normalising

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.

Causes for headaches
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!