While there is a whole heap of research going on in the area of chronic pain, something that seems to be missing at times is the experience of the person who has the pain. When I take a look through a journal I can see loads of articles with fabulous treatments and awesome brain scan findings – but in the end, pain is and always has been, a private, personal, subjective experience that has individual meaning and impact. Today I’m looking further into this phenomenon called health anxiety in people with chronic pain, and discussing the themes that a group of researchers based at King’s College London found when they talked to people with chronic pain with both high health anxiety and low health anxiety.
It’s thought that the prevalence of high health anxiety in people attending a tertiary pain management centre is roughly 50%. Health anxiety is about ‘preoccupation with a belief in, or fear of, having a serious illness’ (Salkovskis & Warwick, 1986; Warwick & Salkovskis, 1990). It’s not just found in people without any health problems (ie a mental health problem), it’s also found in many people who have a diagnosed health condition, and it is a particular problem in chronic pain because so often it’s impossible to ‘locate the cause’. This means the usual reassurance (as I wrote about yesterday) doesn’t have much effect, and the person with the health anxiety can become incredibly distressed. Distress and health anxiety can lead to zealous pursuit of investigations and treatments and create havoc for the person and his or her treatment providers.
The cognitive behavioural model of health anxiety states that people with this problem tend to have a long-standing bias towards misinterpreting or overinterpreting bodily symptoms or health-related information as evidence that they have a serious health disorder (or are at great risk for developing something serious). As a result, they can demonstrate unhelpful responses in the domains of cognition (e.g. selective and enhanced attention to information perceived as illness related); affect (e.g. anxiety, depression, anger); physiological (e.g. increased bodily arousal); and behaviourl (e.g. increased bodily checking, reassurance-seeking, avoidance, and other safety-seeking behaviours).
This study by Tang and colleagues took a group of 60 patients with chronic pain attending a pain management centre, half of whom had high health anxiety and half with low health anxiety. They conducted in-depth semi-structured interviews with these patients, and looked at how much the cognitive, affective, physiological and behavioural responses described by the participants were consistent with the predictions of the health anxiety model.
The groups were distinguished in terms of health anxiety by their responses on the Short Health Anxiety Inventory, a popular tool for assessing clinically significant health anxiety. The high health anxiety group all scored well above 18, the cut-off score for Health Anxiety, while the low health anxious group didn’t reach this cut-off at all.
The interviews were then carried out by a clinician who was not aware of their health anxiety status, and the interviews covered topics based on the health anxiety model – things like appraisal of pain, cognitive, affective, physiological and behavioural responses to an episode of intense pain, and their own experience of pain and looking for treatment.
Five themes were identified from these interviews, and there were some distinct differences between the people with high health anxiety and those with low health anxiety.
Appraisal of pain – high health anxious people described it as ‘horrible’ and meaning that something is wrong and it’s a sign of worse to come. Low health anxious people described it as hurting, but nothing sinister is going to happen.
Preoccupation with pain – high health anxious people indicated that pain cannot be ignored while people with low health anxiety said things like ‘there’s not much point in thinking about the pain’
Coping strategies (sleep) – people with high health anxiety had a lot of trouble with sleep, but at the same time it was a source of escape, while none of the people with low health anxiety mentioned sleep in this way.
Coping strategies (engagement in activities) – high health anxiety people make a lot of alterations to the way they do things to avoid adding to the pain, while people with low health anxiety carry on with what needs to be done.
Self-identity – people with high health anxiety described themselves as being ‘taken over’ by the pain, while those with low health anxiety indicated that pain is part of them, but doesn’t define them.
Suicidal ideation – people with high health anxiety said things like living with pain is a punishment and not worth living, while people with low health anxiety didn’t discuss this at all.
Tang and colleagues believe that these findings support the cognitive behavioural model of health anxiety in chronic pain. Along with the themes I’ve described here, Tang et al also describe how behaviours associated with these themes would serve to maintain and potentially exacerbate distress, avoidance, rumination and reassurance seeking. And we know from the study I discussed yesterday, that patients who are highly distressed often receive more information about physical aspects of their problem, often have more investigations, and procedures rather than receiving empathic and psychosocially supportive input from their treatment providers.
I know that the Centre in which I work doesn’t routinely assess health anxiety. I wonder whether it could help us identify those people who really need less biomedical input, particularly more investigations, and help us to guide their GP’s and other health providers to provide them with more emotional support. While we can certainly use the cognitive behavioural model of health anxiety in our treatments, it seems from the work of Salkovskis and others that there is a underlying processing bias towards interpreting body symptoms in a more fearful way that may not be able to be completely abolished. Maybe for this group of people we need to help their health care providers to give them consistent emotional and psychosocial support for every health problem they see their treatment providers for, along with, of course, best practice help for the health conditions they have.
I’ve posted before about strategies to help people with high health anxiety cope with their problem, using the cognitive behavioural model promulgated in this paper – take a look here – and it does look as though this is helpful. One question: why is it not integrated into usual clinical practice?
Tang, N., Salkovskis, P., Hodges, A., Soong, E., Hanna, M., & Hester, J. (2009). Chronic pain syndrome associated with health anxiety: A qualitative thematic comparison between pain patients with high and low health anxiety British Journal of Clinical Psychology, 48 (1), 1-20 DOI: 10.1348/014466508X336167