Yesterday’s post about ‘hypochondria’ and chronic pain created a bit of a storm. Emotions run high when you have chronic pain and someone somewhere suggests (a) that it’s ‘all in your head’ or (b) you’re just being a ‘hypochondriac’. There are loads of reasons why both of those comments are inaccurate and unhelpful, but as I said yesterday, there is also a lot of research suggesting that health anxiety might play quite a big part in increasing the distress and disability associated with having persistent pain, and maintaining both.
How would you know if you, or a patient you were seeing, was anxious about his or her health?
You know I’m going to say there is no black and white answer to this one, don’t you?! Anxiety about health varies along a continuum, but there are four main characteristics that you could use to guide your thinking.
(1) Excessive preoccupation with, and fear of developing or having a serious illness
(2) The fear persists despite medical reassurance
(3) It interferes with everyday life
(4) It has been a problem for at least six months
First, the problems with this set of criteria: what is ‘excessive’? This depends on the person’s experiences in the past, and what is happening at the moment. For example, if someone has had a previous heart attack, I’m pretty sure the next time they have chest pain they’re not going to ignore it. Similarly with a breast lump – I’m sure I’d be double-checking each change in my breasts if I’ve had a past lump biopsied. If there is a current flu epidemic (H1N1 pandemic anyone?) I’m sure anyone with a cold or ‘the beginnings of the flu’ will be checking to see whether this is The Flu, and taking it pretty seriously.
A rule of thumb for me would be whether the worrying is taking up time and energy from what the person has to do, or wants to do every day. And it would also be the degree of distress associated worrying – if the person is starting to get panicky, tearful, has physiological arousal symptoms (increased heart rate, nausea, sweating, shallow breathing and so on), then I’d be starting to think this worrying was a problem. I’d also be concerned if the person was catastrophising, and thinking that any and every body symptom was associated with a dread disease, or that maybe the underlying cause was inevitably cancer or something terminal.
But that’s not the only criteria – the next is that the fear persists despite medical reassurance. Some examples from my clinical work recently:
- despite having had imaging (X-ray & MRI) and four surgeons from different parts of New Zealand who confirmed there was no need for surgery, one client continued to believe that there was ‘something wrong’ in his shoulder, possibly cancer, and doctors weren’t telling him.
- after full investigations and x-rays showing well-united ankle fractures (fractured some 5 years ago), another patient wanted more images to confirm that it was ‘safe’ to walk for more than an hour because he worried that the ‘bone had ulcerated and maybe they need to scrape some of the stuff out of it’.
The third criteria is interference – both of the people described above had stopped working, stopped their usual recreational activities (fishing and playing with the grandchildren and mowing lawns), and were miserable. They spent more time either on the internet or seeking medical opinions than they did doing any of their usual ‘fun’ activities. Despite the reassurance they’d had from specialists, they stopped life and worried.
And yes, for both of these men, this worry had been present for more than six months – more like six years in fact.
The fine line between being informed and advocating for yourself – and health anxiety
Yesterday someone mentioned that she was worried that by describing health anxiety as ‘excessive worry’ and describing some of those behaviours such as
- not moving much
- seeing doctors who then give them investigations, maybe MRI, CT, X-ray, nerve conduction
- checking their bodies all the time
- palpating various body parts for pain
- examining body parts for colour change, temperature change
- asking other health providers to examine them
- going onto the internet (!) and reading forums, web pages, searching for syndromes that ‘explain’ what is going on
That I might be treading a fine line between being a self-advocate and having health anxiety.
I hope I’m not, but I can see the difficulty! Here’s my opinion, for what its worth.
To me, the main differences between being a self-advocate and having health anxiety is the degree of distress about the symptoms, and the interference experienced because of the ‘safety behaviours’.
My bottom line? In the process of searching for the ’cause’ and ‘cure’ – are people living well?
Health anxiety persists because of four main factors:
- Selective attention – attending to a biased selection of information. Instead of hearing ‘we found degenerative changes on your x-ray that are quite normal and there’s no need to operate, but I don’t know the exact cause of your pain”, the person with health anxiety might hear ‘your x-rays are normal so your pain is in your head’.
- Safety seeking behaviours – avoidance, reassurance seeking, checking. By avoiding certain movements or activities, the person doesn’t test out whether his or her dire predictions are true. By seeking reassurance, this temporarily alleviates distress, but because of selective attention and hypervigilance to body symptoms, worries sneak in. This can lead to checking – and like the spider phobic who gets really worried when a spider disappears from view, checking but finding nothing means nothing is there – yet!
- Physiological arousal – as a result of feeling anxious about the meaning of sensations, it’s common for people to experience increased sympathetic nervous system arousal. This means that in addition to finding that ‘strange bump on my leg’, or ‘the colour change over my elbow’, the person can also experience nausea, sweating, heart racing and shallow breathing. Sometimes this can progress to a full-blown panic attack, which can feel at the time like something terrible is going to happen! Then these symptoms can be misinterpreted as confirmation that there is something seriously wrong and the person was right to be worried. Which in turn leads to more anxiety … and so on…
- Mood – finally, low mood and anxiety can lead to negative brooding or ‘ruminating’ where thoughts go around and around in never-ending cycles of ‘what if’ and ‘then this will happen’ and ‘what does this mean?’ Ruminating can often disrupt sleep, certainly reduces the ability to concentrate on what is happening here and now, and most importantly, it interferes with taking action.
I’m sure you can see the difference between being informed and advocating for good information and open, honest communication between a patient and a clinician, and the negative effects of being anxious about health.
Tomorrow I’ll start to explore some ways to work with people who are really worried about their health – and it’s not so different from what we do when we work with people who are less bothered by their health. It does mean listening, being genuinely concerned, being empathic, and asking questions so you can understand the meanings the person is placing on his or her symptoms. It also involves you as a clinician not judging or dismissing the person’s health concerns – what you need to do is ‘walk a mile in the person’s moccasins’, really understand what the person thinks is going on. More tomorrow on this!