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!