I think that label has to be one of the most feared amongst the people I see with chronic pain. To be judged as being obsessed about nonexistant illnesses when actually having pain every day must be incredibly difficult to cope with. At the same time, being anxious about health and having mistaken beliefs about the meaning of symptoms can be part of both having chronic pain and having health anxiety (the condition previously known as hypochondriasis). And the temptation some health providers have to say “Oh just go and pull yourself together and stop worrying” is both unhelpful and part of the problem!
I’ve been reading about health anxiety as I look at ways to identify and work with people who are fearful of experiencing pain while at the same time have been told, and to a certain extend believe, that they’re not harming themselves.
One of the major contributors to a cognitive behavioural understanding of health anxiety is Salkovskis , Professor of Clinical Psychology and Applied Science at the Institute of Psychiatry, Kings College, London. I was lucky enough to attend a health anxiety workshop based on his work last year, and some of the strategies I learned there were really helpful. I’ll discuss them later this week.
The model he proposes for health anxiety is fairly similar to those for obsessive compulsive disorder and panic disorder. It’s also not that different from the ‘fear-avoidance’ or pain-related anxiety and avoidance model that so many of us are familiar with. In it, there are two main characteristics that need to be addressed to help the person cope with their anxiety about body sensations.
- Misinterpreting body symptoms as something indicating a serious or threatening health problem
- Using ‘safety-seeking behaviour’ to cope with this anxiety, but in fact maintains it
An example might help.
Joe Bloggs, (not his real name!) experiences a queasy stomach, often just before he eats. He is certain this means he has a stomach ulcer, or that if he eats, he will vomit. As a result, he delays eating and only eats once a day and then only tiny amounts of food. As he swallows, he monitors the feeling of the food passing down to his stomach, and his stomach feels full and tight. He starts to feel nauseous.
Does this look a bit familiar?
At the top is the belief that, for example, ‘these symptoms should not be there, they mean something horrible is happening to me’, this leads to hypervigilance, or scanning the body for possible symptoms of ill health, and this leads to misperception of normal symptoms as if they’re something abnormal. In ‘Joe’, you can see that it’s normal to feel a bit queasy if you haven’t eaten all day, but to him it’s a sign that he’s unwell and should avoid eating. He’s also very aware of the sensation of food as he swallows, and interprets this as abnormal rather than how food normally feels!
The symptoms that are noticed then generate anxiety and uncertainty about what is going on in the body, leading to ‘safety seeking behaviours’. In ‘Joe’, this has lead him to restrict his food intake to once a day, making him even more likely to feel queasy and to experience stomach cramps and bloating after he’s eaten. By restricting his food intake, he believes he is preventing or avoiding the strange symptoms when in fact he’s more likely to experience them – and he’s monitoring his internal state all the time. When he does experience these sensations, he takes this as confirmation that he was right to avoid food during the day, and there must be something wrong with his digestive system.
In the same way, people with chronic pain can misinterpret not just their pain symptoms, but also physiological arousal (such as nausea, sweating, heart racing and breathing changes, cold extremities and feeling nauseous) as definite signs ‘something is wrong’. It’s especially noticeable in people with noncardiac chest pain, but it’s present in many people with pain in other parts of their body.
By monitoring their body all the time, and being afraid of what they find, people with high health anxiety confirm their worst fears – there is something strange going on!
Some of the other ‘safety behaviours’ people with health anxiety use are:
- not moving much
- seeing doctors who then give them investigations, maybe MRI, CT, X-ray, nerve conduction
- checking their bodies all the time
- palpating various body parts for pain
- examining body parts for colour change, temperature change
- asking other health providers to examine them
- going onto the internet (!) and reading forums, web pages, searching for syndromes that ‘explain’ what is going on
Reassurance doesn’t reassure! In the case of health anxiety, it serves just to reinforce that something strange is going on – after all, the symptoms are there.
There are several ways to assess for health anxiety. One is the Short Health Anxiety Inventory, described in the paper by Abramowitz, Deacon and Valentiner (2007), and also in Salkovskis, Rimes, Warwick & Clark (2002) where it appears in full. Another is the Beck Anxiety Inventory. Remember: don’t use these if you’re not going to learn what they mean and how to interpret them!
I’m still mulling over whether they tap into the areas I’m concerned about in the people I see. I’m not sure – but I can see how this model applies in some people with chronic pain, and how the strategies I learned might be useful. Stay tuned and I’ll discuss those strategies and how I’ve used them in my sessions with people.
Abramowitz, J., Deacon, B., & Valentiner, D. (2007). The Short Health Anxiety Inventory: Psychometric Properties and Construct Validity in a Non-clinical Sample Cognitive Therapy and Research, 31 (6), 871-883 DOI: 10.1007/s10608-006-9058-1
Interesting post! Without doubt, some folks definitely engage in obsessive “worst-case” thinking which, even if they do have a chronic pain condition, just adds to the stress which adds to the pain perception experience.
My concern is that this list of “safety behaviors” looks a lot like what we advise people to do to become empowered patients, too: don’t take no, do your research, get involved, educate yourself … it’s a question of degree and attitude, to be sure, but we’re all human.
I’ve heard many stories of friends and readers who were told “you worry too much” and “there’s nothing wrong with you!” when what the doctor really meant was “we can’t find what’s wrong with you and your stress level is starting to freak ME out, too.”
I guess my point is: tread carefully because this is a very fine line from where I’m standing as a patient and writer/advocate.
Yes, I agree that this is a very fine tightrope to walk! I’ll expand on ‘safety behaviours’ as I go on with this series of posts. To identify when safety behaviours interfere with life and wellbeing is a judgement call that only the person with pain can determine, and often then, only in collaboration with a sensitive clinician. The reason I say ‘often only in collaboration’ is that sometimes we (I include myself as a person with chronic pain!) don’t recognise how much impact these activities are having on living our values until someone points it out!
By recognising the influence of health anxiety on how people cope with pain, I hope we can progress from negative labelling to looking at strategies that can reduce the anxiety and increase the flexibility with which people live their lives.
I did chuckle at your description of the doctor’s meaning ‘your stress level is starting to freak ME out!’ that’s SO true! It’s also unhelpful to tell something they worry too much! As a past spider phobic, it didn’t help me one bit to know there are no poisonous spiders in New Zealand and I didn’t ‘need’ to worry – and you can bet that when a spider fell behind a chair or something where I couldn’t see it – I didn’t stop worrying! In fact, I probably worried more. Which is why reassurance isn’t reassuring, and why telling someone ‘you worry too much’ is unhelpful.
Thanks for taking the time to comment – and keep reading, there will be more about health anxiety over the next few days.
I thik hypochondria is the same as pretty any other anxiety disorder. it just focuses on health
I agree, health anxiety has similar characteristics – perhaps it’s a little more difficult to treat because it can be so easily and inadvertently reinforced by well-meaning clinicians and at times because of the litigious environment in which we practice.
A hypochondriac if I am correct presents a benign symptom which in their minds is seen as a catastrophic illness.
By lumping Hypochondria as being an anxiety health disorder shows a great lack of understanding of the variety of problems.
Somatoform disorder is lumped under Hypochondria but presents entirety different issues. With somatoform disorder there is pain. Cause can’t be diagnosed so is considered psychological.
From my own experience a diagnosis of somatoform disorder was devastating. For a year I had severe pain in the upper right quadrant. Gallstones weren’t found. Diagnosis somatoform disorder. Because in Boston all hospitals share medical information no further testing would be done. It would be a waste of time and money. The following year I went to every ER in the city and was told nothing more could be done. I began treatment with a psychiatrist. Psych meds were prescribed. Did nothing. Finally, I saw a different gastro doc who explained that there was one more test and if it proved to be negative the only option left was a pain management clinical.
The test was a Gallbladder function test. The results were positive for Gallbladder Dysconacia. The Gallbladder had to come out. The Gallbladder Function test should have been done a year before. Instead the diagnosis was somatoform disorder. Doing an internet search after the Dysconacia diagnosis I found that can be extremely painful and at times necessitates hospitalization.
So lumping together somatoform disorder and Hypochondria is like trying to mix oil and water. Two very different. Then you add a third element. Misdiagnosis and it becomes nearly impossible.
I think using the term “somatoform disorder” risks exactly what you’ve found out – it means an individual’s distress is discounted, and any physical contributors to the lack of wellbeing are often overlooked. We’re not very good at identifying the “cause” of many forms of pain and to label them as “psychological” or “psychiatric” once again dichotomises the mind vs the body.
Excellent post. Very useful. Such an interesting topic and always difficult in terms of patient management. I recently wrote a blog about the amygdala’s role in chronic pain and depression. Looking forward to more of your posts.
I’m looking forward to reading your post about the amygdala’s role, I know there is quite a good body of literature looking at this, but I haven’t really spent much time reading about it in depth. I’ll be disucssing more about the idea of health anxiety and pain-related anxiety both from a theoretical perspective but also with some practical ways to work with it when anxiety or safety behaviours get in the way of living a well life. Hope you keep in touch!