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

Posted Mar 29 2010 10:06pm

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.

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 InventoryRemember: 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

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