You may wonder why I’m writing about health anxiety: how does this fit with pain management? Read on – the connection is pretty clear.
Health anxiety (or hypochondriasis) is thought to be fairly common in the community, maybe 5% lifetime prevalence. It involves being extraordinarily worried about the meaning of body symptoms, over-interpreting the significance of ambiguous body sensations. As you can probably imagine, people who experience health anxiety turn up in many different guises in the health system. It’s distressing to the person, not just because they’re afraid they have some dire disease, but also because the interactions between people with the problem, and healthcare providers, can be strained. Health providers can think people with health anxiety are “just wanting attention”, that they need a firm hand and should be turned away so that people with “real” problems can then be seen.
Health providers generally like to give explanations to people seeking help, and try to demonstrate that “there’s nothing wrong”. This means in the early stages at least, people with health anxiety get a lot of investigations and imaging to try to either establish there’s nothing wrong, or to find out what IS wrong. The problem is, in this group of people, giving reassurance by way of a clear MRI or blood test just doesn’t work. In fact, a bit like the spider phobic who covers the spider up with an upturned glass, clear imaging reduces anxiety for a very brief time and then the anxiety goes up. Spider phobics might cover the spider up with a glass, but they keep on coming back just to check it’s still there. And woe betide if it disappears – where oh where has it gone?!
If giving reassurance via imaging doesn’t work, what does? Well, explanations don’t always cut it either – logic doesn’t really play a part in anxiety of any kind. I mean, if you’re afraid of speaking in public, you KNOW the crowd is not going to kill you, but does your mind know that? In New Zealand spiders are not, by and large, poisonous, but my goodness, a big spider will make my heart go pit-a-pat!This response to reassurance or explanation means I’m just a little skeptical about thinking that “pain education” on its own is enough to get people doing things again.
The study that triggered this post is a really large CBT trial in the UK in which patients attending general hospital clinics were screened for health anxiety using a 14-item questionnaire (Health Anxiety Inventory). 28 991 patients were screened and 444 were identified as having excessive health anxiety. This group were randomised into two groups – one to receive standard care, and the other to receive up to 10 CBT sessions.The outcomes were reduced scores on the HAI as well as some important health use indicators two years later.
The outcome this group obtained were significant reductions in health anxiety for the CBT group, little change in the standard care group. A slight reduction in healthcare use was found between the two groups.
A couple of important points:
- People with chronic pain are not mentioned in this article, but other research shows elevated health anxiety in those with chronic pain . Health anxiety increases treatment seeking, so that if a person has pain somewhere – maybe chronic noncardiac chest pain, chronic abdominal pain, and even chronic pelvic pain – a health anxious person is likely to look for help for it, while someone who is less anxious may just let it go and get on with life.
- The clinicians delivering CBT for health anxiety were not specialist clinical psychologists. Instead, they included nurses, graduate research workers, or “other health professionals trained for this intervention.” When cost effectiveness calculations were made, the costs were close to equivalent. This suggests that allied health clinicians can contribute a great deal, at a reasonable cost, to reducing the distress and over-use of health care resources. I’m not just thinking of the dollar value saved by people not attending for unnecessary treatments, but also the human cost saved, and that by treating this group of people appropriately, other people can access those treatments otherwise absorbed by people with health anxiety.
- Interestingly, many people were identified as having health anxiety – 5769 scored more than 20 on the HAI. 3935 declined to participate. 1389 were excluded because they didn’t meet the DSM-IV hypochondriasis diagnosis. People don’t like being told they’re anxious about their health. Somehow the message they get is that their problem is not real. Or they think it’s being trivialised.
Go watch someone who is really stressing about their health, it’s no trivial matter. And the more reassurance we give in the form of investigations the longer they stress. I wonder what would happen if we took the time to listen to what the person is scared about, the meaning they give to their experience, and how this relates to their life, would that investment improve the lives of people with health anxiety?
The link between general health anxiety and treatment seeking for chronic pain (and wanting a “real” diagnosis, “real” treatment, “something to take the pain away”) is pretty close. I wonder what would happen if we ALL got better at responding appropriately to health anxiety?
I wrote about health anxiety in 2010 – here’s a link to one of the posts, or you could use the search function on the blog.
Hadjistavropoulos, Heather D., Asmundson, Gordon J. G., LaChapelle, Diane L., & Quine, Allisson. (2002). The role of health anxiety among patients with chronic pain in determining response to therapy. Pain Research & Management, 7(3), 127-133.
Tang, N. K. Y., Salkovskis, P. M., Hodges, A., Soong, E., Hanna, M. H., & 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(Part 1), 1-20. doi: 10.1348/014466508×336167
Tyrer P, Cooper S, Salkovskis P, Tyrer H, Crawford M, Byford S, Dupont S, Finnis S, Green J, McLaren E, Murphy D, Reid S, Smith G, Wang D, Warwick H, Petkova H, & Barrett B (2013). Clinical and cost-effectiveness of cognitive behaviour therapy for health anxiety in medical patients: a multicentre randomised controlled trial. Lancet, 383 (9913), 219-225 PMID: 24139977