Pain and health anxiety – working with beliefs

Over the past few posts I’ve been looking at pain and health anxiety, and how anxiety about body symptoms can be misinterpreted to represent something sinister when it may be a reflection of the level of physiological arousal in the individual. In fact, one definition of anxiety is ‘over-estimating the threat’ while ‘under-estimating the resources to cope with the threat’.

I really like Salkovskis statement ‘People suffer from anxiety because they think situations as more dangerous than they really are’, and ‘Treatment helps the person to consider alternative, less threatening explanations of their problem’. These explanations have to fit with past experiences of the person – and work when they’re tested out. The process of therapy is about two (or more) people working together to find out how the world really works. Now THAT is a great description of the way I hope I work with people!

Another way of looking at the ‘anxiety equation’ is to think of it this way:

Anxiety is proportional to the perception of danger, or…

perceived likelihood it will happen  x  perceived ‘awfulness’ if it did

perceived coping ability when it does +perceived rescue factors

After developing a formulation, or shared understanding of how the person views his or her symptoms, the next step is to validate the person’s experience. Remember that symptoms are what the person experiences, not what we can see (these are signs). The person probably has had health professionals or family members suggest that they are not experiencing their symptoms and yet the person IS actually experiencing them! So to deny that they’re having them is unproductive – it’s not that they are having symptoms that isn’t certain, it’s the meaning or conclusions that the person is drawing from their experience that we need to work through to establish their accuracy.

To decrease the belief in the inaccurate conclusion we need to remember: the more we ‘tell’ a person one thing, the more they are likely to argue their original belief, so this is not a process of ‘telling’, it’s a process of learning together…The best way to decrease belief in a highly threatening idea which cannot be disproved is to build up belief in an alternative explanation. The alternative explanation does not have to be completely incompatible with the threatening belief; initially, it probably helps if it is not. (Salkovskis)

This alternative explanation develops as you and the person work through alternative interpretations of the symptoms. Treatment also involves self-monitoring, re-attribution of originally misinterpreted symptoms, and a combination of discussion and ‘mini-experiments’ that work to help the person develop confidence in the alternative explanations.

Behavioural experiments are used to gather new information to feed into the discussion. “Don’t trust me, test it for yourself”

A useful technique is the pie chart. In this technique, you and the person write down the symptoms and the conclusions they’ve drawn:

“My tingling legs and that cramp mean my back is weak and the fluid is oozing out of the discs and into my spine”

The person is asked to rate how much they believe in this statement – 90% perhaps?

The person is then asked to write down all the other possible reasons for tingling and cramp that might be occurring in the same city today (or supermarket, mall, neighbourhood), starting with ‘fluid oozing out of the discs and into my spine”.  Things like, sitting in one position too long, cutting off the circulation a bit, maybe being unfit and doing more than usual, a tumour, multiple sclerosis, stroke  etc

When the list is complete, draw a pie chart circle.  Divide the pie chart up into pieces, with each piece representing a different possible cause starting at the bottom of the list, so that the first reason given (the catastrophic belief) is the last ‘slice’ of the pie.

Then ask the person to re-rate their belief in their original statement – usually by now it’s dropped! 

Points to note:

  • We’re not trying to convince the person, we’re asking him or her to look at the situation differently by drawing on his or her own experiences. 
  • We’re definitely not suggesting his or her symptoms are imaginary – this is unhelpful! 
  • We’re also not suggesting further investigations – as I mentioned in an earlier post, this can suggest either that you agree, it could be something sinister, or it can be evidence that ‘nothing has shown up – yet’.

Many people with anxiety about their health (or pain) develop quite strong ‘checking’ behaviours, along with seeking reassurance.  The problem with checking is that if any of the symptoms are associated with anxiety, the act of checking is likely to increase the probability that anxiety will also increase.  Checking can also mean usually normal or benign symptoms can be found – and misinterpreted!

Some strategies that can help with checking:

  1. Counting the cost – how much time/effort/anxiety is wrapped up in checking?  You could use a balance sheet of pro’s and con’s to identify the good and not-so-good aspects of checking
  2. Is it working? Asking the question ‘Does checking prevent something from developing? Does it change anything?‘ What is the effect of checking?
  3. Handing responsibility to you as a therapist for a defined period of time (eg a weekend).  This is similar to running an experiment – what would happen if the person allowed you to ‘worry’ about his or her symptoms for a weekend to experience the effect of not checking while at the same time keeping a safety-net in place (you!).  I can hear some therapists saying ‘Ooooh but what if it’s for real and something horrible does happen?’ – my answer is that if we’re doing this kind of work, we need to have had the medical ‘say-so’ that nothing sinister is present. 

I hope these strategies provoke some discussion.  They’re not meant to dismiss the person’s experiences, but they are meant to help the person decide, on the basis of guided discovery, whether the cost of misinterpreting body symptoms is worth it.  For much more information, any of the papers by Professor Paul Salkovskis, Professor Heather Hadjistavropoulos will be useful reading.


  1. As usual, a lot of great well-written information, Bronnie.

    Two comments:

    1. The problem with checking is that often we find what we look for. I used to keep a health diary, or more to the point, an ill-health diary. I’d keep track of visits to doctors ( a lot!), aches, pains, flare-ups, infections, etc.

    Since I’ve started this stress work, I’ve turned things around. One of the things I changed was to start keeping track of my good health and in so-doing, I had more good health. (Bad days would be evident because of the unreported good days – they just weren’t being chronicled)

    2. The other thing I’ve learned to change is my self-talk. I used to wake up with stiff, inflamed joints and my first thoughts would go something like…”Oh no! I’m having a flare-up! Wonder how bad this will be? Am I going to get everything done that I need to do? Oh dear…” and on it went.

    All these negative thoughts and emotions surrounding this would create stress and the cascade of neuro-chemicals would create more stress and on that went.

    I’ve learned to do a stress technique and substitute the self-talk. What a difference that has made.

    It’s been 33 years in the making and has been quite a learning journey for me.

    1. Thanks so much for sharing your experiences! I agree that if we look for negative/stressful things, we’ll surely find them and the good things seem to vanish, and again, if we look for good things each day, we’ll find them – and then the not so good things seem to have less impact!
      And yes again to the self talk – if I keep on saying ‘Oh no, I’m really sore today’ it’s certainly not helping me want to move and do things, even if it’s accurate! Which is why I don’t like calling self talk ‘maladaptive’ or ‘erroneous’ as some CBT clinicians do, I’d rather call it ‘unhelpful’ self talk, and set about putting in more helpful self talk that does support me in what I want for my life.
      And it’s so great to read that 33 years of learning it and doing it has been effective. For me, I expect I’ll keep on learning to do it every day because it can be so easy to slip up… but if I look at how I respond to situations now compared with how I used to – and the effect of doing it differently? Well, what a difference!

    1. I’d love to be able to reference that “equation” but it’s one of those memes that have been circulating for many years – I’ll reference it as “anon”.

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