorphopho- documented clinical experience of such phenomena ap- bia, obsessive compulsive and monosymptomatic hypo- pears to be rare in the context of diseases other than chondriacal psychotic states [7] AIDS. The quote opening this paper indicates that An important sub-set of these patients have somatic clinicians have always had management difficulties asso- symptoms misattributed by them to some form of STD. caited with patient misperceptions of their level of risk MacAlpine [8] describes 24 patients suffering from 'sy- relative to epidemic phenomena. In recent times, the philophobia', in which the patient presents with a wide public awareness of Legionnaire's disease and breast spectrum of physical symptoms which are expressions of cancer, for example, has led to numerous referrals of their morbid fear or conviction of being infected, yet with persons convinced that they have such illnesses despite no objective evidence of infection or disease upon exam- thorough clinical investigations indicating otherwise. In ination. Frost [9] described 36 patients suffering from this the appearance of the worried well appears to hypochondriasis. His presentations featured morbid bo- respect, represent a continuum of expressed vulnerability in those dily concern (with disease phobia, psychogenic pain and members of the general population who are susceptible to and of physical symp- misperception misinterpretation media discussion of health concerns. toms), and abnormal illness behaviour (failure to be The worried well may present for a variety of reasons: reassured by medical staff and demands for further may have had sex with a bisexual or drug injecting investigation, affective distress and psychological defen- they man or woman in the past; they may be homosexual or siveness). Other reports [10-13] have described similar have a history of homosexual activity (fre- conditions associated with STDs, variously referred to as (periodic) quently involving only low-risk activity); they may be 'hypochondriasis', 'nosophobia', 'venereophobia' and psychologically vulnerable personalities responding to 'pseudo AIDS'. Over 30 per cent of patients present with media reports or advertising about AIDS. The public these symptoms. anxiety about AIDS appears to act as a vehicle for the The 'worried well' are patients suffering the conviction expression of their sexual guilt or anxiety, or of their general vulnerability [16]. Address for correspondence: Dr D. Miller, Academic Department of Based on the clinical phenomenology, the worried well Genito-Urinary Medicine, James Pringle House, University College are for the reasons: and Middlesex School of Medicine, 73-75 Charlotte Street, London significant following WIN 8AA. 1. There appears to be a remarkable consistency in both 158 Journal of the Royal College of Physicians of London Vol. 22 No. 3 July 1988 within Table 1. Demographic features of 19 worried well patients. presenting and background features of patients of or this group, irrespective sexuality gender; Number Mean age S M D W 2. Chronically disturbed patients often become suicidal; considerable amounts of 3. Patients in this group require Heterosexuals: clinical time in investigation and management; Male 6 40 2 3 1 0 an of 4. This population appears to represent expression Female 2 35 0 2 0 0 3 41 2 10 0 vulnerability in previously described populations Bisexuals: Homosexuals: 8 30 6 2* 0 0 which, in the context of rapidly increasing public of HIV homosexual men were in a awareness of AIDS and routes transmission, *Where co-habiting stable, loving health mutual assent over have 'latched on' to this present major public relationship by for 12 months, they were classified as 'married'. issue; a a 'window' which 5. through = = This = population provides S = M D W widowed. to the single; married; divorced; form of heterosexual (and homosexual) reaction the HIV can be assessed. To present time, pandemic with studies of psychosocial morbidity associated most ance of obsessive-compulsive behaviours and ruminative AIDS have concentrated on the social subgroups men states, the presence of HIV dis- affected, such as homosexual [17-20], specifically concerning directly ease. centred on and/or users Ruminations images thoughts of haemophiliacs [21] and injecting drug [22]. HIV disease and death, past 'high risk' sexual practices, threats presented to lovers and family members, dirtiness and Presenting background phenomenology or infectivity of body fluid (for example, semen, saliva or have described a urine) and the need for repeated reassurance. A recent series of reports [14, 16, 23] Each Obsessive-compulsive behaviours involved responses phenomenological study of 19 worried well patients. sexual his- to ruminative or obsessive thoughts such as those de- subject was assessed on protocols concerning and scribed above, including checking the body for Kaposi's tory, clinical and laboratory examinations, psychi- to HIV sarcoma lesions, the of atric and examination. All who consented (KS) usually involving counting history freckles and skin and were found to be moles, blemishes, palpating specific antibody testing after counselling nega- sexual activities bodily areas to 'confirm' a swelling or pathology. Not tive. In only two cases were there any HIV infection in surprisingly, such palpation itself often caused pain and reported that may have led to possible and exacerbated the held the were HIV swelling suspicions by the previous six years; they too antibody Other included sources of This review excluded patients who showed a patient. compulsions washing negative. as shared health education and contamination, such clothes, bathrooms and maintained response to appropriate books, and and scrutinis- after with anxieties over their lavatories, repeated questioning counselling presenting areas of for was of bodily spouses/lovers signs of HIV possible status. An important distinction ing antibody related disease. Rituals associated with such made between 'AIDS anxiety' in which cognitive preoc- phenomena were and not of an avoidance cupations and somatic indices of anxiety relating to primarily anxiety-reducing etc, was associated with a of risk membership or sensationalist type: washing, palpating recognition group in the transient concerns temporary reduction subjective tension concerning media reporting may have provided in which HIV infection. over personal health, and 'the worried well' In all but five of the 19 cases, obsessive symptoms were patients were chronically ruminative about their possible and associated with a primary diagnosis of Where exposure to infection informed sympathetic depression. despite an re- this was not the case, obsessive disorder was counselling, clinical physical examination and often diag- The nosed. Two subsequently developed a delusional peated negative antibody screening. demographic patients state their supposed infection. features of the 19 cases are presented in Table 1. regarding Depressive phe- nomena were associated with fears or feelings of the 'inevitability' of exposure and HIV-related disease and Presenting features decline, the effects of fears on the relationships in which was at them- Almost all subjects showed an unshakeable and anxiety- the patient involved, guilt having placed 'at risk' in the and done the same to laden conviction that they had HIV infection or disease, selves past having of their loved ones. was associated as indicated to them by the presence anxiety-based Depression frequently with a full somatic and and a physical features which they had misinterpreted as signs cognitive symptomatology sweat- decline in at work