Years ago, the relationship between depression and chronic pain was the hot topic, and it’s only more recently that anxiety and pain have become popular. So slightly tangentially, but I think you’ll see how it relates, today I want to muse a bit about health anxiety and some of the findings from this interesting area of health management, and how it might transfer into pain management.
One of the things a person with chronic pain often fears is being thought of as a hypochondriac. Somehow ‘That Word’ has a load of really negative connotations that suggest the person is simply making more of their problem than necessary and really ‘should’ pull themselves together, build a bridge, and get over it. Hypochondriasis is better-named ‘health anxiety’ and the underlying thinking processes associated with it are very similar to those underpinning the anxiety disorders – things like checking (OCD), reassurance-seeking (separation anxiety), avoidance (phobia) for example are very much part of health anxiety. People with health anxiety seek health care input often, and can remain dissatisfied and unreassured as well as using more health care – and in this paper by Muse, McManus, Hackman, Williams and Williams, is thought to occur in about 5% of the population. While the actual figures on the prevalence of health anxiety in people with chronic pain don’t seem to be readily obtained, it’s no surprise to me to think that some of the people with high health use associated with chronic pain could also have health anxiety.
One of the things that is known to maintain PTSD is flashbacks or visual imagery of events, situations or items similar to the triggering event, and in this paper the authors tried to identify whether people with health anxiety also experience intrusive imagery – which may also serve to maintain the anxiety disorder.
Basically, they interviewed 55 patients, asking them to focus on their experiences of being anxious about their health in order to identify related intrusive imagery. Participants were then asked to describe their most distressing image and then answer questions relating to this image. These responses were analysed using content analysis to identify themes, and to identify the frequency of imagery and the intrusiveness.
Participants were then asked to focus on their image, and identify whether it was a memory, and if so, how distorted their memory was (although I think this is a pretty difficult challenge!). Finally they were asked to rate five behavioural responses to that image, the responses being those associated with health anxiety such as avoidance, checking, seeking reassurance and so on.
What they found was a large percentage of the participants clearly recalled instrusive images (43 from 55), and there were no differences in terms of gender, or socioeconomic status, nor even symptom severity between those that did, and those that didn’t.
On average, the 78% of participants who did describe intrusive imagery experienced this about 3 – 4 times a week, images were vivid and distressing, and the majority of participants felt as if they were ‘right there’ – or looking out through their own eyes at the event, with more of them seeing this as an event occurring in the future.
What did they see? Four main themes were identified – i) being told ‘the bad news’ that you have a serious/life-threatening illness (6.9%), ii) suffering from a serious or life-threatening illness (34.5%), iii) death and dying due to illness (22.4%) and iv) impact of own death or serious illness on loved ones (36.2%).
72% of those describing intrusive images also said their imagery was associated with a memory – either of an actual event occurring to themselves, or an event occurring to someone else but with the person being the one affected rather than being an onlooker.
It looks very much like memories of serious ill health, or of someone else being seriously unwell, can become a source of negative imagery that then can become a maintaining feature of health anxiety. By engaging in the typical anxiety-maintaining behaviours of checking, reassurance-seeking, avoidance, distraction and rumination both the images and the anxiety about health continue. It’s worth remembering that the images were projecting forward in time – and probably helping to increase the belief in the probability of the event actually occurring.
What might this mean for people with chronic pain?
When I recall the number of people who develop chronic pain after a traumatic initiating event like a motor vehicle crash, or a sudden work accident, and when I think of some of the ways in which the news can be conveyed to people: ‘I’m sorry you will need surgery’, ‘there’s nothing I can offer you’, ‘you’ll have to take these medications for the rest of your life’, or ‘I don’t really know what’s wrong with you’ – I can quite easily accept that for some people this could trigger health anxiety, but a specific health anxiety related to their pain problem.
It helps to explain, at least to me, some of the reasons people carry on looking for more tests, more investigations despite nothing significant being found, and need more reassurance that somehow doesn’t actually reassure.
This paper also makes me wonder whether it’s worthwhile exploring the events surrounding the initial onset of pain, and just as importantly, the things the person has learned from his or her interactions with health care providers. It might also be useful to explore how members of the person’s family have heard about their health status – has anyone else in the family and friends had a serious illness, or been advised they have an ongoing pain problem.
Once again I’m struck by the need to go beyond the individual and his or her immediate problem, and take the time to explore the context in which the problem developed – especially the other people and events that have occurred in the person’s life.
A lot more work needs to happen for this idea of health anxiety imagery and chronic pain anxiety to be scientifically established as a robust phenomenon. But it’s an intriguing possibility because treatment of health anxiety, while challenging, is reasonably well-etablished. It might give some guidance to GP’s and other primary health care providers as to what NOT to do for people who are anxious about their pain. Don’t ‘reassure’ because it’s not that reassuring, don’t go ahead with more investigations ‘because it might reassure the person that nothing’s wrong’. The process of checking and re-checking seems to increase the anxiety and maintain it.
Next post? What to do instead of reassuring!
Muse, K., McManus, F., Hackmann, A., Williams, M., & Williams, M. (2010). Intrusive imagery in severe health anxiety: Prevalence, nature and links with memories and maintenance cycles Behaviour Research and Therapy, 48 (8), 792-798 DOI: 10.1016/j.brat.2010.05.008