Health Anxiety (Hypochondriasis)
Some Initial Questions
Copyright © Donald Robertson, 2011. All rights reserved.
Health anxiety is a general term for a variety of problems involving worry about and preoccupation with physical illness. Cognitive-Behavioural Therapy (CBT) is the psychological treatment most widely recommended for health anxiety and related problems. One of the main focuses of CBT for health anxiety is to develop an alternative, plausible explanation for the apparent symptoms. It’s assumed that the symptoms reported by clients with health anxiety are generally real and often very distressing but not necessarily due to serious physical disease. In other words, the possibility is explored that symptoms may be understood primarily in terms of psychological causes such as worried thinking, unhelpful beliefs, and selective attention to bodily sensations, maintained by associated patterns of behaviour, such as reassurance-seeking, bodily-checking, or avoidance of certain activities or situations, etc. It’s useful to ask yourself the question, “How is this working out for me?”, in relation to existing patterns of thinking and coping strategies. How are your existing ways of dealing with things working out, in particular, over the longer-term, both in terms of your overall level of emotional suffering and your ability to engage in life? We often find they’re not working out well, in which case it can be worth experimenting with certain behavioural changes.
A number of ways of behaving are typically problematic for people with health anxiety and may help to maintain misinterpretations of symptoms and unfounded fears. You don’t necessarily need to do the “behavioural experiments” described below at this stage, you should normally do these under the supervision of a qualified therapist. However, you might want to consider, as a “thought experiment”, what might happen if you were to either increase or decrease behaviour linked to your symptoms or health anxiety.
Body Checking & Self-Focused Attention
Repeatedly checking your body for symptoms of illness can cause a number of problems. Increased preoccupation with symptoms and heightened self-focused attention can contribute to hyper-vigilance for symptoms such as pain or other bodily sensations and make them seem more pronounced. Body-checking or self-focused attention can cause other sensations, which may seem unusual. For example, when people see an animal with fleas and become worried about getting too close, they may begin to feel a real itch, imagining fleabites on their own body even where none exist. Repeatedly checking the body for problems, e.g., by feeling lumps or sore areas, may interfere with normal functioning or cause increased tenderness and discomfort. If you focus very intensely on your throat for a few minutes and repeatedly swallow, observing even the smallest sensations very closely, you’ll probably find this soon begins to feel awkward and uncomfortable. What happens then if someone focuses all day long, every day, for months or years on a part of their body? Too much focus on bodily functions can create unpleasant sensations and even interfere with normal physiological processes.
Moreover, increased self-focused attention may automatically increase muscular tension in problem areas, which can contribute to some symptoms. What happens if you spend several minutes focusing all of your attention on one part of your body, e.g., your little finger? Do you notice any feelings of tension or other sensations? What do you think would happen to your problem if you focused much more attention on your symptoms for a week or more? What would happen if you could focus on other things and pay much less attention to your symptoms for a week or more?
People who are anxious about their health often avoid situations, activities, or experiences that they fear might cause problems (or some “catastrophe”) related to their health concerns. For example, someone who is anxious about heart disease might avoid physical exercise or strain. People who are anxious about digestive problems might avoid eating certain foods. However, avoidance thereby prevents unfounded fears from being disconfirmed (disproven) by experience. For example, for someone who is anxious that they have a heart problem, engaging in vigorous exercise successfully may provide evidence that helps to undermine their fears.
Some forms of avoidance may cause other problems, e.g., someone who is anxious about back pain and stays in bed to avoid straining may unintentionally make things worse by weakening their muscles through disuse. Avoidance often also leads to periods of inactivity in which time is filled by more worry and anticipatory anxiety, e.g., the more time people spend at home the more their worries may escalate. What would happen if you reversed your patterns of avoidance for a week or more? What would happen to your anxiety if you reversed your avoidance, repeatedly, and nothing bad ever actually happened?
Worry, although a type of thinking, is often also viewed as a pattern of behaviour, or a process. Whereas “anxiety” refers to the feelings of nervous arousal, “worry” refers to prolonged thinking about the worst-case scenario, sometimes called “catastrophising” or “What if?” thinking (“What if something catastrophic happens?”). Thinking about problems for a long time when anxious can create a vicious circle because anxiety tends to distort thinking by making you focus more and more on the worst that could happen, which in turn leads to increased anxiety.
What are the pros and cons of worrying about your health? If you had a switch on the side of your head that made it impossible to worry when switched “off”, would you ever be tempted to turn it back “on” again? Are the perceived benefits of worrying real benefits? Could you gain the benefits of worrying in a better way? For example, some people feel that worrying helps to “motivate” them but clarifying your goals may be a healthier way to increase your motivation.
One of the criteria for a formal diagnosis of “hypochondriasis” is that repeated reassurance is sought from medical practitioners but fails to alleviate anxiety in the long-term. People who are anxious about their health often seek reassurance from doctors, or medical tests, or seek information, e.g., by searching the internet. However, this search for evidence of safety doesn’t seem to be very helpful. Seeking advice repeatedly from doctors can lead to conflicting information and further confusion, in some cases, and it generally increases preoccupation with health concerns.
The fact that symptoms often improve temporarily when medical reassurance is given, however, might be taken as evidence for a psychological rather than purely physical explanation of the symptoms. If a doctor or another expert tells you that your symptoms are not serious what happens? Do they improve? How might reassurance cause your symptoms to improve? How could reassurance have any effect on symptoms caused purely by a physical disease?
Other Safety Behaviours
People who are concerned about their health often engage in a variety of other “safety-seeking” strategies, i.e., things done to “protect” oneself from perceived threat, closely related to avoidance strategies. However, sometimes people get into the habit of doing things to protect themselves against dangers that don’t really exist. For example, it’s said that some pre-literate tribal people carry out rituals, prayers and sacrifices, to protect themselves against threats such as curses or ghosts. These threats probably don’t exist in the first place, though, making their precautions unnecessary. People with health concerns may take vitamins, or rest for long periods, to try to protect themselves from illness. Sometimes people try to seek safety from health problems by doing things pre-emptively, in anticipation of symptoms occurring, and sometimes they try to protect themselves during or after symptoms are experienced.
Sometimes the things people do to protect themselves may simply maintain health anxiety by preventing unfounded fears from being disconfirmed. Safety behaviours may also sometimes contribute to symptoms in subtle ways, making things worse instead of better. For example, someone who tries to breathe more slowly or deeply to control sensations of choking or tightness in the chest may potentially make things worse by tensing their muscles and hyperventilating. What would it mean if you dropped your safety-seeking behaviour permanently and nothing catastrophic actually happened? How could you test and find out for sure whether it’s really necessary to “protect” yourself in this way?
Thinking & Beliefs
Certain styles of thinking may contribute to health anxiety. For example, “catastrophising” or dwelling on the worst-case scenario will tend to contribute to anxiety. Similarly, over-estimating the probability and severity of health problems is commonly a factor in health anxiety. In addition, genuine evidence of safety is often overlooked and alternative explanations for symptoms are often prematurely discounted and rejected.
If you believe your symptoms are due to a combination of physical and psychological factors, it might be useful to draw a pie chart to help work out to what extent different factors contribute to any symptoms experienced. Of course, if you believe accurately that your main problem is the presence of a serious physical disorder then you should seek medical advice from your doctor. However, for many people psychological problems can cause emotional suffering and even physical symptoms, or make existing physical conditions much worse.