What do people with chronic pain & health anxiety worry about?

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

Is reassurance reassuring?

Having started yesterday’s post by discussing health anxiety, and pointing out that one of the things people do to cope with their anxiety about their pain is to seek reassurance, I thought it might be useful to go back to a paper published a couple of years ago by Linton, McCracken & Vlaeyen (2008).  In this paper, the authors reviewed the concept of reassurance and see whether it is, in fact, reassuring.

What is reassurance anyway? We talk about it as if we know what we mean, and it’s even part of most guidelines for managing acute low back pain – but what is it? In this paper, the authors refer to the Oxford dictionary definition where reassurance is defined as ‘‘. . .removes the fears or doubts of (pain/illness); to comfort’’. As they point out,

“Reassurance always takes place within the dynamics of the interaction between the caregiver who has the intention to reduce worry, and the patient who is concerned. Ultimately, reassurance is achieved if the patient changes his/her behavior, understanding or thoughts.”

Reassurance is therefore a social act (once again, do you get the social theme?!) And the tools that health providers use are mainly verbal – information, persuasion and instruction.
When I think about what this actually means in a health care encounter, it usually looks like the provider gives information and recommends some sort of test or investigation. Hopefully the patient will make the link between his or her symptoms and the information the provider gives – and more hopefully, the results of the test or investigation come back showing that everything is A-OK.

Linton and colleagues discuss a study showing that “Only when doctors provided reassurance that included a relevant (to the patient’s concerns) explanation that linked physical and psychological factors was the explanation accepted.” Otherwise, the patient simply repeated or detailed his or her problems and asked for more tests. Sounds like it’s important for clinicians to demonstrate that they’re listening and really answering the specific concerns of the patient, rather than just giving general information. The interpretation these authors give to this response by patients suggests that “when patients experience the information as a lack of understanding of the legitimacy of the complaint, they responded by asserting the complaints more forcefully.”

I’m reminded of a quote attributed to the late Bill Fordyce ‘Information is to behaviour change as spaghetti is to a brick’ – just telling people things doesn’t seem to reduce their concern or change their behaviour.  Maybe simple reassurance via information giving works fine for people with low health anxiety, but it doesn’t cut it for people who are anxious about their health.  Our problem as clinicians is to work out whether the person we’re seeing is or is not health anxious and that’s not such an easy task.

Now another strategy that especially doctors use is acquiescing to the person’s desire for more investigations and sending him or her off for something like an MRI.  Of course, the belief behind this is that there will be ‘nothing there’ and the patient will feel relieved and all is well.

A couple of things make this a problem – many MRI scans do show artifacts or changes that are unrelated to the pain problem, but because of the strong prevailing belief that these things ‘could’ be associated with the problem, these findings can send the person off on another round of medical consultations – sometimes ending up in unnecessary and invasive procedures or surgery.   The second thing is less intuitive – Linton and colleagues discuss the findings from a study conducted in the Netherlands in which women with breast pain and women without breast pain were scanned – the results found that only transient positive effects were found in those in whom the scans were negative for cancer.  So while it might temporarily relieve the worry, this is only a temporary effect.

A similar finding was obtained in a study of people receiving MRI for low back pain – all participants received the MRI but only half had their results released to them and their doctors.  All of them received the same conservative care, but those who received information about their MRI findings actually felt less well in themselves.  It had basically the opposite effect.

So far I’ve discussed the clinician’s responses and the overall effect on patients.  Next I’ll look at the effect of reassurance on the patient.  It makes sense to me as a clinician to want to reassure the person I’m seeing that their problem is mild, that they’ll recover and everything will be fine.  Hmmm.  Not so according to the findings discussed in Linton, McCracken and Vlaeyen’s paper.  It seems that this actually increases the worry about future pain, so the patient hears ‘Your problem isn’t so bad – yet’.

Their recommendation? Expressing empathy, or in other words, reflecting to the patient that they are worried about their health, the meaning of the symptoms and that it must be very frightening.  Just by doing this, clinicians can show that they are really hearing what the person says – and that’s in part what the person is looking for.  It seems likely that the conclusion Linton and colleagues came to “while patients signaled psychosocial difficulties, GPs focused more on physical disease and that few GPs empathized with their patients. ..unnecessary physical interventions [are] associated with the GP’s responses rather than the patient’s demands.” That old adage ‘if all you have is a hammer, all you’ll see are nails’ comes to mind.

Just to put a spanner in the works, a study looking at parental reassurance is discussed in Linton et al’s paper – in this it was found that when parents reassured their children it actually increased verbal expressions of fear and worry.  Some reasons this might occur are proposed – maybe by reassuring, parents are conveying that the kids actually do have something to worry about; maybe kids who are more anxious trigger reassurance from their parents more quickly; and finally by giving reassurance this could actually trigger release of negative emotions in the form of crying or pain behaviour.  There is much to learn about interpersonal communication and pain, it seems!

So, to conclude.  Even though reassurance is suggested as a mainstay for reducing the fear and worry associated with things like acute low back pain, it seems that the evidence is mixed in terms of how effective this can be.  Giving advice without tempering this with what the patient actually wants to know about is not likely to be very effective.  It looks like at the very least we’ll need to learn more about how to respond empathically to our patients, show them that we really are listening, and give individualised information that they’re ready to receive. We might also need to consider helping people ‘sit with’ or tolerate their anxiety about their pain – or should I say, we might need to help ourselves as health providers learn to tolerate our own anxiety about not suggesting things like investigations ‘to reassure’, because it doesn’t seem to actually do the trick.

And, as usual, there is so much more to learn.

LINTON, S., MCCRACKEN, L., & VLAEYEN, J. (2008). Reassurance: Help or hinder in the treatment of pain Pain, 134 (1-2), 5-8 DOI: 10.1016/j.pain.2007.10.002

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.

Health anxiety & chronic pain – ways to work with worried people

There are many strategies to use when working with someone who is really anxious and worried that their pain is something nasty, and becomes hypervigilant to symptoms that are actually physiological arousal, or symptoms of anxiety.

The first practical thing to do is take the time to listen and understand what the person thinks his or her symptoms indicate.

Sounds easy, right?  But as people with persistent pain say time and again, very few clinicians go beyond asking for a description of symptoms, and few ask about the conclusions the person has drawn from both symptoms and bits of information they’ve heard (or misheard) from the various health providers they’ve seen (or even the internet sites they’ve been on, or books they’ve read).

How could you do this? One way is to simply ask the person “what do you make of your symptoms? What do you think this all means?”  Another way is to ask “What’s your theory about what is going on with your health?”  Or “You’ve heard lots of different explanations for your problem, what do you make of it?”

It’s really important at this stage to avoid correcting the person’s beliefs.  That can come later – for now, listen, and listen hard.  To help you do this well, use reflective listening.  What this means is to summarise what you think you’ve heard the person say, and then ask something like  “Have I got this right?”

The aim of doing this listening and understanding is that it helps you understand how the person came to believe what they now believe. This is the first step in developing a formulation.

The next part is to identify assumptions the person has about reassurance and their experience of the  medical consultation.  This could be something like ‘if he was to tell me I didn’t have a tumour, it still wouldn’t tell me why I have this pain’.

Listening also helps you to understand the personal meaning of the symptoms they experience. What this means is that you learn what they think ‘that burning pain under my bellybutton is exactly where I had the pain when they found out I had an ulcer, so even though they haven’t found an ulcer (yet) it could be just starting’. You might also learn that they have occasional tingling in their fingertips and a heavy feeling in their chest when their pain levels are high, and they think this means they’re about to have a heart attack even though their examinations at Cardiology are clear, and yes, they do get a racing heart and yes, they also breathe really fast and feel hot and sweaty, and this too is a sign that they are about to have a heart attack.

As Salkovskis says ‘Patients are grateful if they find out what the problem is not; but they really want to know what the problem IS.’

There are some general cognitive biases that people with high health anxiety tend to have:

1. Bodily changes are always a sign that something is wrong
2. If I don’t worry about my health, something will go wrong
3. Detailed tests are the only way to really rule out an illness
4. If the doctor sends me for any tests, this is because he or she is convinced that there is something wrong (this is why sending someone for more investigations doesn’t actually reassure at all!)

Before starting to treat someone who is experiencing high health anxiety (and especially when they’re seeing you about their chronic pain) it’s important that the person is not concurrently receiving referrals for investigations or other interventions that could suggest that the problem ‘could be serious’.  For example, it’s not helpful to see someone to help them self manage their chronic pain when they’ve also been referred for more investigations (eg MRI scans), or for injections or infusions.

On the other hand, it’s not necessary to exclude people from treatment for their anxiety about their health on the basis that they actually do have a physical condition.  So even people who have angina can benefit from help with their anxiety about having a serious heart problem because the anxiety contributes to their distress and increases their heart rate and blood pressure – all contributing to the risk of more angina!

Another important step in coming to understand the person’s situation is to ask them to recall a recent episode where their anxiety and distress was high in relation to their health.

While exploring this situation, ask about things like where and when did these symptoms occur?  What were you doing just before it? What was the first sign of trouble?

Step the person through their experience, the situation and their reactions to it. This is a process of ‘guided discovery’, where the two of you are collaborating to understand what was going on.  Some examples might help:

“When you noticed your fingers tingling, what did you think at that time, was the worst this could be?” – and ask the person to rate how much they believe this – from 0 – 100%

“When you thought this tingling meant your back had gone out again, how did that affect you?(how did it make you  feel…..what did you do……what did you pay attention to…….how did you try to deal with it…..)

As you do this, you can write down or draw arrows from one aspect to a thought, to an emotion, to a behaviour or next action or symptom, as you develop a shared picture of what happened.

BTW – this diagram is from Salkovskis.

I’m going to stop here, because there is much more to do – but this is the first step.  You might notice that it’s not much different from what we’d do for chronic pain management – we’re basically trying to learn how experiences link with thoughts, emotions, and behaviours to form a chain that maintains the distress about the experience.  Treatment is therefore about helping the person look at things differently, reality testing what they anticipate will definitely happen with the likelihood of that horrible thing actually happening – and boosting their own sense of how well they can manage this sort of situation.

Health anxiety & chronic pain

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:

1. 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’.
2. 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!
3. 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…
4. 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!

“You’re just being a hypochondriac” – health anxiety & chronic pain

I think that label has to be one of the most feared amongst the people I see with chronic pain.  To be judged as being obsessed about nonexistant illnesses when actually having pain every day must be incredibly difficult to cope with.  At the same time, being anxious about health and having mistaken beliefs about the meaning of symptoms can be part of both having chronic pain and having health anxiety (the condition previously known as hypochondriasis).  And the temptation some health providers have to say “Oh just go and pull yourself together and stop worrying”  is both unhelpful and part of the problem!

I’ve been reading about health anxiety as I look at ways to identify and work with people who are fearful of experiencing pain while at the same time have been told, and to a certain extend believe, that they’re not harming themselves.

One of the major contributors to a cognitive behavioural understanding of health anxiety is Salkovskis , Professor of Clinical Psychology and Applied Science at the Institute of Psychiatry, Kings College, London.  I was lucky enough to attend a health anxiety workshop based on his work last year, and some of the strategies I learned there were really helpful. I’ll discuss them later this week.

The model he proposes for health anxiety is fairly similar to those for obsessive compulsive disorder and panic disorder.  It’s also not that different from the ‘fear-avoidance’ or pain-related anxiety and avoidance model that so many of us are familiar with.  In it, there are two main characteristics that need to be addressed to help the person cope with their anxiety about body sensations.

1. Misinterpreting body symptoms as something indicating a serious or threatening health problem
2. Using ‘safety-seeking behaviour’ to cope with this anxiety, but in fact maintains it

An example might help.

Joe Bloggs, (not his real name!) experiences a queasy stomach, often just before he eats.  He is certain this means he has a stomach ulcer, or that if he eats, he will vomit.  As a result, he delays eating and only eats once a day and then only tiny amounts of food.  As he swallows, he monitors the feeling of the food passing down to his stomach, and his stomach feels full and tight.  He starts to feel nauseous.

Does this look a bit familiar?
At the top is the belief that, for example, ‘these symptoms should not be there, they mean something horrible is happening to me’, this leads to hypervigilance, or scanning the body for possible symptoms of ill health, and this leads to misperception of normal symptoms as if they’re something abnormal. In ‘Joe’, you can see that it’s normal to feel a bit queasy if you haven’t eaten all day, but to him it’s a sign that he’s unwell and should avoid eating. He’s also very aware of the sensation of food as he swallows, and interprets this as abnormal rather than how food normally feels!

The symptoms that are noticed then generate anxiety and uncertainty about what is going on in the body, leading to ‘safety seeking behaviours’. In ‘Joe’, this has lead him to restrict his food intake to once a day, making him even more likely to feel queasy and to experience stomach cramps and bloating after he’s eaten. By restricting his food intake, he believes he is preventing or avoiding the strange symptoms when in fact he’s more likely to experience them – and he’s monitoring his internal state all the time. When he does experience these sensations, he takes this as confirmation that he was right to avoid food during the day, and there must be something wrong with his digestive system.

In the same way, people with chronic pain can misinterpret not just their pain symptoms, but also physiological arousal (such as nausea, sweating, heart racing and breathing changes, cold extremities and feeling nauseous) as definite signs ‘something is wrong’.  It’s especially noticeable in people with noncardiac chest pain, but it’s present in many people with pain in other parts of their body.

By monitoring their body all the time, and being afraid of what they find, people with high health anxiety confirm their worst fears – there is something strange going on!

Some of the other ‘safety behaviours’ people with health anxiety use are:

• 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

Reassurance doesn’t reassure!  In the case of health anxiety, it serves just to reinforce that something strange is going on – after all, the symptoms are there.

There are several ways to assess for health anxiety.  One is the Short Health Anxiety Inventory, described in the paper by Abramowitz, Deacon and Valentiner (2007), and also in Salkovskis, Rimes, Warwick & Clark (2002) where it appears in full.  Another is the Beck Anxiety Inventory.  Remember: don’t use these if you’re not going to learn what they mean and how to interpret them!

I’m still mulling over whether they tap into the areas I’m concerned about in the people I see.  I’m not sure – but I can see how this model applies in some people with chronic pain, and how the strategies I learned might be useful.  Stay tuned and I’ll discuss those strategies and how I’ve used them in my sessions with people.

Abramowitz, J., Deacon, B., & Valentiner, D. (2007). The Short Health Anxiety Inventory: Psychometric Properties and Construct Validity in a Non-clinical Sample Cognitive Therapy and Research, 31 (6), 871-883 DOI: 10.1007/s10608-006-9058-1

More on anxiety and pain – pain-related anxiety

It seems obvious that something unpleasant is something to be avoided – and if we’re meant to avoid it, we’re likely to be just a little bit afraid of it. Yesterday I talked about health anxiety in general, and today I want to touch on a specific sub-group of health anxiety – pain-related anxiety.

Many people will be familiar with pain-related anxiety and avoidance, the model of so-called ‘fear avoidance’ that is a compelling explanation for how so many people become deactivated and disabled when they have persistent pain. It might be a surprise to some that the term ‘fear avoidance’ is actually not technically correct! There are two parts to the phenomenon: fear (or really, pain anxiety) and avoidance. It’s possible to be fearful or anxious about something but not avoid it – and it’s the avoidance part that creates the disability, which is why we are so keen to get people to DO things, even if they’re afraid.

If we look at yesterday’s post about anxiety, and review Beck’s cognitive model of anxiety, we can see that it’s really about how a person perceives a situation rather than the facts of a situation that is the problem in health anxiety. With an increased perception of the probability that something horrible will happen, multipled by the ‘awfulness’ factor we can begin to understand how some people will be really afraid of having pain. This is modifed by their personal resources and ‘rescue’ factors which might be things that other people do to reduce the person’s distress or decrease the ‘awfulness’ factor.

Pain anxiety is somewhat more problematic, IMHO, than general health anxiety. The reason being that so many conflicting messages are available in the community about having pain. It’s all around us that to have pain means ‘something is wrong’ – we’ve all grown up with this belief, developed through our own experiences with acute pain, and the media and almost all health care pushes the idea that we should not have to experience pain. Which is all very well except that it creates an unrealistic expectation for people who have persistent pain that doesn’t respond to pharmacology, surgery, injections or anything else that is ‘done to’ the person. Because like it or not, we don’t yet have all the answers to all the health care problems – just think of the common cold!

In the case of classic health anxiety, there is usually a nice clear-cut statement from a medical person that ‘there is nothing wrong’, health investigations are clear, there is nothing sinister going on, the person is not going to die from something nasty. In pain? Well all around us there are messages saying that ongoing pain is not OK, and it only takes one practitioner to suggest that there is some removable cause for their pain that will take the pain away for a person to start to worry again about their pain (and start looking for ‘the cure’).

It’s understandable. Pain isn’t pleasant – that’s part of the definition of pain! But people don’t die simply from having chronic pain. It can be depressing, distressing, and invade much of life, ruining the quality of life in many spheres – but many many people do cope well despite having pain, and have rewarding, fulfilling lives even though they have persistent pain.

The difference between being anxious about pain and living well with pain? Not so certain actually. We do know a lot about people who have pain and look for treatment. In fact, we know heaps about these people. We don’t know very much about people who don’t look for treatment simply because they don’t turn up at treatment centres. As a result, we don’t really know how people who live good lives despite their pain actually do so.

Maybe this group of people have developed ways of viewing their pain that reduces the ‘awfulness’ factor, maybe they have more resources, maybe they can be flexible about how they go about achieving what is important in their lives, maybe their goals are different, maybe they don’t have some of the vulnerability factors discussed in the paper I’ve identified today.

The fact is, we simply don’t know. Almost all our research on pain and coping is on people who are worried about their pain, anxious about it, and want it gone. Our treatments are based on models like Beck’s and Vlaeyen’s, that are developed from our understanding of people who don’t live well with their pain. So we focus on reducing the level of catastrophising, reducing the use of ‘safety behaviours’ and ‘checking’ and ‘reassurance’, increasing the use of active coping, help people confront what they fear and find out that it doesn’t make life unbearable and intolerable.

This paper by Carleton, Abrams and colleagues identifies that pain-related anxiety might be a separate type of fear that exists alongside other anxiety types – blood/needle phobia, panic, OCD and so on.

It might have taken a while to recognise it, but maybe it’s important to recognise that for a reasonably large group of people, having pain, or anticipating that pain will be experienced, is such an anxiety-provoking problem that this fear needs to be treated rather than the pain itself. This is why simply removing the pain doesn’t solve the problem – in the case of a simple phobia, just not being able to see a spider doesn’t remove the fear of there possibly being spiders under the bed, in the garden, in the shed! In fact, reassurance that there are no spiders doesn’t actually help if the person still looks for one. In the same way, removing pain through anaesthetic blocks or medication or even surgery doesn’t help if the person still fears having the pain – because they’ll be checking their body, any investigations and probably any other body sensations to try to make sure there is nothing going wrong. You can be sure that any slight change in body sensation will be monitored, and in someone who is anxious about having pain, be evidence that there is something wrong, eliciting all those worries and leading to avoidance.

What to do? Not sure yet – while we can help individuals, it only takes one person to re-establish that fear by inadvertently suggesting that ‘something is there’, or that pain ‘must be’ abolished – and the whole anxiety process starts again. More on this tomorrow!

Carleton, R., Abrams, M., Asmundson, G., Antony, M., & McCabe, R. (2009). Pain-related anxiety and anxiety sensitivity across anxiety and depressive disorders☆ Journal of Anxiety Disorders, 23 (6), 791-798 DOI: 10.1016/j.janxdis.2009.03.003

Health Anxiety

We used to call it hypochondriasis – and that’s a term loaded with unhelpful meanings if ever there was one!  What hypochondriasis meant was ‘it’s in your head, there’s nothing wrong with you, go away and pull yourself together’.  Ask someone who has had an episode of noncardiac chest pain to ‘go away and pull yourself together’!

The definition of heath anxiety is:

– preoccupation with, and fear of developing or having a serious illness

– it persists despite medical reassurance

– this worry interferes with everyday life

– it’s been going on for 6 months or so

Health anxiety is about misinterpreting body sensations and changes and thinking that they are evidence of underlying serious illness – despite reassurance and lack of confirmatory findings from investigations.  What it can lead to is high distress, more medical appointments, more investigations, more visits to the Emergency Department, and reduction of both quality of life and engagement in life.

Salkovskis and colleagues have been workiung with people experiencing health anxiety within a general medical setting as well as people with chronic pain.  I attended a workshop run by Dr Helen Seivewright, a Senior Clinical Research Fellow in a programme run at Imperial College & King’s Mill Hospital, on health anxiety and immediately saw the parallels between people who experience problems with chronic pain and those who have health anxiety.

Health anxiety persists because of:

– selective attention leading to bias in processing information about the person’s health condition – for example, the person may only hear parts of the ‘reassurance’ that a doctor gives, so the advice to ‘keep active because you won’t need surgery until you’re much worse than this’ becomes ‘you’ll inevitably become much worse than this even if you keep active’

– safety seeking behaviours that may include avoidance (we know about this in terms of pain!), reassurance seeking, and checking (how many MRI’s does a person need?)

– physiological arousal causing symptoms of anxiety such as pounding heart, tingling fingers and tight chest

– eventually low mood which can lead to, and reinforce, rumination or thinking, thinking, thinking about what might be going wrong

The model Salkovskis and colleagues uses is a CBT one developed by Beck.  This is where anxiety is = to the likelihood of something horrid multipled by the ‘awfulness’ is divided by the ability to cope + rescue factors.  To help a person with health anxiety means learning to understand their perception of the ‘something horrid’ and the ‘awfulness’, and reality testing the likelihood of that happening, while at the same time helping to increase their ability to cope by developing their own resources, and identifying ‘rescue factors’.

The process of learning to understand the person’s perception of what is going on is fundamental to developing a formulation.  A formulation will include predisposing factors, precipitating factors (for this presentation), perpetuating factors and protective factors – and I use a biopsychosocial model to flesh out the relevant factors for this individual.

The actual strategies introduced as part of the workshop are quite familiar to those who have been using CBT for some time, but I don’t think I’ve mentioned these ones on the blog before.

The first is a pie chart.

Angie has headaches.  She is convinced the headaches are a sign of a tumour but despite lots of reassurance and and MRI, she isn’t ready to accept that there is no sign of a tumour.  In a pie chart, all the possible causes for headaches are listed – making sure there are plenty of low threat examples in there like dehydration, hunger, fatigue, hangover and so on.

Then, starting with the low threat examples first, we ask Angie to tell us what percentage of people in the local supermarket would have a headache from fatigue – maybe 40%.  We mark this in on the pie chart.  Then we go on to stress, and ask how many might have a headache from stress – she might say ‘around 25%’ – so we mark this in on the pie chart.  We work through all the common causes for headaches, using Angie’s percentages (and we ask her to ‘have a guess’ if she’s uncertain), until we come to the ‘serious’ factors like stroke, tumour and so on.  By this time the pie chart has very little room left for these – so it starts to reality test Angie’s belief that her headache is definitely a tumour.  We let her draw her own conclusions about her own headache, but we ask her to go away and think about the pie chart.  The aim of this activity is to normalise what is a common experience, but which Angie has misperceived as a highly threatening and personalised problem.

moar funny pictures

You can also do this as a pyramid – where at the bottom are all the people who have been seen by a GP for headache, then maybe 20% of them are seen again (this can be the next layer on the pyramid), then maybe 5% might need further investigation as another layer, 2% of these might come back as abnormal on the next layer, 1% of these need to be referred to hospital as the next layer, half of the people referred to hospital might have a disease that is significant, and finally on top of that a teeny tiny proportion have something really nasty.

Again this is one way of normalising and reducing the threat value of the belief that the person has. It won’t remove their anxiety, but it might help reality test it a little, and help them start to look at their problem in a slightly less catastrophic way.

More about this tomorrow!