How we treat Health Anxiety (Hypochondria) using CBT
Health anxiety, also sometimes referred to as hypochondriasis or hypochondria, is an anxiety disorder in which we become preoccupied with the possibility of us having a serious illness. This preoccupation leads us to feel excessively anxious, and spend a lot of our time using behaviours focused on our health and anxiety. These behaviours can become so entrenched that they begin to have a negative impact on our normal functioning. The disorder can affect as many as 5% of people at any one time, with many not being aware of the fact that good quality, evidence-based psychological treatment (i.e. CBT) is available. In this article, I am going to detail how I treat health anxiety using Cognitive Behavioural Therapy (CBT).
These are the main sections that I cover in this article, feel free to jump ahead.
A Cognitive Behavioural Model of Health Anxiety
Understanding the real problem (Theory A vs Theory B)
Safety Behaviours and Avoidance:
- Symptom Checking
- Avoidance
- Reassurance seeking
- Selective attention
- Googling symptoms
- Response prevention
- Exposure
- Cognitive restructuring
A Cognitive Behavioural Model of Health Anxiety
Similar to many other anxiety and mood disorders, there are several different CBT treatment models that have been developed to understand Health anxiety. Some of these models have a more behavioural slant, whilst others are more cognitive in nature. The model that I present below, one that I tend to lean upon more in therapy was developed by Patricia Furer and colleagues, but another commonly used model was developed by Paul Salkovskis and Hilary Warwick. Both models inform treatment just as well as each other, and it is more through familiarity that I choose one over the other.
The Furer model presents a representation of how health anxiety and illness related beliefs are maintained through the use of unhelpful behaviours which include symptom checking, reassurance seeking, and avoidance. The model suggests that two types of triggers, external and internal, can lead to anxiety through the presence of negative illness related beliefs. For example, an internal trigger like a headache, a palpitation or stomach pain can be misinterpreted as a stroke, heart disease or stomach cancer respectively. Seeing an advert on TV about a health concern or reading about someone of a similar age to ourselves on social media with a health problem are examples of external triggers that can activate anxiety through negative thoughts about health also.
The emotion of anxiety emerges when we perceive something, both in our external or internal worlds, as a threat. So, when we interpret a physical sensation as a sign of catastrophic illness (which is of course a threat), our body and brain react the only way that they know how to – with the activation of anxiety. Anxiety has the effect on our body of preparing it for danger, and as such this leads to lots of physical changes, these changes include (but are not exclusive to) increased heartrate, rapid breathing, nausea, dizziness, physical tension and butterflies in the stomach. While these are all perfectly normal and indeed appropriate and helpful in the right circumstances, in health anxiety, we misinterpret these as further evidence that there is something wrong with our health.
This illness interpretation then leads to an escalation in our anxiety to which we respond with a change in our behaviours.
Safety Behaviours and Avoidance
The most common (and unhelpful) behavioural changes in health anxiety are:
- Symptom checking
Symptom checking in health anxiety involves repeatedly checking the area of health-related concern frequently and excessively. Symptom checking can be done visually or manually. There are two main problems with symptom checking in health anxiety. The first is that visual checking leaves us prone to misinterpret normal variations. For instance, if someone is continuously checking their skin for signs of cancer, they may overly focus on natural areas of skin discolouration and misinterpret these as evidence of illness. With manual checking, as we check areas like the testicles or breasts excessively, the actual act of checking may contribute to redness, tenderness and even soreness, which is again misinterpreted as an indication of something bad.
- Avoidance
People with health anxiety may avoid triggers associated with their health concerns or, and in some cases getting help from medical professionals. The avoidance of medical professionals in health anxiety serves the function of the health anxious individual never having to get full confirmation that their health anxiety fear is true. Obviously, the two downsides to this are that a) they never get disconfirmation and b) there may be actual illness that they fail to get the right treatment for.
Because of the way in which the anxiety makes people feel, they will also avoid things which activate the whole anxiety cycle. It is common for people with health anxiety to avoid quite general illness related triggers such as talking about illness, or to avoid representations and reports of illness in media. The downside to this is that the avoidance, rather than disconfirming or confirming any health-related beliefs, stops the individual from ever habituating to the emotion of anxiety itself and keeps the whole health anxiety cycle going.
- Reassurance seeking
How do we feel when someone reassures us that everything is ok? Typically, we feel a reduction in our distress. In health anxiety people may get reassurance from medical practitioners, from family members, from friends etc. Like with the earlier described behaviours, reassurance seeking serves to keep the anxiety going because the elements of relief that one experiences, become reinforcing in that we begin to rely on reassurance to reduce our anxiety. It becomes an emotional regulation strategy, rather than a behaviour which changes anything about our health.
This is why we will see people with health anxiety attend their G.P. surgery multiple times, despite being told by their doctor that everything is ok with their health. We end up using reassurance seeking as a way to relieve our emotional distress, even though we have been reassured many, many times that we are well.
We may also seek reassurance from a number of medical professionals, rather than just one. This is problematic because multiple opinions, or even just variations in the ways that different medical practitioners present and explain information, can lead to ambiguity and doubt as to which one is telling us the right information. This leads to us having such thoughts like, “why did they tell me this, and the other told me that?”. The doubt and uncertainty that this generates leads to more and anxiety and, you guessed it, the need for more reassurance.
- Selective attention
We can’t visually or manually check for all signs of illness, due to the fact that many of the things that we can become concerned with in health anxiety are internal. We can’t visually check for heart problems, for a stroke or for intestinal cancer for example. Instead, we develop the behaviour of selectively attending to the areas of the body that we assume to be the location of the illness. So, if I am concerned about having a heart attack, I may pay extra special attention to the sensation of my heartbeat. The downside to this is that I am likely to notice aspects of my heart activity which are typically normal, but which I interpret inaccurately. There are natural subtle changes in heart rate depending on the activities that we are engaged in and our consumption of substances like caffeine, alcohol or nicotine, and so we are likely to notice these as we selectively attend to them. Because we are already prone to misinterpreting symptoms as aspects of illness, our misinterpretation will lead to more anxiety, which we will then pay further attention to.
Another example is if we fear having a stroke, we may selectively attend to tension in the head and neck, or for floaters in the visual field. Again, despite these all being completely normal and benign experiences, in health anxiety we will misinterpret these as signs of catastrophic illness.
- Googling symptoms
There are a few reasons why using google, or other search engines, to research our health fears can be problematic. Firstly, there just isn’t enough information in our questions to access information to point to a specific diagnosis. Diagnosis of health problems involves measurement of symptoms, monitoring and excluding of other criteria which may also explain our problems. Diagnosis is a skilled process which is undertaken by appropriately trained professionals using appropriate tools and techniques. Googling, “why do I keep getting headaches?” or “what causes palpitations?” is likely to bring up a variety of different causes, most of which are not applicable to your own perceived symptoms.
Secondly, we are also prone to selectively attending to the worst, most scary piece of information, rather than the more benign explanations for our symptoms. So, even though many health-related webpages will present a broad spectrum of potential causes for a headache for example, we will dismiss causes like stress, dehydration, and tiredness in favour of more catastrophic interpretations like strokes, brain tumours and dementia.
Lastly, the quality of information on the internet can vary greatly. Because of the need in health anxiety to get certainty around our health-related fears, we may turn to multiple websites to get the answers that we feel we need. This can then range from more trusted sites like NHS pages, to more dubious and less evidence-based ones like internet forums. Again, we can selectively attend to negative information or even anecdotes about health professionals getting it wrong, which again leads to maintained health anxiety.
In the above examples, we can see that these changes in our behaviour are all contributing factors to keeping our health anxiety going. In treatment, one of our goals is to drop these as much as possible. But as you can imagine, if we have a strong belief that these behaviours are actually preventing us from succumbing to disease, then dropping them is often easier said than done. To support us in making these changes, I’m going to show you one of the first interventions that I use with my clients, which is called Theory A vs Theory B.
Theory A vs Theory B for Health anxiety.
The Theory A vs Theory B technique is a cognitive strategy which invites us to reflect on our perceptions of what our problem really is. This technique can be used in a number of common mental health problems including OCD, Social Anxiety Disorder and Panic Disorder. In terms of health anxiety, the technique asks us to establish two interpretations of what our problem really is. These are our two Theories. Theory A is typically what our illness beliefs are saying the problem is, while Theory B is that we have an anxiety problem that makes us believe that we have serious illness. Below are some examples of what this looks like in practice:
Theory A Theory B
I have a brain tumour I have health anxiety which makes me worry that I have a brain tumour.
I have bowel cancer I have health anxiety which makes me worry that I have bowel cancer.
I have heart disease I have health anxiety which makes me worry that I have heart disease.
See the distinction? Theory A suggests that the problem that we need to solve is a real illness issue. Theory B puts our problem in the realm of a psychological difficulty and is therefore fixed using psychological methods.
We can then assess the degree of evidence that we have for each theory:
Theory A Theory B
I have a brain tumour I have health anxiety which makes me worry that I have a brain tumour.
Evidence for theory A Evidence for Theory B
I get headaches I worry a lot about severe illness.
I see floaters in my eyes When I pay more attention to my symptoms it feels worse,
I get episodes of dizziness. I’ve had scans and been told that there are no physical problems.
The usefulness of using Theory A vs Theory B in health anxiety is that we are able to assess how further CBT interventions support either theory. For instance, if nothing catastrophic happens to our health after a week of not googling and we feel a reduction in anxiety, then this would support our theory B. We check back with theory A/B over the course of treatment, re-evaluating our belief in each theory based on the outcome of subsequent interventions.
Health anxiety treatment
Response prevention
Dropping our responses to health anxiety thoughts is the next intervention that I use in treating health anxiety. As highlighted earlier, health anxiety is maintained through the use of numerous safety behaviours and avoidance strategies. Again, although these behaviours may give the impression that they are addressing and reducing the possibility of our health anxiety fears coming true, they are instead being used as ineffective strategies to manage our anxiety. They become the go-to strategies to deal with illness thoughts, despite them not improving health. As such we need to drop them.
Of course, this can be easier said than done. I invite people to experiment with one of the easier responses to begin with and to then see how this affects their anxiety. For instance, we can see what it is like for a client to ban checking the internet for symptoms for a week in terms of managing their anxiety. Typically, if they do this fully, their anxiety will reduce and we can use this reduction as further evidence for our Theory B.
We would then continue to practice and increase dropping these behavioural responses to health anxiety triggers across the course of treatment.
Exposure
As we develop the ability to prevent using safety behaviours in response to health-related triggers, we next want to increase our exposure to the triggers themselves. Exposure, whether that be to real-world triggers (called in-vivo exposure) or imagined threats (e.g., writing out an illness story) is powerful in that it gives the brain and body the chance to habituate to the trigger. Habituation means that the anxiety is given the chance to reduce of its own accord as the brain learns that the trigger is not an actual, current threat and therefore not warranting a threat based emotional and physiological response. When exposure is repeated again and again with different health related triggers, the triggers become less anxiety activating and the problem reduces.
When I take clients through this, I like to make reference to some of what we understand about the biological bases of our threat response. Anxiety, panic and fear are all emotions which evolved to enable us to deal with real and current danger. So, if we were presented with a predator, we will fight the predator or flee from it, as a consequence of our threat-based appraisal. Threat based emotions are generated in a part of the brain called the amygdala. The amygdala evolved much, much earlier in our evolution than our thinking brain did and as such it has difficulty making the distinction between our internal world and the external world. The consequence of this is that when we have a threat-based thought, e.g., “I’ve got a brain tumour”, our amygdala react to the thought as though it is a real, current threat, rather than recognising that it is just a thought. It treats the thought in the same way as it would treat a real danger and then leaps into action as though we are in real, current threat.
Exposure gives the amygdala the opportunity to sit with the trigger and learn that it is not the same as a real, current danger and therefore no longer needs to react with same fight or flight threat response. The more triggers we habituate to, the less reactive we are to health-related symptoms and we see an improvement in our overall levels of functioning.
Cognitive restructuring
The “C” in CBT stands for Cognitive, and this refers to anything that happens in our minds. In health anxiety this can be a singular thought, e.g., “I’ve got aids”, a process such as worry or rumination, or an attentional bias such as only paying attention to illness associated events in our lives. Cognitive restructuring refers to understanding and changing unhelpful and inaccurate thoughts and biases.
Our minds are full of glitches, and in CBT, we seek to train clients to recognise what these glitches are and to understand how these lead to distorted perceptions of our experience. We call these glitches cognitive distortions, thinking biases, or unhelpful thinking habits. Common thinking biases in Health anxiety are.
Catastrophising:
As the title suggests, this is where we have catastrophic thoughts about our symptoms. For example, an upset stomach is interpreted as stomach cancer.
Mental Filter:
This is where we filter out information that doesn’t support our beliefs. So, if I strongly believe that my symptoms are a catastrophic illness, I will filter out any information that doesn’t support this.
Minimisation and maximisation:
We may be prone to minimising the content of what a health professional has said about our symptoms and maximise our impression of reading a news report of someone becoming ill.
For a full list of common thinking distortions and biases check out my list here.
Cognitive restructuring also involves evaluating the actual evidence that we have for our illness beliefs and working out the cost and benefit of adopting such beliefs. This process can lead us to develop more accurate and helpful beliefs of what is going on for us with out health anxiety symptoms.
So, this is just a summary of what to expect from CBT treatment for Health anxiety. If you have found it helpful and would like to learn more then please feel free to get in touch at [email protected] or [email protected].
Thanks for reading.
George Maxwell
CBT and EMDR Therapist, Positive Psychologist
01/09/2023
