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Treating Health Anxiety A Cognitive-Behavioral Approach
By Steven Taylor Gordon J. G. Asmundson
The Guilford Press Copyright © 2004 The Guilford Press
All right reserved.
Chapter One What Is Health Anxiety?
"I've been sickly ever since I was a kid. For the past week I've been feeling out of sorts, but not in a way I can clearly describe. I'm sure something's wrong. I'm scared I might have MS [multiple sclerosis]. Or maybe it's AIDS." "Every morning in the bathroom I check my body for unusual moles and lesions. Today I found a bump on my skin that I hadn't noticed before. I couldn't stop worrying that it might be cancer. As I prodded and squeezed the bump to check it out, it got bigger, redder, and angrier. That really frightened me, to the point that I had to snip it off with nail clippers."
These people are physically healthy, as their physicians have told them-repeatedly. They are suffering from excessive health anxiety. The purpose of this book is to describe the nature, assessment, and treatment of health anxiety disorders, including hypochondriasis, the various forms of abridged hypochondriasis (among which we include disease phobia), and delusional disorder (somatic type). These are all characterized by excessive anxiety about one's health, stemming from beliefs that one's physical integrity is threatened. Like other forms of anxiety (Lang, 1985),health anxiety is a multifaceted phenomenon, consisting of distressing emotions (e.g., fear, dread), physiological arousal and associated bodily sensations (e.g., palpitations), thoughts and images of danger, and avoidance and other defensive behaviors. Health anxiety ranges from mild and transient to severe and chronic. Our emphasis is on the more debilitating, persistent forms, particularly hypochondriasis. We begin this chapter by defining health anxiety and distinguishing its adaptive and maladaptive forms. We then describe the clinical features of hypochondriasis and related disorders, and explain why health anxiety disorders are important for health care practitioners to understand, detect, and treat.
WHEN IS HEALTH ANXIETY MALADAPTIVE?
Health anxiety varies in the extent to which it is adaptive versus excessive or maladaptive. Virtually all of us have experienced health anxiety at times in our lives. Often the anxiety is adaptive because it motivates us to seek appropriate medical care. Worry about chest pain in a person with a history of cardiac disease, for example, can lead him or her to promptly summon an ambulance when the pain occurs, thereby reducing the risk of mortality.
Health anxiety is maladaptive if it is out of proportion with the objective degree of medical risk. Low anxiety in the face of high risk or high anxiety in the face of low risk can be maladaptive. Lack of worry about the health risks of smoking, for example, can have deadly consequences. Conversely, excessive worry about minor, harmless bodily changes (e.g., spots or rashes) or bodily sensations (e.g., muscle twinges) can cause undue suffering and impairment in social and occupational functioning. The nature and causes of insufficient concern about one's health are not the primary focus of this volume but are discussed in texts on health psychology (e.g., S. E. Taylor, 1999).
Table 1.1 lists the DSM-IV criteria for hypochondriasis (American Psychiatric Association [APA], 2000). Table 1.2 expands on these criteria by describing the cognitive, emotional, somatic, and behavioral features of hypochondriasis. Table 1.1 is useful for diagnosing hypochondriasis, whereas Table 1.2 better conveys the clinical features of this disorder. These features often, but not always, co-occur.
The belief that one is physically ill is known as disease conviction. People with hypochondriasis have strong disease convictions, insisting that they have a serious disease that has been undetected by medical investigations. Disease convictions arise from misinterpretations of bodily changes and sensations.
Strong disease conviction is associated with preoccupation with the possibility of having some dire disease. This is associated with preoccupation with one's bodily appearance and functioning, and hypervigilance for bodily sensations. People suffering from hypochondriasis experience recurrent thoughts and images of disease and death, which intrude, often unbidden, into the stream of consciousness (Warwick & Salkovskis, 1989). One hypochondriasis patient, for example, was bothered by recurrent thoughts that she was about to die from HIV. Her thoughts were accompanied by distressing images of "being pushed into a coffin and buried alive because she is bad" and "husband and son cheerfully visiting her grave with another woman whom he calls mummy" (Wells & Hackmann, 1993, p. 268).
Disease conviction and preoccupation persist even though the person receives reassurance from physicians that there is no evidence of serious disease, and even though the frightening "symptoms" rarely become progressively worse (as might happen in the case of a serious physical condition). People with hypochondriasis typically resist the idea that they are suffering from a mental disorder. Although they may have poor insight into the excessive nature of their health anxiety, by definition they are not delusional. They are able to acknowledge, at least in their calmer moments, that their health concerns are exaggerated.
People with hypochondriasis tend to misinterpret the seriousness of innocuous, natural bodily fluctuations, and overestimate the seriousness of symptoms of general medical conditions1 (Côté et al., 1996). They may complain of highly specific symptoms, or report symptoms that are vague, variable, and generalized (e.g., aching "all over"). Common specific symptoms include localized pain, bowel complaints (e.g., changes in bowel habits), and cardiorespiratory sensations (e.g., chest tightness). People with hypochondriasis are more concerned with the meaning of their physical symptoms than with any associated discomfort or pain (Barsky & Klerman, 1983).
People with hypochondriasis have some form of disease fear (Kellner, 1985; Noyes, Stuart, Longley, Longbehn, & Happel, 2002). There are two types: fear that one currently has a disease, and fear that one might contract a disease in the future. A person can simultaneously have both types of fear, perhaps because both are associated with fears of dying and death. When Jane W. noticed mildly painful sensations around her eyes, she was preoccupied with fear of having a brain tumor. Jane also feared that some day she might have another bout of blepharitis (eyelid inflammation). She had had bouts in the past and worried that further episodes might lead to blindness.
Disease conviction is closely associated with fear of currently having a disease, and is also correlated with fear of contracting a disease in the future (Cox, Borger, Asmundson, & Taylor, 2000; Hadjistavropoulos, Frombach, & Amundson, 1999; Stewart & Watt, 2000). Fear of having a disease is more central to full-blown hypochondriasis than fear of acquiring a future disease (Côté et al., 1996). The latter fear is a core feature of one of the other health anxiety disorders we discuss in this book: disease phobia.
People with disease fears become frightened or anxious when exposed to stimuli that they believe to be disease-related, such as bodily sensations or other somatic changes. These people also become anxious when exposed to disease-related information, such as medical TV programs, which can lead them to worry that they might have acquired the disease in question. They also often become anxious if they come into contact with people who appear to be ill.
The two disease fears can be functionally related: fear of having a disease (and associated disease conviction) can lead to fears of contracting other diseases. Bob H. was frightened that his immune system had been dangerously weakened because of exposure to solvents at work. He interpreted various bodily sensations, such as fatigue and nasal congestion, as evidence of immunological impairment. Bob also feared that he might someday come down with Asian flu, which he thought would certainly kill him because of his compromised immune system. Thus, his fear of Asian flu was a result of his fear (and associated belief) that his immune system had been compromised.
A person can shift from fear of contracting a disease to fear of actually having the disease. George K. had had a serious anaphylactic (allergic) reaction during childhood after eating a handful of peanuts. The attack was rapid and extreme; his face puffed up like a balloon, his tongue swelled, and his throat tightened to the point that he could barely breathe. George would have died if his mother had not rushed him to hospital. As an adult, George constantly feared he would have a future, possibly lethal, anaphylactic attack. On several occasions he believed he was actually having an attack. One day while eating a banana he noticed that the back of his throat felt scratchy. He misinterpreted this as a symptom of anaphylaxis. He became so frightened that he called an ambulance. Thus, there was a shift in George's focus of apprehension, from fear of contracting a disease to fear of actually having the disease.
Behavioral Consequences of Fear of Having a Disease
It is important to distinguish between the two forms of disease fear because they can lead to different behavioral reactions: reassurance seeking and checking versus avoidance and escape (Côté et al., 1996). Fear of having a disease is associated with reassurance seeking (e.g., from primary care physicians), recurrent checking of one's body (e.g., frequent breast self-examinations), seeking out other sources of information on the dreaded disease (e.g., checking medical textbooks), and trying various kinds of remedies (e.g., herbal preparations).
Sufferers may perpetually adopt a "sick role," living as an invalid and avoiding all effortful occupational and home responsibilities (Barsky, 1992). They may persistently complain about their health, discussing their concerns in great detail with anyone who will listen. They frequently seek medical attention even though these consultations rarely confirm their beliefs about having a serious disease. During medical appointments they are often difficult to interrupt in terms of discussion about their health concerns. This is what some frustrated clinicians disparagingly call the "organ recital." It reflects the patient's preoccupation with disease.
Patients with hypochondriasis often have poor relationships with their physicians. Frustration and anger on the part of physician and patient are not uncommon (APA, 2000). Physicians, particularly those working in primary care settings, may have only 15-20 minutes for each consultation, which makes it difficult to thoroughly assess patients with long detailed histories of health anxiety. Physicians also may lack the expertise required to assess and treat health anxiety disorders. These factors can contribute to physician frustration. On the other side of the coin, patients may feel that their physicians are not taking them seriously, and worry that their physicians are not sufficiently competent. People with hypochondriasis commonly complain that their physicians are unable to satisfactorily explain or treat their bodily complaints. This may prompt the person to go "doctor shopping." That is, he or she may visit many different physicians in the hope of finding help (Kasteler, Kane, Olsen, & Thetford, 1976; Sato, Takerchi, Shirahama, Fukui, & Gude, 1995). As a result of doctor shopping, some people with hypochondriasis undergo many different medical and surgical treatments, which can produce troubling side effects or treatment complications, such as scarring and pain from repeated surgeries. Thus, hypochondriasis can be worsened by iatrogenic (physician-induced) factors.
Many people with hypochondriasis repeatedly visit hospital emergency rooms (ERs), believing that this time there is something seriously wrong with them. When the patient repeatedly "cries wolf," the physician may grow dismissive of his or her complaints. Such frequent ER attendees are sometimes put on "time-out" by the attending physicians. That is, the patient is made to wait an inordinate amount of time, sometimes for several hours, before being seen by a physician. This strategy is thought to make ER visits unpleasant for the patient, thereby reducing his or her incentive for repeatedly making unnecessary hospital visits.
Unfortunately, a dismissive approach by physicians can fuel patients' concerns that they are not getting proper medical care. In turn, this can strengthen their belief that they have a serious undiagnosed medical condition. Although it is tempting for busy clinicians to dismiss concerns voiced by the "worried well," one should not assume that their fears are always unfounded. People with hypochondriasis-like everyone else-will eventually succumb to some deadly affliction, such as cancer or cardiovascular disease. Periodic medical evaluations are required for people with hypochondriasis, just as they are necessary for everyone else. Routine evaluations are particularly important for older adults with hypochondriasis, where general medical conditions are quite likely to be present.
[Behavioral Consequences of Fear of Contracting a Disease
Fear of acquiring a disease is associated with avoidance and escape from stimuli that the person believes to be associated with disease. For example, he or she may avoid hospitals, avoid sickly looking people, and limiting contact with people exposed to sickness such as physicians and nurses. Fear that one might contract a disease can also lead to avoidance of all reminders of the disease. Alan V., for example, had an extremely strong fear of contracting cancer. He avoided all things associated with cancer, including newspapers and magazines that carried stories about people battling cancer, TV programs about stars who had battled cancer, and foods supposedly containing potential carcinogens.
Understanding Behavior by Understanding the Interplay among Disease Fears
The fact that a person can shift from one disease fear to the other, means that health anxious people may shift from avoidance to repetitive checking and reassurance seeking. Understanding the nature of their patients' fears can therefore help clinicians understand why health-anxious people sometimes avoid and sometimes seek out disease-related stimuli. People who are frightened of contracting a disease tend to avoid disease-related stimuli such as hospitals and physicians. But when they believe they have acquired the disease they will seek out these stimuli, sometimes assiduously.
Excerpted from Treating Health Anxiety by Steven Taylor Gordon J. G. Asmundson Copyright © 2004 by The Guilford Press. Excerpted by permission.
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