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Health anxiety |
Almost every adult at some point in their life has experienced at least a brief moment of health anxiety. If you find that you’re constantly worried about your health or frequently have periods of anxiety that are focused on your health, then working through this chapter can help you better understand your health anxiety – including how it may have developed and what is maintaining it now. The chapter will also provide you with simple and straightforward ways to manage your health anxiety. Some people find that change comes from reading and understanding health anxiety better. Other people, however, may have to try new strategies for managing health anxiety. Many research studies have shown cognitive behavioural therapy to be an effective way to reduce health anxiety (see the references for further information). Research suggests that even when delivered in a less direct manner, such as a self-help book, this approach to health anxiety can be helpful.
There is no particular disease that people with health anxiety worry about. While some may worry about cancer, others worry about getting multiple sclerosis or heart disease or even mental illness. Some worry that they have the disease right now, while others worry about developing the disease in the future. Some may not worry about their own health as much as that a loved one may develop an illness. For instance, a parent who has noticed that their child has a sore head and neck may become worried that their child has meningitis, or a husband who has noticed that his wife has developed a new mole on her hand may begin to worry that his wife has skin cancer. Although the information contained in this chapter is directed at worries you may have about your own health, most of the exercises could also be used if you are anxious about the health of someone close to you.
Some amount of anxiety about one’s health can be helpful as it tends to motivate us to do something such as taking medication and seeking medical attention when it’s needed. At what point does health anxiety become a problem?
Health anxiety can be described as a problem when it:
• is excessive;
• is out of proportion to the realistic likelihood of having a serious medical problem;
• is persistent despite receiving negative results on medical tests and reassurance from medical professionals;
• leads you to check your body for symptoms, seek frequent reassurance about your health from medical professionals, family and friends, or avoid health-related information, doctor’s appointments, or other people who are ill;
• has persisted for six months or more;
• has caused you significant distress or adversely affected day-to-day life.
Laura is a 38-year-old teacher who is married and has one daughter, aged 4. She began worrying about her health after she read a news story reporting that delaying childbirth until after 30 was associated with increased risk for developing breast cancer. Since then, she has become preoccupied with the idea that she will develop breast cancer. She also fears developing other types of cancer such as ovarian and skin cancer. When Laura notices a slight bump on her body, she will repeatedly check the bump to determine whether it has changed over the course of the day. She will often also ask her husband whether the bump looks ‘normal’ or like ‘something serious’. Laura spends a significant amount of time on the internet each day (ranging from twenty minutes to several hours) looking up information on the signs and symptoms of cancer. In addition to her regular check-ups, Laura has made several visits to her general practitioner requesting additional tests (e.g., mammogram, ultrasound). When tests have been conducted, Laura is not reassured by receiving negative test results or ‘good news’ that she’s in good health. Instead, she tends to fear that the healthcare professional made a mistake in the testing. She then continues to be preoccupied with the thought that she has cancer that has been undiagnosed. When Laura experiences a worry episode, the quality of her work as a teacher decreases and her ability to complete day-to-day tasks at home such as cleaning and looking after her daughter suffers. Laura avoids social events for fear that someone will bring up the subject of cancer and that this will trigger another bout of anxiety for her. Laura believes that the more cancer diagnoses she hears about, the more likely she is to develop cancer. Although she has a caring and supportive husband, their relationship has become strained because of her frequent requests for reassurance.
To know whether your health anxiety is a problem, we recommend asking yourself the following questions:
1. Do you spend significant time worrying about your health?
2. When you notice a bodily change or sensation, do you automatically think that something is wrong with you?
3. Do you think that having an illness will be awful and result in significant disability or death?
4. Do you think you would be unable to cope with having an illness?
5. Do you have low confidence in doctors and other health professionals?
6. Do you find you are on guard and watching to see if there is anything wrong with your health?
7. Do you have images of yourself being ill or having a serious disease?
8. Do you visit your doctor more than most people to ask about symptoms even though he or she has reassured you that there isn’t anything physically wrong with you?
9. Do you find yourself frequently talking to your family and friends about your physical concerns?
10. Do you spend significant time looking up information about illnesses or diseases on the internet or elsewhere?
11. Do you spend time checking and monitoring your body for physical symptoms of a disease?
12. Have you stopped doing things that you enjoy because of your worry about your health?
13. Has your worry affected your relationships with others (e.g. partner, children)?
14. Is your worry or checking interfering with your ability to focus or get other things done (at work, socially)?
If you answered ‘yes’ to six or more of the questions above, then you may be suffering from health anxiety and we suggest you continue to read this chapter.
Health anxiety can affect a person’s life. Below are areas that are commonly affected by health anxiety.
Time spent worrying about your health or time spent seeking help from health professionals may affect your relationships and ability to focus on family. Sometimes family and friends might join you in your worrying, which contributes to everyone feeling distressed. Or they might become frustrated with you if you continue to worry or seek reassurance despite receiving negative test results. You might even notice yourself becoming frustrated with them for not understanding what you are coping with or for not helping you work out what is wrong. Health anxiety might also cause you to avoid social occasions because you fear that you might catch a disease or that the topic of conversation might turn to illness. Often people with health anxiety feel distant or alienated from others. You may be avoiding relationships because of your health anxiety. But people may also be avoiding you because they don’t want to hear about your health worries.
Many people with health anxiety find it difficult to stop thinking about their health and signs of potential illness. When this happens, you might find it difficult to focus and concentrate on tasks at work or college. You might also have difficulty completing household tasks. A considerable amount of your work or study time might also be taken up by medical appointments or searching the internet, which may cause you to fall behind.
You may become so focused on your health and seeking reassurance about your health that you stop doing things you enjoy or that give you a sense of accomplishment. Stopping such activities can lead one to feel depressed. If you have not stopped doing activities, you may find that you are not enjoying things as much as you normally would. It is hard to enjoy things and be present in your life when your health is always on your mind.
As you make your way through this chapter, you will be provided with self-assessment tools that will help you judge the severity of your health anxiety symptoms.
At this point, you might be wondering, ‘What if I really have a medical condition? Does this mean I still have health anxiety?’ Health anxiety can exist in people who are ‘healthy’ and in people who have a diagnosed medical condition (e.g. high blood pressure, multiple sclerosis). An individual who has diabetes or cancer, for instance, can also experience severe health anxiety or health anxiety that is above and beyond what others with these conditions experience. Research shows that quality of life is lower in people who have a medical condition and also experience health anxiety compared with those who have a medical condition but do not have health anxiety.
People who experience health anxiety, whether they have a diagnosed medical condition or not, experience physical sensations. These sensations are not imaginary; they are real. What is different about people who have health anxiety compared with those who do not is how much they focus on these sensations, and how they interpret the sensations. The person who has health anxiety believes that the sensations are a sign of serious disease and illness. The individual who is not anxious about their health may not even notice or may not worry about it. At times, someone who does not have health anxiety may worry about a symptom, though it seems the person takes a more ‘balanced’ approach to the sensation, thinking it could be a sign of something serious or it could be nothing. Once medical attention is sought, if reassurance is given, the person who does not have health anxiety no longer notices or focuses on the sensation.
There is not one specific cause of health anxiety. Research and patients have instead indicated that various types of experience may contribute to its development.
• Genetic vulnerability. If one or both of our parents struggled with anxiety (even if it was not related to health), then our chances of developing anxiety about health and anxiety more generally will be greater.
• Observing family members or others experience a serious illness. Witnessing others experience illness when we are a child or adolescent can contribute to how we respond to bodily changes or sensations. For example, if we witnessed someone experiencing pain and suffering, we may view illness as something awful and to be avoided at all costs. If we witnessed someone with a progressive illness leading to death, we may think that medical treatments are of little to no help. If we observe a family member struggle with an inherited illness, then we might focus on the chances that we, too, will develop such an illness.
• Having a parent who has health anxiety. If you grow up observing others worry about their health or frequently checking for signs of illness, then you will be more likely to behave in a similar way when faced with health issues or unexplained bodily sensations.
• Information through the media or internet. The media and internet can be helpful resources and offer you wide access to information about your health. However, you should keep in mind that media outlets often want to grab your attention. In an effort to do so, health stories frequently focus on rare diseases and fatal conditions. They may also report on stories where doctors made mistakes and patients went undiagnosed. Attending to these types of stories, rather than stories about medical successes, might lead you to question your own medical care and to view rare health problems as common.
Before you begin focusing on how to go about changing your health anxiety symptoms, it is important to understand what keeps your health anxiety alive. We are therefore going to tell you what therapists understand about health anxiety. This understanding has come about through several years of research.
Research suggests that people with high health anxiety have developed problematic beliefs and thoughts about health and illness (Marcus, Gurley, Marchi and Bauer, 2007). These beliefs can be triggered by external events such as illness-related media reports, hearing about someone who has become ill, or by internal events such as bodily sensations or changes (e.g., headache, heart palpitations, diarrhoea, blurry vision). Once these beliefs are triggered, people misinterpret harmless bodily sensations and changes as a threat. This misinterpretation leads them to feel fearful and anxious. In an attempt to make these feelings go away, people try to reduce their anxiety by checking their body, checking the internet, seeking reassurance, or avoiding situations that provoke anxiety. Although these behaviours reduce anxiety in the moment, research suggests that they actually increase anxiety in the long run. There are a variety of reasons why these behaviours increase anxiety. One is that if people look for information that suggests they are in danger, they are more likely to find this information. Another reason is that if we act as if we are in danger, then we are more likely to feel like we are in danger.
Both internal and external situations may trigger health anxiety. Internal triggers are sensations and symptoms in the body. This can include increases or decreases in heart rate, digestive discomfort, tingling or numbness in parts of the body, and ringing in the ears. We may notice unusual sensations such as developing a strange taste in the mouth or a twitch in a muscle. External events can also trigger episodes of health anxiety. External triggers may include but are not limited to: media reports of health scares, medical appointments, hearing about someone who has been diagnosed with an illness, or receiving inconclusive results on a medical test.
The internal and external events can trigger certain beliefs and assumptions about health and illness that have developed over time. In general, people with high health anxiety tend to overestimate the probability that they have a serious illness and underestimate their ability to cope with illness. Perceptions of illness as being awful and medical services as ineffective are also common. You will have a chance to learn more about common thinking patterns in health anxiety in the following section.
Focusing attention on a symptom or sensation can amplify the experience of that sensation. The more we focus on our symptoms, the more we become aware of that symptom. The symptom will also seem more intense. As the intensity of the symptom appears to increase, so will our concern about the symptom, and in turn our focus on it!
When it comes to our health, we are all encouraged to check our bodies and seek medical advice. For example, we are encouraged to monitor moles on our skin and women are encouraged to conduct self-examinations on their breasts. We are also encouraged to go for regular tests, for example of our blood pressure or cholesterol levels, and conduct self-exams. For most people, checking or obtaining reassurance about their health will usually lead to feeling less anxious and they will be able to continue with their day. However, people with health anxiety continue to worry about their health and feel anxious. They therefore continue to engage in checking and reassurance seeking to reduce these anxious feelings. For individuals with high health anxiety, checking and reassurance seeking is repeated and frequent.
Some examples of checking and reassurance-seeking behaviours include:
• Checking your body for new moles, lumps or areas of discoloration.
• Poking or pinching areas of your body.
• Examining bodily secretions (e.g. saliva, urine, faeces) for signs of blood or changes in colour.
• Monitoring bodily processes (e.g. taking pulse, checking blood pressure).
• Asking friends, family members, or healthcare providers about symptoms.
• Researching symptoms on the internet or other resources.
• Requesting additional medical tests and second opinions.
While checking and reassurance seeking are used to reduce anxiety that is already present, avoidance and safety behaviours are strategies people use to prevent anxiety from occurring in the first place. To avoid internal triggers, you may avoid things that lead to changes in your body. For instance, exercise, coffee and certain foods. To avoid external triggers, you may also avoid certain people, places and situations that remind you of illness, for example:
• medical appointments;
• television shows related to health and illness;
• writing a will;
• social events where illness might be discussed;
• hospitals;
• visiting a friend or relative who was recently ill;
• phoning for test results;
• surgery and other medical procedures.
‘Safety behaviours’ are a more subtle form of avoidance. When people use safety behaviours, they may find they are able to face the situations they are frightened of and would like to avoid, but only if they take certain precautions or have certain plans put into place. For example, if we are afraid of catching swine flu, we might not go to public places unless we have hand sanitizer. If we are afraid of cancer, we might not go to the hospital unless we have our mobile phone and can look up medical symptoms that we become frightened about.
Checking, reassurance seeking, avoidance, and safety behaviours may reduce your anxiety in the short term. This is the main reason you have continued to use them – they provide some relief in the moment. But they prevent you from learning that you can survive without them and that you can face your fears.
The following flow chart illustrates how health anxiety is triggered and then maintained.
Figure 10.1: A cognitive behavioural model of health anxiety
To help you apply this approach to your own personal situation, look back at Laura’s story on p. 289. Let’s look at how her health anxiety symptoms fit into the framework above:
Figure 10.2: The Maintenance of Laura’s health anxiety.
Now fill in the framework below based on your own experiences. It might help to think back to a time when your health anxiety was very bad or to a recent episode.
Figure 10.3: A blank diagram to help you work out what is maintaining your health anxiety.
Tips for supporters
If the person you are supporting is comfortable with doing so, you may find it helpful to review and discuss the form above.
As we have seen, a number of things contribute to worries about our health. Some of our worry stems from thinking patterns and problematic beliefs that we may have developed about health and illness. Particular behaviours may also play a role in health anxiety, such as repeated and frequent checking and reassurance seeking as well as avoidance and safety behaviours. Such behaviours ensure that we continue to focus on physical symptoms, which in turn makes us think more about our health. Treatment involves gathering relevant evidence to (i) identify and (ii) challenge the thinking patterns and behaviours that keep health anxiety going. Treatment will help you find out that by changing the way you think and by changing your behaviour patterns, you can feel less anxious about your health.
CBT treatment for health anxiety typically consists of 12–20 sessions in total, with sessions being held once weekly. As described in Chapter 1, we recommend planning sessions with yourself as this will allow you to get the most out of the programme. People’s individual experiences with health anxiety are varied, so this structure can be modified to best fit your own situation.
This chapter covers several different skills and techniques all focused on overcoming your health anxiety. The skills and techniques build upon each other, which means you will get the most out of the programme if you read through and practise the skills in the order that they’re presented. Certain aspects of health anxiety may be less troublesome for you, while others require more attention. If so, you may wish to spend more time on certain sections (e.g. confronting situations you currently avoid) over others (e.g. changing your anxious thoughts).
Even though your health anxiety may be interfering with some aspects of your life and you’d prefer to live without it, sometimes this isn’t enough for you to feel ready to take on a self-help programme and all of the effort that goes into it. Being ready to overcome your anxiety demands your attention, your desire and motivation, and a generous amount of your time. To know whether you’re ready to take these steps, ask yourself: what are the costs and benefits of overcoming my health anxiety?
Some potential costs to consider may be the time you will have to devote to the self-help programme, such as completing forms, self-reflecting, and practising exercises. You may find some of these tasks tedious. Overcoming your health anxiety may involve tasks that are frightening, even if only temporarily. Taking part in this programme may also lead you to do things that you don’t want to do or don’t enjoy doing (e.g. going to visit relatives in hospital). Getting over your anxiety may mean that you receive less support or attention from your family or friends.
But there are benefits of taking part in this self-help programme. By engaging in treatment, you may be finally able to do things that are important to you. You may be able to live a life that is consistent with your personal values. You may become comfortable taking part in activities that you now avoid. You may feel happier and more calm or relaxed. Your self-esteem may be enriched. You may spend less time worrying or checking your body, which may lead you to be more effective at work, school or home. You may be able to focus on things that are important to you, other than your anxiety, which up until now you haven’t been able to focus on. Ultimately, you may be less worried and anxious about your health.
Make a list of the benefits and costs of changing your health anxiety using the worksheet below:
Worksheet 10.1: Cost-benefit analysis of changing your health anxiety
Do the potential benefits of participating in treatment outweigh the costs? If so, this may be a good time for you to begin the journey of changing your health anxiety.
Tip for supporters
Talk to the person you are supporting about the costs and benefits of treatment for health anxiety. Do you think this is a good time for the person to begin this journey? Are there any factors that may interfere with treatment at this time?
A useful strategy for keeping on track with a self-help programme is to set goals. This will help you to identify what treatment strategies will be most appropriate for you and can serve as a marker of how you are progressing. The key to goal-setting is identifying goals that follow the SMART acronym as described in Part 1, pp. 24–5.
An example of a SMART goal is: ‘In 8 weeks’ time, I would like to be able to spend several hours visiting my grandmother at her long-term care facility without needing to leave early or wear latex gloves.’ Before moving on to the next section, take an opportunity to record your own goals for treatment by following the SMART acronym.
Tip for supporters
Talk to the person you are supporting about their goal. Do you have any suggestions? Does the goal seem Specific, Measurable, Achievable, Relevant and Time limited?
As a person with health anxiety, you probably experience bodily sensations that cause you to worry. You may have been told that these sensations are not real, that they’re ‘all in your head’. What you have been told is incorrect. All of us experience bodily sensations daily and occasionally wonder what they might mean and why they’re happening. While the sensations are real, people who are health anxious tend to misinterpret these sensations as a sign of a looming health problem. The human body produces all sorts of sensations and symptoms and can even be rather noisy at times! In fact, even when our bodies are operating as they should be, we can have unwanted bodily sensations. Why does this happen? There are many reasons and sources of these symptoms:
Changes in diet, activity level, and sleeping habits. When our usual daily routine is disrupted, whether this is from eating at different hours, being more or less active, or waking up earlier than usual, this can trigger a number of bodily changes. For example, if your schedule gets overloaded and you don’t get the chance to eat lunch at the usual time, your blood sugar might drop temporarily. This can lead you to feel faint, to sweat and have an increased heart rate. If you didn’t get the typical 6–8 hours of sleep last night, your body might feel achy, shaky, and you may develop a headache or dry eyes later in the day. When you stand up quickly after sitting at your computer desk for a while, you might feel dizzy and unsteady. If there’s been a considerable change in temperature outside (or in!), your body might go from normal to shivering and numbness if it’s cold or feeling thirsty and lightheaded if it’s hot. Alcohol or drugs can have an effect on your mental and physical functioning and bodily symptoms – while you’re using them and the day after. These are just a few examples of the way changes in routine can lead to harmless but ordinary bodily sensations.
Prolonged inactivity. When your body has been inactive for several months or only a few days (depending on your usual activity level), you may experience a change in your cardiovascular fitness, the strength of your muscles, and how fatigued you feel when you’re on the go. Inactivity is associated with shortness of breath, a rapid heartbeat, various pains and muscle aches, and feelings of low energy. Inactivity, even over the course of a day, can result in pain in one’s neck or back and other areas of the body, especially if you are sitting at a computer desk and don’t take periodic breaks to move around. If you’ve been inactive for a period of time and then begin to resume an active lifestyle, this can also produce short-term changes in bodily sensations as you build your strength and your cardiovascular health.
Minor ailments. Minor ailments or conditions can be the source of a number of bodily sensations. Minor ailments may include having a headache, allergies, a head cold or cough, a skin irritation, menstrual cramps, or heartburn. These temporary ailments are unpleasant and can lead you to feel head pain, a sore throat, itching, aching, difficulty breathing, chest pain, lower back pain, and all sorts of other symptoms. Although these ailments and their accompanying sensations are uncomfortable, they are harmless. They don’t usually have long-term negative effects and are not life-threatening.
Fear and anxiety. We can also experience unwanted bodily sensations caused by anxiety and fear. More information about this can be found in Part 1.
Tip for supporters
Have you noticed the person you are supporting become concerned with physical symptoms that could be attributed to any of the above factors? If so, it would be helpful to gently share this with them.
Laura learning about her bodily sensations
A critical component of Laura’s education on health anxiety was learning about how her tendency to monitor and check her breasts resulted in increased rather than decreased worry about them. She also learned that constantly prodding for lumps could lead to swelling in her breasts. The swelling itself was alarming and caused her anxiety to worsen. Laura also learned that she noticed more of her bodily sensations during stressful periods of teaching and marking. She realized that her body’s stress reaction probably caused many of the symptoms that caught her attention.
Sometimes it might seem that situations happen and then you feel anxious. However, it is important to keep in mind that it is not the situation you are in that determines how you feel, but the thoughts and interpretations you have about that situation. Imagine that you are meeting a friend for lunch at noon. It is 12.20 and your friend has not arrived. If you begin to think, ‘My friend stood me up!’ how might you feel? Perhaps angry. On the other hand, what if you think, ‘This is not at all like my friend to be late; what if he/she was in an accident?’ you will probably feel anxious. Finally, what if you think, ‘He/she probably got stuck in traffic and will be here soon.’ If this is your thought, it is likely that you will feel calm. You may also feel annoyed and impatient, but you would not feel angry or hurt. Part 1 has more information on this important idea.
In sum, this means that your perceptions of situations influence how you feel. Anxiety often occurs when we perceive that a threat is present. For example, if you are camping in the woods and you hear branches cracking, you may feel anxious as there may be a predator close by. Experiencing anxiety in a situation such as this is useful because it prepares you to either deal with the threat directly or to escape the situation.
In terms of health anxiety, people perceive there to be a greater amount of threat than there actually is. This does not mean that you should never feel concerned about your health. Rather, it is the tendency to interpret your symptoms and situations in a persistently catastrophic manner that brings about intense negative feelings and additional physical sensations.
People with health anxiety report experiencing common types of thinking patterns described in Part 1 in relation to health and illness. Some of the most common patterns include:
• Black and white thinking: You look at things in black and white categories, rather than seeing the shades of grey. For example, you are either completely healthy, or seriously ill.
• Gloom and doom predictions: You make extremely negative predictions about your health. For example, ‘My mother died of cancer. It is only a matter of time before I get cancer, too.’
• Negative interpretations: You interpret unpleasant or unusual bodily sensations as a sign of serious illness. For example, ‘This pain in my head is a sign that I have a brain tumour.’
• Intolerance of uncertainty: You do not feel comfortable unless you have a complete explanation for the cause and nature of your bodily sensations.
• Assumptions about:
° Likelihood of illness: You overestimate the probability of catastrophic outcomes and assume that an unlikely event is much more likely to occur than it is. For example, you may believe that serious illnesses are easy to catch and are present everywhere.
° Severity: You overestimate the ‘awfulness’ of illness and death. For example, ‘The process of dying would be unbearable, lonely, and painful.’
• Disqualifying evidence: You focus only on certain pieces of information or facts that support your view, but ignore facts that are just as relevant if they do not support it.
• Unrealistic expectations: You hold extremely high expectations of health professionals. You expect that they should be able to understand your bodily sensations and give you a definitive explanation or cause for everything that you think might be wrong with you.
• Anxiety about anxiety: You might fear that health anxiety or emotional discomfort will lead you to ‘go crazy’ or ‘lose control’, or that there may be other harmful medical or physical consequences.
• Distrust in medical services: You believe that if you become seriously ill, medical professionals will be of little, if any, help and may end up harming rather than helping you.
List adapted from J.S. Abramovitz and A.E. Braddock, Psychological Treatment of Health Anxiety and Hypochondriasis: A Biopsychosocial Approach (2008). Boston: Hogrefe & Huber.
Next you are going to learn how to address your anxious thoughts by challenging them directly. This means that you will start to look at the accuracy of your thoughts by questioning and evaluating them as described in Part 1. You can think of this process as similar to being a lawyer. Your thoughts are being put on trial and you are gathering all of the evidence to see whether they hold up or not. When you are starting out, it is best to evaluate your thoughts by writing them down and we suggest using a thought record to help with this process (see page 313). The thought record will guide you through the evaluation process on paper and make things clearer and more helpful for you. Below you will find instructions on how to complete a thought record. Laura used the thought record to identify and challenge the anxious thoughts she had about developing cancer. A blank sheet is provided on p. 313 for you to examine your own thoughts.
The first step in completing a thought record is to identify a time when you notice that you’re feeling worried about your health.
List the situation, physical sensation/symptom, or other trigger that is linked to feeling anxious.
List anxious thoughts that occur in response to the trigger in this column. Use the list of common thought patterns to help you identify your thoughts. Often these thoughts will be automatic or almost unconscious. It will take practice to identify your anxious thoughts. Try to come up with specific thoughts. Thoughts like ‘something bad will happen’ are too vague.
In this column, rate your anxiety on a 0–100 point scale: 0 = no anxiety at all; 100 = as anxious as you can imagine being.
List evidence that you feel supports your anxious thought.
List evidence that does not support your anxious thought. The evidence that you record should be information that others would probably agree with. It should not be how you feel, but instead, something that you could prove. Be objective in identifying potential evidence. Go through the following list of questions to help you generate evidence:
• Have I had any experiences that show that this thought is not completely true all the time?
• If a friend had this thought, what would I tell them?
• If a friend knew I was thinking this thought, what would they say to me? What evidence would they point out to me that would suggest that my thoughts are not 100 per cent true?
• Have I been in this type of situation before? When I felt this way in the past what did I think about that helped me feel less anxious? What have I learned from previous experiences that could help me now?
• Is there any information that contradicts my thoughts that I might be discounting as not important?
Review both the evidence for and against your original thought. Generate a new, more balanced thought that is based on this evidence. Remember that the goal is to develop a thought that is more realistic rather than to develop a thought that is 100 per cent positive.
Table 10.1: Laura’s thought record
Worksheet 10.2: Thought record
Tip for supporters
It may be helpful to work through the thought record above with the person you are supporting. When someone is anxious about their health it can be challenging to come up with evidence against a belief; talking through this with someone one can help.
As previously described in Chapter 5, behavioural experiments are a powerful way of helping people who have anxiety. This holds true of health anxiety as well. We can use behavioural experiments to collect information to test whether our beliefs are true or whether an alternative belief may be more accurate. People with anxiety sometimes feel reluctant to carry out behavioural experiments, but when you can overcome this reluctance, you can benefit tremendously from the experience.
Sometimes people don’t know how to set up the experiment. This section of the chapter is designed to give you an idea of how to take this step.
There is no one perfect experiment. The more experiments you can come up with and test the better. Sometimes you may believe it is enough to just think about the experiment and that it is not necessary to actually do it. In our experience, thinking about the experiment is not nearly as effective as performing the experiment (you could actually test this out if you like).
A helpful way to identify a behavioural experiment is to think of if – then statements that you say to yourself – or that you may be thinking without even realizing that you’re saying these things to yourself – and then design a situation that allows you to test out the statement. In designing the experiment, be as specific as possible.
Let us give you an example of what we mean. Nigel felt that he absolutely could not visit a hospital. When asked how he would feel if he did visit a hospital, his prediction was that ‘If I visit a hospital, then I will be overwhelmed with anxiety and won’t be able to think about anything other than having multiple sclerosis.’ He was then asked to be more specific about his prediction. He was asked to rate how overwhelmed he’d feel if he were to visit a hospital for an hour. Nigel predicted that his anxiety would be 10 on a 1–10 scale (with higher ratings indicating extreme anxiety). Working with his therapist, Nigel then devised an experiment to test out his beliefs. The aim was that he would go to a local hospital and sit in the waiting room and rate his level of anxiety every ten minutes over the course of an hour, and then once an hour for the remainder of the day. Nigel felt he could not possibly do this; it was too overwhelming as a first step. He suggested that he would first drive up to the hospital and sit in his car across the street and rate his level of anxiety. The next day Nigel carried out the experiment. He parked across the street from the hospital and noted that he actually felt very little anxiety. He then decided to cross the street and sit on a bench outside the hospital. Again, he reported that his anxiety was very low and did not go above 2. Nigel then entered the building and sat in the waiting room for an hour. Again, his anxiety did not go above 2. Throughout the day, Nigel reported that when he rated his anxiety on an hourly basis it also did not rise above 2. Following the experiment, he revised his belief stating that ‘Being in a hospital will not necessarily be unbearable and overwhelming and result in feeling more anxious about my health.’ Notice that when he revised his belief, he did not state it in an overly positive way; rather he chose to say it in a way that he felt was realistic for him.
But sometimes behavioural experiments don’t always result in dramatic immediate changes like this. Sometimes predictions do come true – at least initially – and this provides important information as well. Helen, who feared having thyroid cancer, identified that she felt she had to read health-related articles on the internet at least once a day for at least half an hour (this was a minimum amount for her as her preference was to read articles first thing in the morning, over the lunch break and then before bed). When asked what she feared would happen if she did not read these articles, she said that she feared she would miss some important information about how to prevent, detect or treat cancer. Her therapist noted that this type of statement was difficult to disprove so he asked her to rate how she would feel if she did not engage in the behaviour. Her prediction was that her anxiety on the 1 to 10 scale would be 10. Her therapist then asked her to devise an experiment to test her prediction. She decided to start by not searching the internet in the morning. When she did this, she reported that in fact her anxiety was 10 in the morning when she did not engage in the behaviour. The next step was to ask her to note what her level of anxiety was when she did search the internet. Then Helen noticed that her anxiety was ‘15’ on a 1 to 10 scale. What was interesting was contrasting how she felt when she searched the internet with how she felt when she did not search the internet. Her level of anxiety was lower when she didn’t engage in this behaviour. Next, Helen talked with her therapist about different strategies she could employ when not searching the internet for health-related information. Specifically, she experimented with how she felt when she used various coping statements and identified that she in fact felt the best when she did not search the internet in the morning and instead identified and challenged negative thoughts she had about illness as described above. In this case, her rating of anxiety was a 4 on the 1 to 10 anxiety scale.
The form below will help you to set up your own experiments. We’ve completed this form with the first example in mind. There is then a blank form that you can use for your own experiments. We know that carrying out these experiments will be difficult to start with. After all, if the experiments were easy, you would have done them by now! You may find it helpful to do the experiment gradually. If you are afraid of thinking about or talking about a certain disease, you could start small and work your way up and see what happens when you progressively expose yourself to your fear.
Table 10.2: Nigel’s behavioural experiment
Worksheet 10.3: Behavioural experiment worksheet
Beyond setting up your own experiments, there are some experiments that we find beneficial for those who worry about their health to try out. Each experiment only takes a short period of time, but can help you to gain a better understanding of your health anxiety. Again, we strongly urge you to actually do these experiments rather than merely read about them. This makes for much more effective learning.
1. Rub or touch a certain part of your body that you are anxious about to make sure your health is not in danger (e.g. lump in your breast), every hour for six hours; lightly pinch and rub the skin. How does it feel? Do you notice any changes in your skin? find that repeatedly rubbing one’s body will produce redness and uncomfortable sensations.
2. If you are focusing on a certain body part because you’re concerned about an illness (e.g. your stomach because you are worried you have a stomach ulcer), spend a few minutes each hour for at least six hours concentrating on the bottom of your feet and how they feel. What do you notice at the end of the day? How do your feet feel? Unusual? Most will notice that by focusing their attention on a body part, they become aware of uncomfortable sensations that were not previously noticed.
3. Spend an hour reading about a disease you do not fear. How does it make you feel? Does it increase or decrease your anxiety? Most will find that this will make them feel anxious.
4. On different days of the week, spend varying amounts of time looking up information on the disease you fear. How do you feel the more time you spend seeking information? Most find that this will make them feel more anxious.
5. If you tend to be someone who checks a body part, notice how you feel if you limit your checking to once a day compared with checking every hour or every half hour. Most find that the more they check, the more anxious rather than less anxious they feel. They’ll also notice the more they check, the more they think about physical sensations.
6. In your next conversation with family or friends, spend the entire time talking about your physical symptoms. Notice the response of the person you’re talking to. Most will find that the response is negative.
7. Write down all of the symptoms that you are concerned about. Ask those you have a close relationship with whether they have had the same symptoms in the past and what they think the symptoms might mean. You could also do a survey of strangers.
8. Spend fifteen minutes coming up with an alternative and unworrying explanation for physical sensations that are of concern to you. How does this make you feel? Does this reduce your anxiety or increase it?
9. Write down the following statement: ‘I will develop cancer this year.’ How do you feel? Do you feel this increases your chances of developing cancer? Many people who have health anxiety believe that if they think a thought it will happen. As noted in Chapter 11, this is called thought–action fusion. Now write down this statement: ‘I will win 100 million dollars this year.’ Does thinking this thought make it likely? What conclusion can you draw from this experiment?
10. Ask people who have the disease you are frightened about how they cope with the disease? How awful is life for them? What you’ll notice is that the vast majority of people who have a disease are able to manage and cope with having a disease and can even generate positive aspects to having had an illness.
Tip for supporters
A great way to offer support is to do the above experiments with the person you are supporting. The person who is health anxious often benefits from learning how others respond to these same experiments.
People who are health anxious will often check their bodies and seek reassurance from their doctors, those around them, and even from the internet. Why do we do this? Often, we do this to ease our worrying, to help us to feel more in control and certain about being healthy, and to reassure ourselves that our health is not in danger. We may also do this to help ourselves prevent a disease from developing in the future. Checking and seeking reassurance gives us short-term relief from our anxiety.
Figure 10.2: The vicious cycle of health anxiety
Even though your anxiety is relieved for a little while when you seek reassurance or check our bodies for signs of illness, if you suffer from health anxiety, your worry and anxiety eventually comes back. This is because you can never have a 100 per cent guarantee that your health is perfect. None of us, even the healthiest people we know, can ever confirm 100 per cent whether an ailment is lingering or whether we will become ill some day, in the future. While this uncertainty is likely to fuel your health anxiety, a goal of CBT is to learn to tolerate this uncertainty. Excessively checking your body or asking a family member for reassurance stops you from building up this tolerance and accepting that your health is uncertain. We also know from recent research that far from helping to reassure us in the long term, constant checking actually causes us to doubt our memory (see p. 379, Chapter 11 on OCD).
Laura’s checking and reassurance seeking
Laura checks her body for bumps or moles every day for signs of breast or skin cancer. Whenever she notices a new bump, she monitors it all day to see whether or not it changes. She relies on her husband by asking him whether or not any marks or bumps seem ‘abnormal’. Laura has made frequent visits to her doctor and has requested additional testing because she is worried that a diagnosis of cancer has been missed. Despite receiving reassurance from her husband and doctor, Laura continues to feel uneasy about her health and is certain that she will get cancer some day, if she doesn’t already have it.
Tip for supporters
You may find it helpful to talk to the person you are supporting about how you fit into the above cycle. Do they come to you for reassurance? Do you notice that this results in only temporary relief? How do you feel when they talk to you about their health concerns? To help the person you are supporting reduce their reassurance seeking, it is important that you talk to them about this cycle. You should also discuss alternatives to offering reassurance. If they ask for reassurance about their health, then you should gently remind them about this cycle and encourage them to use other strategies to manage their health anxiety, such as examining the evidence for and against their concerns. If they are open to this, you could help review this evidence with them.
The first step towards changing your checking and reassurance-seeking behaviours is to identify which behaviours feed your individual health anxiety cycle. Some of the behaviours may be apparent to you (e.g. searching for information on the internet), whereas others may be more subtle – you may have never considered talking about your body symptoms with your family as a way of seeking reassurance. Below is a list of common ways that people with health anxiety check or seek reassurance. In what ways do you check or seek reassurance?
Worksheet 10.4: Checking and reassurance-seeking behaviour checklist
You may have checked off only one of the items in the above checklist or perhaps you checked off a few and even added a behaviour that wasn’t on the list. If you checked off more than one, which behaviour takes up most of your time? Is there any behaviour that you do every day? Which behaviour do you think may be causing you the most distress? Answering these questions will help to narrow your focus to only one or two behaviours that you can work on in the next step.
A strategy for reducing the amount of checking and reassurance seeking you do is to estimate how helpful these behaviours are, and then come up with and test out a new behaviour. To evaluate how helpful these behaviours are, we’d like you to identify the benefits and downsides of the checking or reassurance-seeking behaviour you currently do. You can use the table on p. 326 to record your answers to the following questions:
1. What do I hope to achieve when I check or seek reassurance?
2. Are there any benefits to carrying out this behaviour as often as I currently am?
3. Are there any downsides to carrying out this behaviour as often as I currently am?
4. Does this behaviour really achieve my goal?
In reviewing your answers to these questions, how helpful do you feel it is to continue carrying out this behaviour? Does the frequency with which you do it make sense? Do the downsides of this behaviour outweigh the advantages?
One thing to keep in mind in going through this process is that it is not always necessary to eliminate the unhelpful behaviour. When we think back to the more helpful nature of having concerns about your health, we know that checking and seeking help from a doctor is necessary and good for you at times. The goal of this section is to help you recognize when your behaviour is excessive and determine when you need to either reduce, delay, or eliminate checking or reassurance-seeking behaviour.
Reducing or delaying a behaviour. You may realize that you need to reduce, or delay a behaviour, if the behaviour is consistent with advice from your doctor but you are doing it excessively, too frequently, or in the absence of any significant bodily symptoms.
Stopping a behaviour: You may realize that it would be better to stop a behaviour entirely if it is at odds with the advice of a doctor. For instance, most doctors would recommend that you limit your use of the internet to self-diagnose your symptoms, including visiting chat rooms to ask other people what your symptoms might mean. This is because it is unlikely you will receive valid information. You can ask your doctor what the appropriate guidelines are for self-examinations and check-ups for a person your age.
Worksheet 10.5: Cost-benefit analysis of behaviour
Tips for supporters
Discuss the above form with the person you are supporting. It can be difficult for someone who is health anxious to think of alternative behaviours and so having your support will help.
Whether you decide to reduce, delay or stop your checking or reassurance-seeking behaviour, the next step is to come up with a new or alternative behaviour. For some behaviours that you do, it may be relatively straightforward to stop them and replace them with more helpful behaviours – for example, if you have a tendency to research ‘causes of stomach pain’ on the internet to find out whether you are likely to have stomach cancer, a new behaviour might be to postpone any further researching on the internet. This alternative behaviour would give you the chance to see whether the stomach pain continues or goes away on its own. You might then set a goal of ‘I’ll wait one week and see if my stomach pain gets worse before I contact my doctor’.
You may need to stop or reduce some checking or reassurance-seeking behaviours more gradually. For these behaviours, you’ll need to set up and plan specific steps for working towards a new, more helpful behaviour. First, you need to identify what you want the new behaviour to be and then identify steps for working towards it. Let’s say that you poke your stomach ten times per hour in fear of having a tumour.
Your new behaviour goal may be to check only once a week. It would be an extreme shift to try to achieve this new behaviour straight away so instead you might take these smaller steps to meet this goal:
GOAL: Check stomach once per week
1. Check stomach eight times a day
2. Check stomach four times a day
3. Check stomach once a day
4. Check stomach every other day
5. Check stomach twice a week
6. Check stomach once a week
By breaking down a more challenging goal into something you can gradually change day by day, week by week, your new behaviour becomes more manageable! When you develop your own goals, focus on how you can reduce the amount of time you engage in the behaviour and/or the frequency of the behaviour. Below, set up your own steps for developing a new behaviour.
1.
2.
3.
4.
5.
6.
After you have worked towards replacing an older behaviour with new, more functional health behaviour, it can be useful to reflect on what you learned. What did you learn about yourself? What advantages were there to trying the new behaviour?
If you were not able to achieve your new behavioural goal, you may need to go back and re-evaluate the benefits and downsides to your old and new behaviours.
1. What are the advantages of trying this new behaviour?
2. How will this change your life?
3. You can also consider breaking down your new behaviour into even more manageable steps.
You can also try a behavioural experiment to reduce checking, in exactly the same way as is described for reduction of checking in obsessive compulsive disorder (see Chapter 11, p. 379).
As you might recall from earlier in this chapter, when you feel anxious or expect to feel anxious, you are likely to do one of two things to reduce your anxiety. You may engage in avoidance behaviours, where you stay away from certain situations, activities, things, people or places that trigger your health anxiety. Avoidance is a natural reaction to things that are uncomfortable, painful, sad, or anxiety provoking. You may also do what we call safety behaviours. These refer to anything you may do as a precaution so that you do not avoid a situation or activity outright.
Avoidance (or escape) brings about a feeling of relief. If you engage in avoidance enough times, it becomes a habit to cope with intense anxiety. Even though you experience relief of your anxiety by avoiding certain situations, you still have health anxiety. This is because avoiding only brings about short-term relief. The anxiety soon returns and may be worse the next time you are faced with your health-anxiety triggers. Moreover, by avoiding, you never give yourself the chance to gain evidence against your health-anxious beliefs. To see long-term effects and triumph over your anxiety, you need to confront the things that make you anxious!
Take a moment to review the section on avoidance and safety behaviours earlier in this chapter (p. 297). Below is a description of the avoidance and safety behaviours that were relevant for Laura.
Laura’s avoidance and safety behaviours
Laura identified that she uses avoidance quite often to cope with her health anxiety. She often avoids talking to friends or acquaintances who have had cancer. She recently stopped talking to a childhood friend when she found out that her friend had been diagnosed with lung cancer. She avoids visiting the hospital and reading about certain aspects of getting cancer – such as what the treatment would be like and about recovery rates. In terms of safety behaviours, she ensures she only eats foods that aren’t thought, rightly or wrongly, to be linked to cancer and does not go a day without taking antioxidant vitamins.
Using the worksheet provided below, identify the avoidance and safety behaviours you have noticed in your own life.
Worksheet 10.6: Identifying avoidance and safety behaviours
To stop avoiding and to start living your life, you can use a method called graded exposure. Graded exposure involves repeatedly exposing yourself to anxiety-provoking situations or activities in a structured and gradual way (see Part 1). In other words, graded exposure means facing your fears. While Stage 4 of the self-help programme in this chapter focused on replacing or stopping behaviours that you do to ease your anxiety (checking and reassurance seeking), graded exposure is about purposefully doing the things that you have been avoiding because of your health anxiety. You may have been avoiding or using safety behaviours for a while and it might be hard to imagine suddenly confronting all of your fears – the anxiety would be too much! The benefit of graded exposure is that you begin by first tackling the situations or activities that provoke the least amount of anxiety before gradually working your way up to more challenging activities.
You will be teaching your body and mind a new response. By repeatedly confronting the situations you are afraid of, bodily sensations that make you worried, and anxious thoughts, you will discover that the anxiety you experience does not remain at a high level for ever. Right now, it is likely that you escape the situation you are afraid of when you become anxious or that you use a safety behaviour to stay in it (e.g. take a pill to calm you, ask a friend for reassurance). Until now, you have not given yourself the opportunity to learn that your anxiety will decline naturally over time. In fact, your feelings of anxiety will actually decrease after you enter a situation again and again for an extended period of time. This is called habituation – your body and mind adapt to the situation or sensation. Each time you come in contact with things you’re afraid of, you are retraining your mind and body to respond in a ‘non-anxious’ way.
You will be learning that what you fear is not as dangerous as you think. While we can’t guarantee that what you fear about a situation or bodily sensation will never happen, graded exposure teaches you that the risk involved in such situations is probably lower than you believe. When we’re anxious, we tend to overestimate how likely and how intolerable a situation is. By staying in a situation long enough for your anxiety to subside, you will learn that: even though the anxiety is at first uncomfortable, what you’re afraid of is not very likely; and despite the discomfort of anxiety, you are able to cope.
You will be increasing your confidence and courage. Every time you successfully confront your health-anxiety fears, you are boosting your self-confidence. After you succeed the first time you might think: ‘I didn’t think I could do it! Maybe I can do it again.’ This success leads to further successes – you might start approaching other activities or situations you’ve been avoiding because the more you overcome, the more motivation you gain to continue conquering your fears!
There are three kinds of exposure that can be used by people with health anxiety.
1. Situational exposure: The most common form of exposure for health anxiety is situational exposure. Situational exposure is used to confront situations, activities, information or disease-related objects that make you feel anxious about your health. These may include hospitals, GPs’ surgeries, reading about a health problem, talking to an ill person, using a public lavatory, and so on. The situational exposures that you engage in will be specific to your own fears. The goal of situational exposure is to put your beliefs and assumptions about the situations to the test – does what you fear actually happen? Does the anxiety last for ever? Through situational exposure you’ll learn that you can tolerate not being absolutely certain about whether an illness or some other feared outcome will occur. The key to choosing a situational exposure is that it needs to target what it is you’re afraid of. For example, if you are afraid that your anxiety will become unbearable if you visit a hospital, the goal is to visit a hospital repeatedly and for a prolonged period of time. By doing so, you will find out that you can tolerate the anxiety that comes up.
2. Imaginal exposure: Sometimes entering a situation or doing something that triggers your health anxiety is too much to start off. In other cases, you may have certain thoughts or images (e.g. of you or a loved one dying) that cause you extreme anxiety. For these fears, it can be useful to begin exposure by imagining your fears. The goal of imaginal exposure is to help you confront mental images or thoughts that are anxiety provoking over and over again so that they no longer trigger an anxiety response. To confront thoughts or images, you can write out a script about an anxiety-inducing event or situation or even use a recording device to articulate your thoughts verbally.
3. Interoceptive exposure (exposure to bodily sensations you fear): People with health anxiety are often afraid of bodily sensations. If you fear developing lung cancer, you might be afraid of having shortness of breath. If you are afraid that you might develop heart disease or have a heart attack, a rapid heartbeat can often bring on anxiety. Interoceptive exposure involves intentionally bringing on the bodily sensations that you fear. For example, if you are afraid of a rapid heartbeat, you would practise running in one spot; if nausea scares you, you could spin in a chair. By bringing on these sensations in a systematic and prolonged manner without attempting to minimize them, you will learn that what you’re afraid of is either unlikely to occur or is manageable and temporary. You will also learn that the intense fear eventually lowers even when experiencing extreme bodily sensations.
The first step in starting exposure is to generate a list of items for your exposure hierarchy. You may want to refer to the avoidance and safety behaviour list that was provided earlier in the chapter for ideas (p. 233). On your exposure hierarchy, you will want to include a range of activities, situations, persons, places, as well as any bodily sensations that you avoid experiencing or try to minimize in your life due to health anxiety. Using the table on p. 337, you can insert the items according to how much anxiety they provoke. ‘Easy’ implies that it provokes the least anxiety, ‘Medium’ provokes moderate anxiety, and ‘Hard’ provokes the most anxiety. To help distinguish the amount of anxiety the item causes you, you can use an anxiety rating scale of 0 to 100, where 0 is equal to no anxiety and 100 is equal to maximum anxiety. Assign an anxiety rating to each of the items on your exposure hierarchy. Below is Laura’s exposure hierarchy followed by the blank hierarchy for you to fill out.
Table 10.3: Laura’s exposure hierarchy
Worksheet 10.7: My exposure hierarchy
Once you have generated a list of items on your exposure hierarchy, you will need to come up with a concrete plan of how to go about exposing yourself to these activities, situations, persons, places or sensations. A lot of the items on your hierarchy are probably lofty goals and need to be broken down into smaller steps so that they are more manageable to begin with. To ensure that your exposure is gradual and does not overwhelm you, first choose something from your ‘Easy’ category. That way you can work your way up to the harder (most anxiety-provoking) situations when you have become more confident and comfortable. It also helps to keep in mind that a good first exposure is one that can be easily arranged.
Concrete steps to take while planning your first exposure
1. Identify exactly how you’re going to arrange the exposure.
• What steps are involved? Identify the situation or setting, the time of day, and how exactly you will go about confronting your fear.
2. Before you begin, practise thought-challenging strategies.
• Prepare your mind with an ‘alternative thought’ that you can have in place of the anxious thoughts you expect to have when in the actual situation.
3. Set a specific goal.
• The goal of the exposure should be realistic but challenging, and should focus on specific actions, not feelings (e.g. I am going to stay in the hospital for 30 minutes vs. I will not get anxious while at the hospital).
• The goal should be measurable (e.g. someone should be able to watch you and tell you whether you met your goal).
• The outcome of the goal should be completely under your control.
• Ask yourself: what is it that you want to learn through this exposure?
4. Begin the exposure.
• It’s now time to do the actual exposure. Expect to feel some anxiety the first few times – if you didn’t become anxious you wouldn’t need to do this!
• During the exposure, pay attention to how anxious or uncomfortable you feel.
• Keep track of your anxiety on the 0–100 anxiety rating scale to notice how your anxiety fluctuates over time.
• Your level of anxiety may not decrease during first exposure, but with more practice, the less anxious you will feel.
• Your anxiety ratings will usually come down each time you repeat the exposure.
5. Afterwards, review your goal.
• Review the anxious thoughts you had before and during; compare them to what actually happened.
• While you may have expected something terrible to happen, pay attention to what really happened – was it nearly as bad as you expected? Did something good come out of the exposure?
6. Continue with the same exposure again a few more times.
• This will help to have an effect on your anxiety in that situation, and it will eventually lower with each practice.
7. Move on to the next item.
• When an item on your exposure hierarchy no longer makes you especially anxious, it’s time to try something more challenging on your list.
• You may move to something else in the ‘Easy’ category, or try an item in the ‘Moderate’ category.
Encourage the person you are supporting to do all items on the hierarchy frequently.
You learned earlier that safety behaviours are things that people with health anxiety do to help them feel safer or to cope in situations that provoke anxiety. The issue with safety behaviours is that they give you a false sense of security – they make you tell yourself that the situation or place is safer because you did something or made sure certain conditions were in place. For example, you may believe that you won’t catch the swine flu virus when you go out in public because you took all of your vitamins and brought medication with you, you used hand sanitizer and will wear a face mask, and you won’t use the public washroom while you’re there. These ‘precautions’ actually make your anxiety stronger because you are reinforcing the idea that the hospital is dangerous. By going out in public without carrying out your safety behaviours, you will learn that being out in public isn’t a threat for catching the swine flu virus.
When practising exposures, gradually reduce the safety behaviours you carry out. You may be able to give them up all at once. If you find this too unmanageable, however, to start off you can work on the safety behaviours one at a time. You should also keep in mind that checking and reassurance seeking also qualify as safety behaviours since you may use them to manage your anxiety. During exposure, we recommend that you work to reduce this behaviour.
If you are assisting in an exposure practice, it may help if you try doing the task first. This will give the person you’re supporting confidence that they can do the task too. When exercises go as planned, be sure to offer encouragement by saying, ‘You’re doing great! See how your anxiety goes down on its own?’ It is best to avoid providing reassurance, even if you are asked, ‘Are you sure this is safe?’ By promising that everything will be all right, you are only strengthening the reassurance-seeking behaviour of the person you are supporting. Instead, help him or her sit with the uncertainty.
At the start of this programme, we discussed how both excessive concern and also lack of concern about one’s health can be problematic. Although you have been learning how to decrease your focus and worry about bodily sensations, we do not want you to ignore symptoms that require medical attention. You might be wondering then, how do I know when to act on my concern and seek medical attention?
Unfortunately, there is no simple answer to this question. However, health-anxiety experts have suggested the following as some basic guidelines:
• Healthy-anxiety clinicians and researchers at the University of Manitoba, Canada have suggested that for symptoms such as pain or colds, it is helpful to try the ‘wait two weeks’ approach. Most symptoms will disappear without medical assistance over this period of time.
• If these types of symptoms persist for longer than two weeks, then you should see your doctor.
For people with a medical diagnosis or who are taking particular medications, then there may be specific indicators of when to seek medical attention. If this applies to you, then we would recommend speaking with your doctor about developing your own guidelines for when to delay seeking medical attention and when you should act on your concerns immediately.
Given that research and current opinions within the medical community can change from time to time, we would also recommend that you speak with your doctor regarding how often various tests (e.g. mammogram) should be performed.
Now that you’ve reached the end of this self-help programme, where is your anxiety at now? This is a good time to reflect on all the progress you’ve made.
How much has your anxiety decreased during the course of this programme?
• Have you met the goals you set for yourself at the beginning of this programme?
• Have you noticed any changes in your mood?
• Have you noticed any changes in your ability to function at work, school or at home?
• Have you noticed any change in your relationships?
• Have you noticed any change in your ability to enjoy life and to participate in hobbies and other fun activities?
• Have you noticed changes in the behaviours you perform to reduce health anxiety?
Discuss the progress you have observed in the person you are supporting. Sometimes we tend to overlook small changes. Even small changes can make a difference and so should be acknowledged.
Are there any areas in which your anxiety is still causing you difficulty?
• If you answered yes to this question, it would be helpful to go back through the programme and practise the strategies further. For example, if you find that you still struggle with being in certain situations, you may need to spend more time with exposure practice. Perhaps you can enlist a supportive friend or loved one to help you arrange the more difficult exposures. Remember that the cognitive skills (the expertise critical for learning) that you learned earlier in the programme should be used in conjunction with exposure – keep challenging those anxious thoughts!
• If you’re still experiencing significant symptoms after giving this self-help programme a true effort, seeking support from a therapist or psychologist should be strongly considered. Speak with your family doctor about making such arrangements or receiving a referral in your community.
In ending this self-help programme, the practice doesn’t stop here. Living a life without health anxiety means that you need to continue practising the strategies you’ve learned until they become habits. This takes time and dedication, but it will be worth replacing your anxious reactions with healthier and more helpful responses. Your anxiety will no longer be in control of your life – you will be!
To ensure you maintain the progress you’ve made, we recommend that you make exposure practice a daily habit. To keep your motivation going, think of exposure in terms of rewards: what reward does it bring to keep up with exposure even beyond this self-help programme? Remember: short-term distress for long-term gain!
Motivation to continue with exposure can also come from listing all that you’ve achieved or been able to do since starting this self-help programme. When you see on paper how far you’ve come and what you’ve gained, this can give you further motivation to continue confronting your fears.
Even if you’re now experiencing minimal health anxiety, you may experience the odd flare-up in the future. For example, your health anxiety may be triggered during times of high stress or if someone close to you becomes ill. When this happens, you need to remind yourself that such flare-ups are common, temporary, and short-term. This is not a full return of your health anxiety. Such flare-ups actually serve as a prompt to practise the skills you’ve learned to manage your health anxiety and take back control.
To help avoid setbacks, identify your high-risk situations. What situations can still trigger distress and health concerns? What situations have in the past? It may not be a situation, as such, but a bodily sensation or an object, or a particular person. When you anticipate encountering such high-risk situations, you can plan ahead and have various coping strategies ready to put into practice. You can:
• Have an alternative thought in place of your anxious thoughts.
• Remind yourself of your new behavioural goals so that you do not seek reassurance or check your body.
• Remind yourself that staying in a situation will have better effects on your long-term health anxiety than escaping or avoiding it will.
• Ask yourself, what other strategies have worked in the past?
Tip for supporters
One way to help the person you are supporting stay on track is by helping them create a contingency plan. What do you think might be high-risk situations for the person you’re supporting? Which strategies do you think seem to help the person you have been supporting deal with their health anxiety best?
By making a list of the exercises or coping strategies that you’ve found effective, you can quickly refer to them when confronted with a high-risk situation. More information about how to maintain your progress can be found in Chapter 14.
