Health anxiety & chronic pain

Yesterday’s post about ‘hypochondria’ and chronic pain created a bit of a storm.  Emotions run high when you have chronic pain and someone somewhere suggests (a) that it’s ‘all in your head’   or (b) you’re just being a ‘hypochondriac’.  There are loads of reasons why both of those comments are inaccurate and unhelpful, but as I said yesterday, there is also a lot of research suggesting that health anxiety might play quite a big part in increasing the distress and disability associated with having persistent pain, and maintaining both.

How would you know if you, or a patient you were seeing, was anxious about his or her health?
You know I’m going to say there is no black and white answer to this one, don’t you?! Anxiety about health varies along a continuum, but there are four main characteristics that you could use to guide your thinking.
(1) Excessive preoccupation with, and fear of developing or having a serious illness
(2) The fear persists despite medical reassurance
(3) It interferes with everyday life
(4) It has been a problem for at least six months

First, the problems with this set of criteria: what is ‘excessive’? This depends on the person’s experiences in the past, and what is happening at the moment. For example, if someone has had a previous heart attack, I’m pretty sure the next time they have chest pain they’re not going to ignore it. Similarly with a breast lump – I’m sure I’d be double-checking each change in my breasts if I’ve had a past lump biopsied. If there is a current flu epidemic (H1N1 pandemic anyone?) I’m sure anyone with a cold or ‘the beginnings of the flu’ will be checking to see whether this is The Flu, and taking it pretty seriously.

A rule of thumb for me would be whether the worrying is taking up time and energy from what the person has to do, or wants to do every day. And it would also be the degree of distress associated worrying – if the person is starting to get panicky, tearful, has physiological arousal symptoms (increased heart rate, nausea, sweating, shallow breathing and so on), then I’d be starting to think this worrying was a problem. I’d also be concerned if the person was catastrophising, and thinking that any and every body symptom was associated with a dread disease, or that maybe the underlying cause was inevitably cancer or something terminal.

But that’s not the only criteria – the next is that the fear persists despite medical reassurance. Some examples from my clinical work recently:

  • despite having had imaging (X-ray & MRI) and four surgeons from different parts of New Zealand who confirmed there was no need for surgery, one client continued to believe that there was ‘something wrong’ in his shoulder, possibly cancer, and doctors weren’t telling him.
  • after full investigations and x-rays showing well-united ankle fractures (fractured some 5 years ago), another patient wanted more images to confirm that it was ‘safe’ to walk for more than an hour because he worried that the ‘bone had ulcerated and maybe they need to scrape some of the stuff out of it’.

The third criteria is interference – both of the people described above had stopped working, stopped their usual recreational activities (fishing and playing with the grandchildren and mowing lawns), and were miserable.  They spent more time either on the internet or seeking medical opinions than they did doing any of their usual ‘fun’ activities.  Despite the reassurance they’d had from specialists, they stopped life and worried.

And yes, for both of these men, this worry had been present for more than six months – more like six years in fact.

The fine line between being informed and advocating for yourself – and health anxiety

Yesterday someone mentioned that she was worried that by describing health anxiety as ‘excessive worry’ and describing some of those behaviours such as

  • 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

That I might be treading a fine line between being a self-advocate and having health anxiety.

I hope I’m not, but I can see the difficulty!  Here’s my opinion, for what its worth.

To me, the main differences between being a self-advocate and having health anxiety is the degree of distress about the symptoms, and the interference experienced because of the ‘safety behaviours’.

My bottom line?  In the process of searching for the ’cause’ and ‘cure’ – are people living well?

Health anxiety persists because of four main factors:

  1. Selective attention – attending to a biased selection of information. Instead of hearing ‘we found degenerative changes on your x-ray that are quite normal and there’s no need to operate, but I don’t know the exact cause of your pain”, the person with health anxiety might hear ‘your x-rays are normal so your pain is in your head’.
  2. Safety seeking behaviours – avoidance, reassurance seeking, checking.  By avoiding certain movements or activities, the person doesn’t test out whether his or her dire predictions are true.  By seeking reassurance, this temporarily alleviates distress, but because of selective attention and hypervigilance to body symptoms, worries sneak in.  This can lead to checking – and like the spider phobic who gets really worried when a spider disappears from view, checking but finding nothing means nothing is there – yet!
  3. Physiological arousal – as a result of feeling anxious about the meaning of sensations, it’s common for people to experience increased sympathetic nervous system arousal. This means that in addition to finding that ‘strange bump on my leg’, or ‘the colour change over my elbow’, the person can also experience nausea, sweating, heart racing and shallow breathing. Sometimes this can progress to a full-blown panic attack, which can feel at the time like something terrible is going to happen! Then these symptoms can be misinterpreted as confirmation that there is something seriously wrong and the person was right to be worried. Which in turn leads to more anxiety … and so on…
  4. Mood – finally, low mood and anxiety can lead to negative brooding or ‘ruminating’ where thoughts go around and around in never-ending cycles of ‘what if’ and ‘then this will happen’ and ‘what does this mean?’  Ruminating can often disrupt sleep, certainly reduces the ability to concentrate on what is happening here and now, and most importantly, it interferes with taking action.

I’m sure you can see the difference between being informed and advocating for good information and open, honest communication between a patient and a clinician, and the negative effects of being anxious about health.

Tomorrow I’ll start to explore some ways to work with people who are really worried about their health – and it’s not so different from what we do when we work with people who are less bothered by their health.  It does mean listening, being genuinely concerned, being empathic, and asking questions so you can understand the meanings the person is placing on his or her symptoms.  It also involves you as a clinician not judging or dismissing the person’s health concerns – what you need to do is ‘walk a mile in the person’s moccasins’, really understand what the person thinks is going on.  More tomorrow on this!


  1. When you reduce it down, health is not the key to this nature of problem. The problem is one of anxiety regardless that the worries are over health. Any unmanaged anxieties will cause significant problems for patients and interfere with their day to day lives.

    1. The main reason that health anxiety and pain-related anxiety are more difficult to manage than ‘ordinary’ anxiety is that people with health problems and pain just don’t want to hear any suggestion that their pain is associated with a mental health problem. So while the principles of treatment are very similar, working toward developing a good relationship with the person, and then being able to maintain positive changes can be much more complex and take more time.

  2. I think it is more acceptable to me, as a patient, for the physician to provide the information that mental health issues are a natural result of chronic pain and need treatment side by side with the pain issues. Chronic pain causes changed daily behavior ex. a gardener with chronic migraine will avoid the bright light and therefore be indoors much more. Indoor time could be spent online researching illness or diverted to indoor plants, training to become a master gardener, or teaching through a blog. An intuitive pain management specialist will help the patient reflect on the effect of behavior choices . My alarm bell goes off if I limit or restrict outdoor activities even when I don’t have a migraine.

    1. Good points about following your interests in different ways. My only additional point is that it’s possible to actually do some of those activities despite pain, like dancing when you’re sore, or gardening when you’re sore. But doing this takes a new viewpoint, good skills in self regulation, and paying attention to limits more carefully than if you don’t have pain. I think it’s a tragedy that people who have chronic pain are so seldom shown that it’s possible to live well despite pain (and instead get lead only into seeking treatment to reduce or abolish pain), and that if they do decide to no longer pursue medical treatment, often they’re left to do this without a lot of help. Being sensitive to helping people live their values despite ‘doing it differently’ is something I’d love to see more health providers learn to do well.

  3. chronic pain affects every matter of your life whether it is your professional life or your family life. you will try to get away with all normal activities showing the worst consequences ever.

    1. There’s a difference between trying to pretend your pain doesn’t exist (which is both untrue – and doesn’t work!), and getting on with life and living well despite your chronic pain. Chronic pain can affect every aspect of your life, but it doesn’t inevitably mean it’s a negative effect – learning to live well despite chronic pain is a lot about learning to think and do things differently, maybe even in a more balanced and healthy manner than before pain, and it’s a shame when people are not given the opportunity to learn this.

  4. I know a few people who receive no help from the medical profession on how to cope with chronic pain on a daily basis. They spend much of the time rejecting and trying to ignore the pain, but as Adiemusfree stated above, it doesn’t work.

    People need to have access to information and skills on how to cope with the pain.

  5. You know, I’m sitting here with 10 different medical conditions… spawned from a very negligent doctor who administered two antagonist medications and antibiotics I am adversely allergic to. I was in the emergency room for pain in my shoulders, all along my back, in my joints, in my chest, my hips, legs, arms… The ER keeps telling e that I need to see the pain specialists, and I kept telling them that a internal medical specialist, Dr. Jennifer White of Borgess Internal Medicine in Portage, Michigan was supposed to have referred me to a pain specialist name Dr. Chafty for four months that I have seen her. Regardless of me telling her what woks for me, she decided to not give me refills on my pain medication until I see her again for an appointment. Now she has received records from the former (Non-Progressive Pain Specialist) Pain doctor which would have told her that the pain therapy that works best for me was utilizing both long-term and short-term medication. The long-term for everyday use (two times a day) and the short-term pain medication for “breakthrough pains.” This is done this way to #1, bring down the high tolerance level from use of hydrocodones for over six years so they would be more effective. And #2, I would have a good working pain management therapy. I told her about this, but still she ignores what I said. Last month I was so upset and hurting I told the office that “How in the *french* can a computer tell me how I feel every damn day?” I needed help. So what happens next was that I received a letter written by the office manager on 03/10/2010 that was mailed out on 03/16/2010 telling me that there has been a breakdown of communications that they are terminating their services to me, however they would give me 30 day emergency assistance (Which was actually 23 days.) and never mentioned if the 04/08/2010 appointment was canceled or not?
    Are you readers out there curious to what medical conditions I have? I’ll tell you… Systemic Lupus Erythematosus, Kidney Insufficiency, Rheumatoid Arthritis, Arthritis of lower back and hips, Antiphospholipid Syndrome, Hypertension, Costcochondritis, borderline Anemia, Idiopathic Chronic Pain. And there is another one that is still undiagnosed, which my feet are constantly tingling, numbing and pricking pain, which Dr. White was to supposed to have arranged me an appointment with an Neurologist, which she never did to this day.
    My family doctor is afraid to help me. I have another week or two wait just to see someone new. In the meantime, what am I to do? I m only 41 years old and I did not asked to be sick like this. This is ALL the one doctor’s fault. He still practicing while I’m going to have this for the rest of my life. So, tell me if this is all in my head? Oh and for the medications… here they are; Amlodipine Besylate (Norvasc) 10 mg. 1 tablet daily. Carvedilol (Coreg) 25 mg. 1 tablet twice daily. Clonidine HCL 0.2 mg. (Catapres) 2 tablets twice daily. Ferrous Sulfate 325 mg. (Iron Tablets) 1 tablet twice daily. Hydrocodone APAP 7.5/325 TAB 1- 2 tablet(s) every 4 to 8 hours as needed for pain.
    Lexapro 20 mg. 1 tablet daily. Mycophenolate 500 mg. (CellCept) 2 capsules twice daily. Potassium CL ER 20 meq. (Klor-Con M20) 1 tablet twice daily. Prednisone 10 mg. 1 ½ tablet(s) daily in the a.m. Protonix DR 40 mg. 1 tablet daily. Spironolactone 25 mg. (Aldactone) 1 tablet daily. Warfarin Sodium 7.5 mg. (Coumadin) 1 tablet daily.

    Now please tell me that the pains are in my head or I have mental issue?

    Thank you for reading.

    1. Chronic pain is certainly not a ‘mental issue’ nor ‘in your head’ – something I’m at pains to point out right throughout this blog. I can certainly hear your frustration at not receiving the kind of help you feel you need. I’m also not the right person to talk with because my focus is not on medications but on self help and more to the point, to help clinicians who provide self help strategies with more of the up-to-date information that is often quite hard to find. I’m sure you’re not alone in your frustration either, and all I can suggest is that you go to one of the sites listed on my blog like ‘How to cope with pain’ for the patient-related information that is provided there. Kind regards

  6. Sorry to bump an old thread. Not even sure anyone reads this anymore I found this out of desperation. I suffer from chronic pain. I also admit to be a sufferer of health anxiety or hypochondria. My health anxiety ruins my life. I will spend most of my day on the internet searching symptoms and reassurance. I dont worry about cancer however or even my kidneys which is what my chronic pain is from. I obsess over my heart and brain. In one day I normally have to convince myself that I will not drop dead at least 4-5 times. Let me please state that if let untreated as mine has been it can become a very real and serious problem. First my marriage is strained. My oldest son from watching me now has his own health anxiety. I was terrified to deliver my second child for fear of dying. To the point I almost considered terminating my pregnancy because it scared me so much (please please dont judge). I have made 147 er visits in two years for my anxiety and what I feared was a heart attack or brain anuerysm. In 2011 I suffered conversion disorder due to my anxiety. It resembles a stroke so that made my anxiety worse. I have been committed twice because I wanted to commit suicide rather than live so afraid. We hypochrondiacs are not fans of what we have. Its debilitating. I havent worked in two plus years and I am actually a behavior specialist specializing in adolescents and young adults. I dont go out, I dont enjoy any part of life. My anxiety has reached points to where I could not be medicated for pain management because I obsessed over how I felt on meds. The first time I felt loopy I had my husband rush me to the hospital for fear I was dying. It may sound absurd but its a look at how serious it can become. I check my pulse normally ever 10 minutes. If its too fast or two slow there must be a problem. I palpate my chest for pain to reassure its not cardiac because as most know cardiac pain cannot be recreated. I ask my family to assure me I am not dying. Now I have had over 100 EKGs, an echocardiogram, ct scans, brain mris, and countless lumbar punctures (oh yes) trying to reassure me. The thing with health anxiety is you are never reassured. My chronic pain is from my kidneys. In the past year I have not gone one day without a kidney stone, and I wish I was joking. Its painful all day everyday. But even now with pain medication, I feel chest and abdominal pain near constantly, and I almost always have a headache. In the time I wrote this post I had a series of palpitations that sent my mind soaring into recurrent panic attacks. I am well aware that if my anxiety werent so bad my kidney pain would not be as amplified. With health anxiety, finding treatment is damn near impossible. A lot of people dont understand it. And it does hurt to have people misunderstand you and make fun. I actually had an ER doc comment one time ‘oh shit do I really have to deal with the fruitloop again’. Now I am 27. My echo was perfect. An ultrasound of my cartoroid arteries was good. My ekgs have only ever showed palpitations and tachycardia (which are symptoms of anxiety). I am having countless palpitations right now. Now logically I am aware that I am healthy and it would be highly unlikely for me to suffer a massive heart attack or anyuerism. However, there is no shut off switch for me. So yes, it was nice to read this as there is a relation. Also, chronic daily pain can lead to depression and anxiety on its own. Everything goes hand in hand. Thank you. (It took courage to write this, so I beg that no one pokes fun. Thanks.)

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