Severe and Persistent health anxiety Hypochondriasis

1
Severe and Persistent health anxiety
Hypochondriasis

• Paul Salkovskis
• Institute of Psychiatry, Kings College
• Centre for Anxiety Disorders and Trauma
• Maudsley Hospital
• Perth AACBT State Conference 2003

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Before beginning

• A supportive relationship with a clinician is
  the main objective of treatment. The clinician
  should inform the person that no organic disease
  is present, but that continued medical follow-up
  will help control the symptoms. The person with
  hypochondrias feels real distress, so the
  symptoms should not be denied or challenged by
  others. http//www.psychnet-uk.com/dsm_iv/hypocho
  ndriasis.htm

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Still More

• Regular appointments with a supportive CAM
  provider, though, may help to relieve health
  related fears because of the consistency of
  visits, the reassurance from a professional, and
  the focus on wellness as well as healthy
  behaviors. http//www.usadrug.com/IMCAccess/ConsC
  onditions/Hypochondriasiscc.shtml

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And yet more

• But the most effective treatment, according to
  Brown, is for the patient to agree to see the
  doctor only for more frequent, shorter and more
  focused visits, versus the less-frequent, longer,
  more meandering visits they've become accustomed
  to. http//www.reviewjournal.com/lvrj_home/2003/J
  an-27-Mon-2003/living/20533766.html

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Health Anxiety

• Anxiety resulting from perceived health threat
• Clinical diagnosis Hypochondriasis, a term
  almost universally disliked by patients and
  misunderstood by professionals
• - Im not just a hypochondriac
• - Its not an imaginary problem

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Prevalence of health anxiety and
functional somatic symptoms

• No reliable estimate of the prevalence of
  health anxiety, but it has been estimated that
  between 30 and 80 of patients who consult
  physicians present with symptoms for which there
  is no physical basis

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Reasons for consultation

• Handicap, Disability e.g. broken leg (cant
  walk)
• Intense and very distracting symptoms
• (e.g. back pain)
• Relatively minor symptoms which might indicate
  something more serious

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Prevalence of Hypochondriasis

• Cross national study in primary care
• (Gureje, Ustun and Simon, 1997)
• Out patient primary care clinics in 15 sites
• in 14 countries, screened using the GHQ 12
  second stage used the CIDI
• ICD10 Hypochondriasis
  0.8
• Unrestricted hypochondriasis 2.2
• Higher rates of Major Depression GAD
• High rates of health care usage

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DSM IV Hypochondriasis (1a)

• The main problem is defined as a
• preoccupation with either
• the fear of having, or
• belief that one already has
• a serious physical illness

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DSM IV Hypochondriasis (1b)

• The main problem is defined as a preoccupation
  with either
• the fear of having, or belief that one already
  has
• a serious physical illness
• These are quite different presentations , and
• have profound implications for the way the
  problem is conceptualized and for engagement in
  psychological therapy

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DSM IV Hypochondriasis (1c)

• The fear of having a serious physical illness
• I want you to help me with my fear of Cancer
• The belief that one already has a serious
  physical illness
• I dont need psychological help. My problem
• is that I have cancer

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DSM IV Hypochondriasis (1d)

• The preoccupation with health is based
• on the persons misinterpretation of bodily
  sensations

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DSM IV Hypochondriasis (1e)

• The preoccupation with health is based on the
  persons misinterpretation of bodily sensations.
• That is, the diagnosis is a cognitive one.
• Compare with the cognitive theory of panic

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DSM IV Hypochondriasis (2b)

• The problem persists despite medical
• examination and reassurance
• To be diagnosed as hypochondriacal,
• reassurance has to have been offered and failed

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DSM IV Hypochondriasis (2c)

• To be diagnosed as hypochondriacal,
• reassurance has to have been offered
• and failed
• Reassurance is the most widely used
• psychotherapeutic intervention in medicine
• Diagnosis therefore depends on the failure of
• psychotherapy delivered by a physician

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DSM IV Hypochondriasis (2d)

• The problem persists despite medical
• examination and reassurance
• Alternatively
• The problem persists because of medical
• examination and reassurance?

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DSM IV Hypochondriasis (3)

• Minimum of 6 month duration
• Not delusional
• The patient can be physically ill, the
• diagnosis give if anxiety is excessive
• Patients hate the label

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Health Anxiety

• Key features of clinical health anxiety
• - Misinterpretation of the meaning of symptoms
• - Misinterpretation of meaning of medical
• information (from health professionals
  media
• - Reassurance seeking from health
  professionals
• sometimes very extreme
• - Reassurance can be subtle and unseen
• - Patients able to elicit not only reassurance,
  but
• also multiple (expensive) unnecessary
  referrals
• and investigations

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The problem of reassurance

• Re (repeat)
• Assurance (reduction of doubt)
• Reassurance tells the patient what is NOT
  wrong with them
• Patients are grateful if they find out what
  the problem is not, but they really want to know
  what the problem IS

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Health anxiety and responsibility

• Patient feels responsible for any problems
• they have developed
• Patient feels responsible for consultation
• Both may result in irritability, defensiveness
• and hostility
• It is possible to be empathic with patients
  who express hostility to you

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How not to help people suffering from health
anxiety

• Secondary gain
• Somatization
• Alexithymia
• Pull yourself together
• Iatrogensis

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How psychological treatments work?

• Anxiety disorders occur because people
• believe situations to be more dangerous
• than they really are
• Good clinicians help patients to consider
• alternative, less threatening explanations
• of their problem

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Alternative explanations in therapy

• People will find an alternative explanation
• believable and helpful if it seems to match
• with past experience and survive future
• experience
• Therapy with well grounded in empirical
• evidence and phenomenology will give
• better outcomes than most which are not

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Engagement requires empathy helping patient to
feel understood

• First, the therapist has to understand

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Why might the patient distrust reassurance?

• History try to understand how the person
• came to believe what they now believe
• about their symptoms
• Identify assumptions about reassurance and
• the medical consultation
• Consider the personal meaning of the persons
  present symptoms

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Anxiety and threat

• Anxiety is proportional to the perception of
  threat factors
• perceived perceived
• likelihood X awfulness
• perceived perceived
• coping rescue

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Health anxiety and threat

• Health anxiety
• I might have X My mother died
• cancer in a terrible way
• Ill fall apart, my Anything the doctors
• family will have to do will just make things
  care for me. worse
• Ill be a basket case

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Negative appraisals examples

• I have aids
• I have cancer
• I am about to die
• I have a serious brain disease
• I have heart disease
• I have a serious illness the doctors
• havent diagnosed yet

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Applied example of Cognitive Theory

• Learned assumptions
• Im like my mother, who had a
• heart attack when she was 40
• Palpitations
• Doctor sends for ECG, queries diet
• I have heart
• disease
• Anxious, sad Take pulse, looks on internet,
  selective attention

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Assumptions examples and scale

• Bodily changes are always a sign that
• something is wrong
• If I dont worry about my health,
• something will go wrong
• Detailed tests are the only way to really
• rule out an illness
• If the doctor sends me for any tests, he or
  she
• is convinced that there is something wrong

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• Previous experience of illness and
• medical type factors
• Critical (precipitating) incident/s
• Inflexible or negative
• assumptions about health
• negative interpretations
• probability X awfullness
• coping rescue

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• events, stimuli and situations
• negative
• interpretations
• Anxiety probability X awfulness
• 
  coping rescue physical reactions
• safety seeking
• behaviour

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• The persistence of health anxiety
• the vicious flower
• Attention to health
• information
• Terrified I have terminal feeling weak
• cancer and ill
• Checking Seeking
• lumps assurance

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• Previous experience of illness and
• medical type factor
• Clinical (precipitating) incidents
• Inflexible or negative
• assumptions about health
• events, stimuli and situations
• negative interpretations
• Anxiety probability X awfulness
  Physical rescue
• coping rescue

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Cognitive disturbance in health anxiety

• Similar to panic, in that the interpretation
  of
• bodily sensations commonly occurs.
• However, health anxious patients also
• misinterpret other things, including
  bodily
• variations, medical information from
  doctors
• and from the media, and the results of
  health
• screening and tests

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Cognitive theory of panic

• Patients with recurring panic attacks have an
• enduring tendency to misinterpret certain
  bodily
• sensations as a sign of imminent disaster
  (thinking
• palpitations are a sign of a coronary
• Acute panic attacks result from the
  misinterpretation of bodily or mental sensations
  as signs of imminent personal disaster. (Clark,
  1986 1988 Salkovskis, 1988, 1998)

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Cognitive disturbance in health anxiety (2)

• Some other key differences
• Relatively delayed time course
• Different behaviors (checking and
• reassurance seeking are prominent)
• Alteration of dwelling and avoidance
• Assumptions concerning health prominent

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Treatment of Health Anxiety general issues

• Treatment should not begin when the patient
  is currently receiving seriously ambiguous
  cross-referral
• Exclusion of a physical condition is, however,
  NOT a requirement
• Audiotape of session helps memory and
  processing
• Involvement of others helpful
• 8-16 Sessions, sessions up to one hour long

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Overview of the cognitive theory

• The same event can have different meanings for
  
• different people (or even for the same person
  on
• different occasions)
• It is this meaning which gives the event its
  emotional impact
• Emotional problems persist because of
  reactions driven and/or motivated by key negative
  interpretations these reactions can increase
  source of misinterpretations and the negative
  beliefs

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Overview of cognitive treatment

• Treatment involves some combination of
• (i) helping the person to make changes in their
  situation (problem solving)
• (ii) The correlation of counter-productive
• and interpretations
• (iii) Learning and testing alternative ways
• interpreting their experience
• (iv) Helping patients to try different ways of
• behaving consistent with the alternative

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Treatment underpinnings

• Engage with the person
• Engage the person
• General clinical assessment
• Goal setting (short, medium and long term)
• Identifying problems which may be
• amenable to practical change
• Helping with problem solving

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Treatment Cognitive-behavioural therapy
information, information, information

• Agree on main target problem/s
• Specific assessment
• Formulation and shared understanding
• Identify the formulation as an alternative,
  less
• threatening account of the persons problems
• Discussion techniques intended to help the
  person
• understand how the alternative explanation
  works
• Behavioral experiments intended to allow the
  person
• to gather new information which allows
  them to extend
• their understanding of how the alternative
  explanation works

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Helping people to accept new information just
telling them is not usually enough

• Accommodation vs assimilation
• Guided discovery allows greater depth of
  processing,
• and the assimilation of new information
• Dont trust me, find out for yourself
  experience within a new framework leads to
  accommodation
• To be helpful, new information has to be
  readily self-
• referenced negative views of self can
  interfere with this

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Preventing treatment from making things worse

• Hypochondriacal patients are particularly
  likely
• to misinterpret health relevant information as
• indicating they may be ill therefore, they
  may
• misinterpret the information discussed during
• therapy sessions
• Ask the patient to summarize at the end of
  each
• therapy session
• If the patient has misinterpreted what was
  discussed turn this to therapeutic advantage

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Treatment elements general

• Validating the patients experience
• I have pain in my legs, intense tingling and
  I
• think I have multiple sclerosis
• The best way to decrease belief in a highly
  threatening idea
• which cannot be disproved is to build up
  belief in an alternative
• explanation The alternative explanation
  does not have to be
• completely incompatible with the
  threatening belief initially, it
• probably helps if it is not
• This type of reattribution will proceed best
  of the patient feels
• understood. The formulation therefore is
  best done as a shared
• understanding

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Assessment History can help

• Helps establish a rapport, helps the person to
  
• feel understood
• Can help the therapist to understand the
  persons
• distrust of reassurance
• Can establish aspects of the Developmental
• Formulation
• Development of depression and demoralization
• Can help establish the personal meaning of
  illness
• Often give particularly vivid examples of the
  key
• process in action

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HAI

• Health anxiety inventory
• 1. Six months or last two weeks
• 2. Scales Symptoms, cost Avoidance,
• Reassurance
• 3. Brief (12/4) item version available

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General issues in assessment and treatment

• Questionnaires and scales
• Health anxiety Inventory
• Illness attitudes scale
• Cognitions Questionnaire
• Severity and preoccupation scales
• Beck Anxiety and Depression
• Inventory

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Meaning links bodily variations and
misinterpretations

• Heart racing, pounding Im having a heart
  attack,
• palpitations my heart will stop
• Lumps under skin Ive got cancer
• Loss of sensation and Ive got multiple
  sclerosis
• Tingling in arms and legs
• Feeling dizzy, faint, weak legs Ive got HIV
• Feeling dizzy, heart pounding Im dying
• Chest tight and painful,
• palpitations

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Assessment identifying a specific instance

• A recent a relatively well remembered episode
• is identified
• Situation and time are primed where and
• when was it? What were you doing just
• before it?
• What was the first of trouble?
• Step through the situation and the persons
• reactions
• Emotion is the guide
• Slow things down if steps are skipped

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Assessment guided discovery

• Guided discovery is main method aims to lead to
  a
• vicious flower formulation
• Pay attention to sequencing of questions
• When you notice your fingers tingling, what
  seemed to
• you, at that time, was the worst thing this
  could mean?
• ( belief ratings)
• When you thought this tingling meant you
  had Multiple
• Sclerosis, how did that affect you? (how did
  it make you
• feel.what did you do.what did you pay
  attention to.
• how did you try to deal with it.?
• What did that do? At that time, what was
  the effect
• of..on the belief that you had multiple
  sclerosis?

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• Events, Stimuli, Situations
• Anxiety Negative Interpretations Physical
• (Prob x Awfulness)
  Reactions
• (Coping Rescue)
• Safety Behaviors

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• Trigger Stimulus
• (internal or external
• Perceived threat
• Interpretation of
• Sensations as
• Catastrophic Apprehension
• Body
• Sensations

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Cognitive model of the persistence of anxiety a
validated multi-component model

• Bodily sensations
• Anxiety
• Anxiety illness
• interpretations
• physical
• reactions
• Safety seeking behaviour
• (escape and avoidance)

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Treatment elements general

• The main element is re-attribution, based on the
  fact
• that the best way to decrease belief in a highly
• threatening belief which cannot be disproved is
  to build
• up belief in an alternative explanation. The
  alternative
• explanation does not have to be completely
  incompatible
• with the threatening belief, initially, it
  probably helps if it
• is not.
• This type of reattribution will proceed if the
  patient feels
• understood. The formulation therefore is best
  done as a
• shared understanding.

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Shared understanding and formulation

• The shared understanding provides the basis
  for explicit
• discussion of two different ways of
  understanding their
• problem
• Guided discovery aiming to explore the
  treatment
• rationale, not didactic
• Panic attacks
• Obsess ional type presentation

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Treatment elements (1)Engagement and
socialisation

• The necessary first step in treatment (and
• sometimes in assessment) is engagement
• Issues surrounding engagement
• Are you saying its all in my mind?
• What guarantees can I have
• Ill be dead by then
• Pros and cons of being anxious about health
• Forward time projection
• You are 80 years old and
  looking back on your life.
• The engagement deal theory A / theory B

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Goal setting in CBT

• Short term goals goals which can reasonably
  be
• achieved in 2-4 sessions
• Medium tern goals what can reasonably be
  achieved
• by the end of therapy
• Long term goals what the patient would like
  to do
• over the next few years, particularly
  emphasising
• positive changes and growth targets

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• The persistence of health anxiety
• the vicious flower
• Attention to health
• information
• Terrified I have terminal feeling weak
• cancer and ill
• Checking Seeking
• lumps assurance

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Treatment elements (2)

• Treatment involves a range of other
• components, including
• Self monitoring
• Specific re-attribution
• Discussion and behavioural experiments
• aimed to help the patient to evaluate the
• alternatives

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Treatment elements (3)

• Discussion and behavioural experiments are
• linked and interwoven
• Discussion and verbal techniques usually help
• the patient to draw upon their past
  experience
• to understand the alternative explanation
  which they
• are considering
• Behavioural experiments are used to gather
  new
• information to feed into the discussion.
  Dont
• trust me, test it for yourself

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Treatment elements (4)

• Discussion techniques
• Reviewing the evidence for and against both
  ways
• of looking at things
• Using the alternative explanation/framework
  to
• understand the significance of old
  information
• Specific discussion techniques
• - challenging beliefs
• - pie charts

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Pie chart in health anxiety

• Identify the distorted belief
• (e.g. brain tumorgtgtgtgtgtheadaches
• Therefore headachesgtgtgtgtgtgtbrain tumor)
• Belief rating (0-100)
• Encourage the patient to make a list of all
  possible
• causes of headaches in your town today
  always
• begin with brain tumors
• When the list is complete, divide the pie
  chart up
• into percentages start at the bottom of the
  list
• Re-rate belief
• What if anxiety is not included?

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Pie charts in people with multiple serial
concerns

• Patient repeats exercise with a previous
  symptom-illness link
• Finally, repeats exercise with a possible
  future symptom-illness link

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Treatment elements (5)

• Helping doctors/therapists to deal with
• reassurance and medical consultation
• seeking
• How helpful is reassurance
• Promising large amounts of reassurance for a
  price
• The medical test as a demonstration
• of psychological mechanism

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Treatment elements (6)

• The focus in on discovery, with the
• patients experience as the starting point
• Helping the patient to deal with reassurance
  and medical consultation
• Dealing with the cry wolf worry
• (I) programmed postponement
• (ii) worries about emergencies

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Behavioural experiments what do you want to
achieve?

• 1. To help the person to discover that the
  things
• which they fear will not happen
• 2. To help them discover the importance of
• maintaining factors
• 3. To help them discover the importance of
• negative thinking
• 4. To help them find out whether using an
• alternative strategy will be of any value
• 5. To discover the truth about beliefs

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Relapse prevention

• Discuss idea of setback rather than relapse
• Seek to confront all possible situations in
  the course of therapy (no red areas on map)
• Emphasise the setback as positive experience
• Blueprint and relapse pack (action plan)
• Anticipate problems
• Build positives

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Health anxiety research model

• Anxiety
  Depressed mood
• Negative appraisal of
  Processing of self as
  Bodily
• Mental elaboration health
  relevant information biological
  object variations
• (worry) preoccupation (bodily)
  variations priority to
  health (incl, pain
  medical information
  relevant information
  sensations)
• 
  
  Effortful attentional
• 
  
  deployment,
• Seek reassurance Selective
  (avoidance suppression
• medical information attention
  active
  vigilance) Decreased
  threshold
• for orienting/defensive
• responses (including
• heightened activity)
  Altered overt behaviour
• (active avoidance, limping
• passive avoidance
• disease syndrome
  
  

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The present status of treatment for
Hypochondriasis

• Good evidence that CBT and cognitive based
• psychoeducational interventions are effective
• (level 1)
• Some evidence that the effects of CBT are not
• solely due to non-specific factors
• Some evidence that Behavioural Stress
• management (a composite treatment which
• includes the engagement elements of CBT) is
• effective (level 2)
• Some evidence that SRIs are effective (level
  2)