The Clinician's Guide to Treating Health Anxiety

Diagnosis, Mechanisms, and Effective Treatment

Erik Hedman-Lagerlöf

• Publisher: Academic Press
• Year: 2019
• Print ISBN: 9780128118061
• eBook ISBN: 9780128118078
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

The Clinician's Guide to Treating Health Anxiety: Diagnosis, Mechanisms, and Effective Treatment provides mental health professionals with methods to better identify patients with health anxiety, the basic skills to manage it, and ways to successfully adapt cognitive behavioral therapy to treat it. The book features structured diagnostic instruments that can be used for assessment, while also underscoring the importance of conducting a comprehensive functional analysis of the patient's problems. Sections cover refinements in assessment and treatment methods and synthesize existing literature on etiology and maintenance mechanisms. Users will find an in-depth look at who develops health anxiety, what the behavioral and cognitive mechanisms that contribute to it are, why it persists in patients, and how it can be treated. - Provides clinicians with tools to better identify, manage and treat health anxiety - Outlines a step-by-step behavioral treatment program - Looks at the similarities and differences between health anxiety and other anxiety disorders - Reviews self-report instruments that can be used to measure health anxiety on a dimensional scale - Includes information about recent diagnostic changes according to DSM-5

Chapter One

The Concept of Health Anxiety

Gordon J.G. Asmundson⁎; Thomas A. Fergus^{† ⁎} Department of Psychology, University of Regina, Regina, SK, Canada
^† Department of Psychology and Neuroscience, Baylor University, Waco, TX, United States

Abstract

Health anxiety occurs when perceived bodily sensations or changes are interpreted as symptoms of a serious disease. Everyone experiences health anxiety at some point in their lives, and in some cases, it can be persistent and distressing. Contemporary cognitive behavioral models conceptualize health anxiety as existing along a continuum, ranging from mild to severe, and as being a core facet of several psychiatric diagnoses. Maladaptive presentations of health anxiety, often referred to as severe health anxiety, are associated with various dysfunctional beliefs and several forms of health-related checking behavior. These maladaptive presentations are often personally debilitating and associated with considerable societal costs. The purpose of this chapter is to introduce contemporary cognitive behavioral models proposed to understand health anxiety, to provide an overview of its clinical profile, to describe the core features associated with its etiology and maintenance, and to introduce considerations for assessment and treatment.

Keywords

Health anxiety; Cognitive behavioral models; Epidemiology; Psychiatric disorders; Treatment; Dysfunctional beliefs

Health Anxiety Defined

Health anxiety occurs when perceived bodily sensations or changes are interpreted as symptoms of a serious disease. Everyone experiences health anxiety at some point in their lives, and in some cases, it can be persistent and distressing. Contemporary cognitive behavioral models conceptualize health anxiety as existing along a continuum, ranging from mild to severe, and as being a core facet of several psychiatric diagnoses. Maladaptive presentations of health anxiety, often referred to as severe health anxiety, are associated with various dysfunctional beliefs and several forms of health-related checking behavior. These maladaptive presentations are often personally debilitating and associated with considerable societal costs. The purpose of this chapter is to introduce contemporary cognitive behavioral models proposed to understand health anxiety, to provide an overview of its clinical profile, to describe the core features associated with its etiology and maintenance, and to introduce considerations for assessment and treatment.

The Case of Paul

Paul is a 40-year-old man who works in a fast-paced and often demanding information technology department of a large corporation. About 6 months ago, he began experiencing pain in his left chest and shoulder and recently noticed increased shortness of breath and coughing when active. He was concerned by the persistence of the pain and breathing issues, particularly given that his father had poor cardiac health and had died following a stroke. His cousin, Sarah, a triathlete also in her 40s, was also struggling with some cardiac issues for the past few years. Paul went to see his family physician, who performed an EKG and immediately thereafter referred him to a cardiac specialist for a stress test. Paul began to worry that his chest pain and breathing issues may be related to a problem with his heart and, although his family physician did not recommend any changes in activity, stopped exercising and playing with his children. During the several months that he waited for his stress test, his chest and shoulder pain became progressively worse, and he noticed increasing difficulties with his breathing. Paul was relieved following his stress test, which the cardiologist noted as being indicative of a healthy heart, but his relief faded quickly as he began to wonder whether his pain, breathlessness, and coughing might be a consequence of cancer, COPD, or some other disease process. Against the advice of his family physician and his own best judgment, he now spends many hours every day searching online information for a potential explanation for his concerns and is constantly anxious and worried about his well-being.

Contemporary Cognitive-Behavioral Models

Available research findings generally converge on viewing health anxiety as a dimensional, rather than a categorical, construct (Ferguson, 2009; Longley et al., 2010); however, there is preliminary evidence that qualitatively distinct forms may exist (Asmundson, Taylor, Carleton, Weeks, & Hadjistavropoulos, 2012). Conceptualizing health anxiety as a dimensional construct has several important implications for theory, research, and clinical practice (Asmundson, Abramowitz, Richter, & Whedon, 2010). First, if differences in health anxiety are one of severity rather than qualitative differences in experience, then contemporary conceptualizations are in line with the available evidence. Second, research seeking to examine health anxiety should include a range of potential vulnerability and maintenance factors, such as biological and environmental correlates, dysfunctional beliefs, and maladaptive coping behaviors. Third, when examining potential vulnerability and maintenance factors for health anxiety, research would benefit from examining large unselected samples that include a full range of health anxiety rather than focusing exclusively on samples of individuals with severe levels of health anxiety. Finally, from a clinical perspective, a dimensional conceptualization highlights the possibility of identifying points along the continuum where health anxiety rapidly worsens and for developing prevention efforts for individuals at risk for developing severe presentations.

There have been several contemporary cognitive behavioral models proposed to understand and explain health anxiety (Abramowitz, Schwartz, & Whiteside, 2002; Salkovskis & Warwick, 2001; Taylor & Asmundson, 2004; also see Abramowitz & Braddock, 2011). In essence, each of these models posits that severe presentations of health anxiety develop from underlying vulnerability factors (e.g., biological factors that influence somatosensory stimulation and experiences that influence the way somatosensory changes are perceived and interpreted) that interact with dysfunctional beliefs about maladaptive coping in response to bodily sensations and changes. For example, the perception of “bodily noise”—an ache or pain, racing heart, tightness in the chest, a rash, or feeling itchy—may be viewed through the lens of underlying beliefs (e.g., overestimating likelihood and the cost of a health problem) that lead to concern, worry, and more “bodily noise.” Paul likely overestimated the probability that his chest pain and breathing difficulties were indicative of a serious health problem given a familial history of related health problems. He also likely concurrently held beliefs about the costliness of a serious health problem, as his father died as a consequence of health problems. In Paul's case and like many individuals with severe health anxiety, body vigilance rendered him more likely to notice innocuous bodily sensations or changes (e.g., monitoring the propensity of shortness of breath when active) and misinterpret them as indicative of a potentially serious health issue. Cognitive behavioral models hold that for individuals with severe health anxiety, the perception of bodily sensations or symptoms is met by persistent “what if” thinking surrounding the possible catastrophic nature and consequences of those bodily states. In Paul's case, that type of thinking related to “what if my chest pain and shortness of breath relate to a problem with my heart?”

Cognitive behavioral models also posit that, in response to such health-related worries, individuals engage in maladaptive coping. Typical forms of maladaptive coping associated with health anxiety include body checking, Internet searches, seeking out advice from multiple health professionals, or reassurance seeking from friends or family. In Paul's case, he visited his family physician and a cardiac specialist and also began spending hours searching the Internet. Although these behaviors temporarily reduced his health anxiety, Paul's health-related worries reemerged and persisted given that dysfunctional beliefs and body vigilance remained unchanged. Consequently, Paul remained locked into a pattern of monitoring for the presence of feared bodily states and was prone to catastrophizing about the meaning of those bodily states when they occurred. As Paul did not get the corrective experience that his health-related worries are unfounded, he became increasingly preoccupied by those worries and engaged in additional maladaptive coping in the form of repeated Internet searches that served to maintain his health anxiety.

For Paul and others with severe health anxiety, a repetitive cycle (see Fig. 1) develops. He notices bodily sensations and changes, perceives these changes as unpleasant, worries about the causes and potential consequences of his bodily sensations and changes, engages in coping that temporarily reduces his health anxiety, notices more bodily sensations, and so forth. The cycle is, unfortunately, self-perpetuating and chronic without intervention.

Fig 1 The cognitive behavioral model of health anxiety. (Adapted from Asmundson, G. J. G., Taylor, S. (2005). It's not all in your head: How worrying about your health could be making you sick and what you can do about it. New York: Guilford.)

Clinical Profile

Severe health anxiety typically manifes...

Table of contents

• Cover image
• Title page
• Table of Contents
• Copyright
• Contributors
• Chapter One: The Concept of Health Anxiety
• Chapter Two: A Diagnostic Perspective on Health Anxiety
• Chapter Three: Etiology and Epidemiology of Health Anxiety
• Chapter Four: Cognitive and Behavioral Mechanisms of Health Anxiety
• Chapter Five: Assessment of Health Anxiety
• Chapter Six: Cognitive Behavioral Therapy for Health Anxiety
• Chapter Seven: Acceptance and Commitment Therapy for Health Anxiety
• Chapter Eight: Using the Internet to Provide Treatment for Health Anxiety
• Chapter Nine: Dealing with Health Anxiety: The Physician’s Experience
• Chapter Ten: Health Anxiety in Children and Adolescents
• Index