The Clinician's Guide to Treating Health Anxiety: Diagnosis, Mechanisms, and Effective Treatment

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

• Language: English
• Publisher: Academic Press
• Release date: Mar 14, 2019
• ISBN: 9780128118078

Book preview

Kingdom

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 manifests during periods of significant stress, following serious illness or the loss of a family member, or subsequent exposure to disease-related stories in the popular media (Barsky & Klerman, 1983; Taylor & Asmundson, 2004). The bodily sensations and changes that Paul was concerned about began during a particularly demanding several months at work and were similar in nature to those experienced by his now deceased father and his cousin. In cases where health anxiety is sufficiently severe and prolonged and where conceptualization as continuous may be less than ideal (e.g., where required for insurance purposes), there are several diagnoses that may be warranted. Below, we highlight various conceptualizations of maladaptive presentations of health anxiety (also see Chapter 2), their prevalence (also see Chapter 3), and associated societal and personal costs.

Maladaptive Presentations and Related Psychiatric Disorders

In cases where diagnostic nomenclature and classification schemas are applied, contemporary cognitive behavioral models often conceptualize severe presentations of health anxiety as hypochondriasis (Abramowitz et al., 2002; Salkovskis & Warwick, 2001; Taylor & Asmundson, 2004), a psychiatric disorder marked by the misinterpretation of normal bodily states as a serious health problem. Whereas the diagnosis of hypochondriasis still exists in the ICD-10 (1992), major changes to the classification of somatoform disorders occurred in the DSM-5 (American Psychiatric Association, 2013), and the diagnosis of hypochondriasis was removed from DSM nomenclature.

Despite considerable controversy regarding issues of reclassification (Collimore, Asmundson, Taylor, & Abramowitz, 2009; Starcevic, 2013), the DSM-5 now classifies hypochondriasis and several other somatoform disorders (i.e., somatization disorder and pain disorder) within a new diagnosis of somatic symptom disorder. Another new diagnosis—illness anxiety disorder—applies to people who experience severe health anxiety without any salient bodily sensations or changes. The ramifications of these changes to the diagnostic classification of severe presentations of health anxiety remain to be determined (Rief, 2013); yet, there are already proposed modifications to DSM-5 criteria for severe presentations of health anxiety (Rief & Martin, 2014), with some researchers proposing diagnostic criteria for a distinct health anxiety disorder (Fink et al., 2004). Such modifications and alternative diagnostic criteria have yet to be formally adopted and require further examination. Importantly, diagnostic changes surrounding severe presentations of health anxiety have minimal impact on either contemporary cognitive behavioral models or associated approaches to assessment and treatment where the focus is on the health anxiety construct.

Preliminary research has examined potential differences in the presentation and associated characteristics of somatic symptom disorder and illness anxiety disorder, respectively (Bailer et al., 2016; Newby, Hobbs, Mahoney, Wong, & Andrews, 2017). This research has produced mixed findings as to whether individuals previously diagnosed with hypochondriasis primarily meet criteria for somatic symptom disorder versus illness anxiety disorder, with Bailer et al.'s (2016) findings providing evidence of a greater prevalence split favoring somatic symptom disorder than did Newby et al.'s (2017) findings. Newby et al. (2017) found greater levels of health anxiety among individuals meeting criteria for somatic symptom disorder, whereas Bailer et al. (2016) generally did not find differences. A consistent pattern across these two studies is that individuals with somatic symptom disorder endorse greater somatic symptom severity than individuals with illness anxiety disorder. Additionally, somatic symptom disorder may be marked by greater levels of maladaptive coping, in the form of the overutilization of medical care and increased functional impairment relative to illness anxiety disorder. There is a need for additional research comparing somatic symptom disorder and illness anxiety disorder; yet, results from these two preliminary studies suggest differences between the disorders are likely best conceptualized in terms of severity rather than substantive qualitative differences (Bailer et al., 2016; Newby et al., 2017).

Paul's presentation seems best characterized as somatic symptom disorder (American Psychiatric Association, 2013), which requires the experience of one or more somatic symptoms that are distressing or disruptive and associated with excessive cognitive, emotional, or behavioral responsivity to the somatic symptom or related health concerns. Paul has substantive concern surrounding both chest pain and shortness of breath. Paul experiences disproportionate and persistent thoughts about the severity of these somatic states and persistent high levels of health anxiety. Paul finds himself constantly plagued by worries that his bodily sensations and changes are the sign of a serious health problem. Finally, Paul spends excessive time and energy in response to his health anxiety, ultimately spending hours nightly searching for the meaning of his symptoms and finding himself preoccupied by health-related worries.

How to best classify health anxiety is not isolated to considering somatic symptom disorder versus illness anxiety disorder, as health anxiety shares considerable overlap with other anxiety disorders (Olatunji, Deacon, and Abramowitz, 2009). Overlap includes the tendency to make catastrophic misinterpretations of bodily states (e.g., panic disorder; Noyes Jr., et al., 1994), the occurrence of distressing thoughts and engagement in repetitive safety behaviors to mitigate the threat surrounding the thoughts (e.g., obsessive-compulsive disorder; Asmundson et al., 2010), and the tendency to worry (e.g., generalized anxiety disorder; Taylor & Asmundson, 2004). Despite this overlap, severe presentations of health anxiety have been posited to be conceptually and empirically distinct from anxiety disorders (e.g., Barsky, 1992; Hedman et al., 2017; Salkovskis & Clark, 1993; Starcevic, Fallon, Uhlenhuth, & Pathak, 1994; Warwick & Salkovskis, 1990). Nonetheless, the overlap does raise the possibility that severe presentations of health anxiety may be best conceptualized as a manifestation of severe anxiety as opposed to intense somatic focus (Collimore et al., 2009; Olatunji, Deacon, et al., 2009).

Prevalence

A detailed discussion of the prevalence of health anxiety appears in Chapter 3 of this volume. Briefly, extant prevalence estimates for clinically severe presentations of health anxiety are based upon the prevalence of hypochondriasis and range from 0.5% (Bleichhardt & Hiller, 2007; Looper & Kirmayer, 2001; Martin & Jacobi, 2006) in community samples to 0.4%–6% in primary care and medical clinics (Barsky, Wyshak, Klerman, & Latham, 1990; Escobar et al., 1998; Fink, 'rnbøl, & Christensen, 2010; Gureje, Ustun, & Simon, 1997; Liu et al., 2012). When considering severe forms of health anxiety that may not meet full diagnostic criteria, the extant research points to prevalence estimates in community samples from 2% to 13% (Looper & Kirmayer, 2001; Martin & Jacobi, 2006; Noyes Jr., Carney, Hillis, Jones, & Langbehn, 2005; Sunderland, Newby, & Andrews, 2013) and in medical clinics from 12% to 20% (Fink et al., 2010; Tyrer et al., 2011). Challenges in establishing accurate prevalence estimates, including differing definitions of health anxiety and recent changes to diagnostic categories in the DSM-5, are discussed elsewhere (Asmundson and Le Bouthillier, 2018).

Cost

Because medical overutilization is considered a core form of reassurance seeking among individuals experiencing severe health anxiety (Abramowitz et al., 2002; Salkovskis & Warwick, 2001; Taylor & Asmundson, 2004), the cost of severe presentations of health anxiety has typically be assessed in the form of the impact on the health-care system. The estimated medical cost of patients with somatization is around $256 billion (USD) annually (Barsky, Orav, & Bates, 2005). This estimate is relevant to severe presentations of health anxiety, as somatic symptom disorder includes individuals previously diagnosed with somatization disorder (American Psychiatric Association, 2013). Within primary care settings, patients experiencing severe health anxiety utilize between 41% and 78% more health-care services per year than individuals with a well-defined medical condition (Fink et al., 2010). The mean cost of a single primary care patient with heightened health anxiety and somatic symptoms, a symptom presentation akin to DSM-5 somatic symptom disorder, is around $1500 per year (Barsky, Ettner, Horsky, & Bates, 2001). Spontaneous recovery from severe health anxiety is rare (olde Hartman et al., 2009), suggesting that the concerns of individuals with severe health anxiety are likely to be chronic if left untreated. Individuals with severe health anxiety are more likely to initially present to a physical health provider (Taylor & Asmundson, 2004), relative to a mental health provider, and severe health anxiety typically goes unrecognized by physicians (Fink, Sorensen, Engberg, Holm, & Munk-Jorgensen, 1999). Difficulties recognizing severe health anxiety delay potential treatment and perpetuate a maintaining factor of medical service