Jonathan Abramowitz on Health Anxiety
By Lynn Mollick
On Sunday, April 10, Jonathan Abramowitz delivered NJ-ACT’s 21st Master Lecture to 88 mental health professionals. Below is a summary of Dr. Abramowitz’s morning lecture “Health Anxiety and Health OCD.”
Health Anxiety is a preoccupation with having a serious medical condition that is based on a misinterpretation of bodily sensations. It persists despite reassurance and proper medical evaluation. The following cognitive, behavioral, and physiological components maintain and define health anxiety:
Cognition: Core beliefs create catastrophic interpretations of innocuous physical sensations. Typical core beliefs include:
“I am weak (or frail) and unable to endure distress.”
“People who are in good health do not experience symptoms.”
“Serious disease is everywhere.”
“There is an explanation for my distress. Doctors should be able to find it.”
“It’s possible to be absolutely certain you’re not sick.”
“If the doctor orders a test, it means the doctor suspects a problem.”
“Medical tests aren’t accurate unless you have symptoms when you have the test.”
“Accurate assessment of my problem includes medical tests.”
Dysfunctional thinking – jumping to conclusions, emotional reasoning, catastrophizing, intolerance of uncertainty, body vigilance, and the confirmatory bias – amplify Health Anxiety.
Physiology: Normal bodies are alive with sensation, but patients with Health Anxiety attend to them more than others. In addition, uncomfortable sensations occur when people worry about health. Interpreting physical sensations as dangerous creates a vicious circle that intensifies sensation and worry.
Behaviors: Avoidance and safety behaviors strengthen Health Anxiety by preventing correction of mistaken beliefs. Common avoidance and safety behaviors include:
Seeking reassurance from doctors, friends, and family members
Reading and online research (for reassurance)
Avoiding reading and online research (to avoid anxiety)
Body checking (which sometimes irritates a small problem)
Avoiding hospitals and sick people because you might get sick
Exaggerated health behavior, e.g. too much exercise, too many vitamins
Whether Health Anxiety symptoms are cognitive, behavioral, or physiological, always find out how they are related to each other. Also assess when they occur. Triggers can be external stimuli (e.g. TV shows, cemeteries or bad news), physical sensations (e.g. headaches, pains), or intrusive thoughts or images.
Salkolvski’s 18-item Health Anxiety Inventory provides a normed rating of overall health anxiety.
Health Anxiety occurs in a number of DSM diagnoses — OCD, Panic Disorder, or Illness Anxiety Disorder (formerly known as hypochondriasis). However, Dr. Abramowitz emphasized functional assessment of Health Anxiety because it leads to empirically-supported cognitive behavioral interventions.
CBT for Health Anxiety combines techniques that help patients recognize and correct dysfunctional beliefs about health, provides experiences that support more accurate beliefs, and eliminates barriers to self-correction of dysfunctional beliefs about illness and health. It is a blend of interventions:
Health Anxiety patients fear being told “you’re crazy,” “nothing’s wrong,” or “this is in your head.” Validate patients’ uncomfortable experiences.
Suggest you will help them find a new way to think about or cope with their problem. Use medical rather than psychological language and never suggest that the problem is psychological. On the other hand, raise ambivalence about the medical explanation for the problem with comments like:
“What do you think will happen if you visit another doctor?”
“How frustrating is this? How does frustration contribute to your problem?”
“What percent of your problem is caused by frustration?”
“Wouldn’t it be nice to be less frustrated?”
“Would it be worth it to relieve a small part of your problem by focusing on your frustration and other psychological factors?”
“In the absence of medical findings, let’s discuss an alternate explanation for our problem.” Discuss the “Noisy Body,” hypervigilance, and how stress might intensify uncomfortable sensations. (“Noisy Body” handout attached.)
Always convey that you know the patients’ symptoms are real. Ask what might happen if the patient began to respond without alarm to physical sensations.
Treatment is about finding a new way to think about and respond to symptoms, not about convincing patients they are not ill. Explain how cognitive, behavioral and physical sensations interact and maintain Health Anxiety. Patients should become experts on this model of Health Anxiety.
The goal is to help patients make accurate appraisals of threat. Thought records are always helpful and observing links between thoughts and emotions provides a new way to interpret physical sensations.
Challenge jumping to conclusions. Ask patients to estimate the threat (likelihood of illness). Often they exaggerate or confuse severity of a diagnosis with probability. Have patients write down the evidence for and against having a serious illness.
Pie chart technique. Get more information to discover alternate explanations for a symptom (but not for reassurance.) Draw a pie chart that illustrates how much each cause contributes to the problem. Revise the estimated contributions based on all the evidence. To weaken the patient’s dysfunctional beliefs, use the Court Technique — have the patient argue against the dysfunctional assessment of illness.
Challenge catastrophizing by asking about worst possible outcomes. Examine real and probable outcome of serious illnesses. If patients fear death, correct faulty beliefs. Dr. Abramowitz recommended John Walker’s (2006) Treating Health Anxiety and Fear of Death: A Practitioner’s Guide for helpful information.
Challenge intolerance of uncertainty by focusing on probability of illness which is low, instead of possibility which is always present. Absolute certainty is an illusion and overcoming Health Anxiety involves learning to tolerate acceptable levels of uncertainty.
You can demonstrate the ubiquity of uncertainty by asking the patient whether someone who is not in the room is alive and safe. When they answer “yes,” ask them how they know for sure. They can’t, but with this issue they tolerate a certain amount of uncertainty, as they must about their health.
Ask patients about the advantages and disadvantages of 100% guarantees.
Socratic questioning is also helpful: “What’s happened in the past when you worried about this?” “Why do you think it will be different this time?” “What would a friend tell you about your desire for certainty in this situation?”
Most important: Do not offer reassurance that the patient is not sick.
Exposure and Response Prevention
Exposure: Dr. Abramowitz believes that exposure is the most powerful technique for changing Health Anxiety beliefs. Tell patients that exposure will put their beliefs to the test and change the way their bodies respond to fear triggers.
There are 3 kinds of exposure, all relevant to Health Anxiety:
1) Situational exposure means confronting fear-evoking situations, e.g. hospitals, medical books, and photos of sick children.
2) Imaginal exposure means confronting fear-producing thoughts and doubts, e.g. the possibility of having cancer. Ask the patient to write a script that describes the fear and the thoughts. Include details about the worst possible outcomes turning out to be real.
3) Interoceptive exposure means confronting fear-producing sensations, e.g. dizziness, breathlessness, headache. Produce these sensations intentionally by having patients hyperventilate, spin around, shake their heads, hold their breaths, swallow quickly for 45 seconds, breathe through a straw, ingest caffeine, or do anything else that creates physical symptoms.
Response prevention means refraining from all attempts to gain certainty about a health worry. This means not asking for reassurance, not doing self-examinations, not praying for the illness not to occur, not reviewing the situation obsessively. The purpose of response prevention is to allow distress to subside on its own. When anxiety subsides, patients can tolerate their fears.
Dr. Abramowitz believes that complete response prevention is essential to the success of CBT for Health Anxiety. He believes that Health Anxiety is an anxiety disorder that is similar to OCD and Panic Disorder. As with these and other anxiety disorders, cognitive therapy and exposure and response prevention are the most appropriate techniques, and relaxation therapy, biofeedback, and reassurance are not useful.