There are many strategies to use when working with someone who is really anxious and worried that their pain is something nasty, and becomes hypervigilant to symptoms that are actually physiological arousal, or symptoms of anxiety.
The first practical thing to do is take the time to listen and understand what the person thinks his or her symptoms indicate.
Sounds easy, right? But as people with persistent pain say time and again, very few clinicians go beyond asking for a description of symptoms, and few ask about the conclusions the person has drawn from both symptoms and bits of information they’ve heard (or misheard) from the various health providers they’ve seen (or even the internet sites they’ve been on, or books they’ve read).
How could you do this? One way is to simply ask the person “what do you make of your symptoms? What do you think this all means?” Another way is to ask “What’s your theory about what is going on with your health?” Or “You’ve heard lots of different explanations for your problem, what do you make of it?”
It’s really important at this stage to avoid correcting the person’s beliefs. That can come later – for now, listen, and listen hard. To help you do this well, use reflective listening. What this means is to summarise what you think you’ve heard the person say, and then ask something like “Have I got this right?”
The aim of doing this listening and understanding is that it helps you understand how the person came to believe what they now believe. This is the first step in developing a formulation.
The next part is to identify assumptions the person has about reassurance and their experience of the medical consultation. This could be something like ‘if he was to tell me I didn’t have a tumour, it still wouldn’t tell me why I have this pain’.
Listening also helps you to understand the personal meaning of the symptoms they experience. What this means is that you learn what they think ‘that burning pain under my bellybutton is exactly where I had the pain when they found out I had an ulcer, so even though they haven’t found an ulcer (yet) it could be just starting’. You might also learn that they have occasional tingling in their fingertips and a heavy feeling in their chest when their pain levels are high, and they think this means they’re about to have a heart attack even though their examinations at Cardiology are clear, and yes, they do get a racing heart and yes, they also breathe really fast and feel hot and sweaty, and this too is a sign that they are about to have a heart attack.
As Salkovskis says ‘Patients are grateful if they find out what the problem is not; but they really want to know what the problem IS.’
There are some general cognitive biases that people with high health anxiety tend to have:
- Bodily changes are always a sign that something is wrong
- If I don’t worry about my health, something will go wrong
- Detailed tests are the only way to really rule out an illness
- If the doctor sends me for any tests, this is because he or she is convinced that there is something wrong (this is why sending someone for more investigations doesn’t actually reassure at all!)
Before starting to treat someone who is experiencing high health anxiety (and especially when they’re seeing you about their chronic pain) it’s important that the person is not concurrently receiving referrals for investigations or other interventions that could suggest that the problem ‘could be serious’. For example, it’s not helpful to see someone to help them self manage their chronic pain when they’ve also been referred for more investigations (eg MRI scans), or for injections or infusions.
On the other hand, it’s not necessary to exclude people from treatment for their anxiety about their health on the basis that they actually do have a physical condition. So even people who have angina can benefit from help with their anxiety about having a serious heart problem because the anxiety contributes to their distress and increases their heart rate and blood pressure – all contributing to the risk of more angina!
Another important step in coming to understand the person’s situation is to ask them to recall a recent episode where their anxiety and distress was high in relation to their health.
While exploring this situation, ask about things like where and when did these symptoms occur? What were you doing just before it? What was the first sign of trouble?
Step the person through their experience, the situation and their reactions to it. This is a process of ‘guided discovery’, where the two of you are collaborating to understand what was going on. Some examples might help:
“When you noticed your fingers tingling, what did you think at that time, was the worst this could be?” – and ask the person to rate how much they believe this – from 0 – 100%
“When you thought this tingling meant your back had gone out again, how did that affect you?(how did it make you feel…..what did you do……what did you pay attention to…….how did you try to deal with it…..)
As you do this, you can write down or draw arrows from one aspect to a thought, to an emotion, to a behaviour or next action or symptom, as you develop a shared picture of what happened.
BTW – this diagram is from Salkovskis.
I’m going to stop here, because there is much more to do – but this is the first step. You might notice that it’s not much different from what we’d do for chronic pain management – we’re basically trying to learn how experiences link with thoughts, emotions, and behaviours to form a chain that maintains the distress about the experience. Treatment is therefore about helping the person look at things differently, reality testing what they anticipate will definitely happen with the likelihood of that horrible thing actually happening – and boosting their own sense of how well they can manage this sort of situation.