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!

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!