By Wasim Kakroo
MOST medical professionals including general physicians, gastroenterologists, cardiologists etc. have encountered patients who have physical problems for which an organic cause cannot be established, or for whom no amount of reassurance is enough to alleviate their extreme concern about the possibility of having catastrophic illnesses like cancer. Such people may call or see the doctor frequently, seeking reassurance over seemingly small (even undetectable) signs and symptoms, or to request further medical testing. In the short term, such questioning may cause interpersonal and practical management issues; however, in the long run, these symptoms lead to the wastage of medical resources, increase costs, and, paradoxically, expose otherwise medically healthy individuals to risks associated with medical or surgical procedures. As a result, extreme health anxiety (HA; also known as hypochondriasis) is a public health and financial concern in many areas of medical practice.
The focus of this article is on a recurrent contradiction found among patients with this disorder: why do patients’ strong fears of disease continue for a longtime if they do not have any major illness? Why, do such people fail to respond correctly to reassurances from their physicians or other reliable sources?
I will try to answer these questions by explaining the physiologic, cognitive, and behavioral mechanisms that contribute to the development and persistence of HA as it is also necessary to be aware of these processes in order to provide appropriate therapy.
According to the Diagnostic and Statistical Manual of Mental Disorders, health anxiety or hypochondriasis is defined as a preoccupation with the (inaccurate) belief that one has a serious illness or is in danger of acquiring a serious illness. The belief of being ill is usually functionally debilitating and continues even after proper assessment and confirmation of absence of any sort of illness. The obsession with some sort of illness might be symptom-driven, with a focus on physiological processes (e.g., heartbeat, peristalsis), small physical anomalies (e.g., a sore), or vague and ambiguous physical feelings (e.g., “weary heart,” “aching veins”). The signs and symptoms are attributed to the suspected disease, and the individual is worried about their meaning, validity, and origin. Alternatively, there might be an obsession with a specific organ or illness (e.g., fear of having cancer).
Psychodynamic understanding of health anxiety:
People over a period of many centuries have tried to make sense of this condition. A number of psychodynamic explanations for hypochondriasis have been offered, including the idea that patients need doctors’ reassurance to satisfy unfulfilled attention demands. Such hypotheses, on the other hand, are not based on scientific study and are not backed up by actual evidence. In the medical and psychiatric fields, the concept that hypochondriacal behavior is driven by “secondary gain” is frequently discussed. While intuitively attractive and clear, this viewpoint indicates that the patient’s behaviour is intentional or due to a “personality problem.” Furthermore, it ignores the importance of a more thorough examination of specific symptoms, which is an essential element of properly treating hypochondriasis.
Hypochondriasis as a form of anxiety:
Anxiety and fear have an adaptive function in the presence of threat; they protect animals from damage by activating the sympathetic nervous system—often referred to as the “fight or flight” response. It’s crucial to realize that the anxiety response is triggered in the face of a perceived threat, irrespective of whether or not the threat is real. Furthermore, the frequency, severity, and length of anxiety is related to importance and imminence of the perceived threat. As a result, issues that are thought to be critical to one’s well-being elicit significant levels of anxiety. It should come as no surprise that health-related anxiety is a common phenomenon among population, given the fact that perceived risks to one’s physical well-being are likely to be considered very important by any individual. Thus, hypochondriasis can be thought of as an extreme form of excessive and persistent anxiety focused on a perceived threat to one’s health. In another words, the major symptom of hypochondriasis is the misinterpretation of apparently harmless physiological feelings and symptoms as indicative of a major health concern.
Why do some people view health-related information as dangerous when there is no need to be concerned?
Basic (though incorrect) beliefs about health and sickness, as well as memorable health-related experiences, are likely to be the source of such misinterpretations. For example, associating “pain” with “damage” or seeing a loved one’s some incident with heart disease might lead to indigestion being misinterpreted as an indication of heart failure. Faulty general health beliefs can stem from a range of sources, including media reports or negative personal experiences with illness. If such assumptions about illnesses are extremely rigid or severe, HA is likely to result. Individuals with HA, for example, may have extremely limited conceptions of good health, believing that good health entails no physical sensations at all. For example, whereas most individuals would seek medical advice if they experienced unexplained neck discomfort for several days, someone who is predisposed to HA may mistakenly believe that any neck pain is an indication of serious illness. Whereas the former belief leads to proper use of medical resources, the latter leads to illogical and irrational behavior, such as obsessing over and constantly analysing one’s own symptoms, and strong impulses to seek medical consultation.
Other such faulty assumptions that may contribute to incorrect interpretations (and hence to HA) include attitudes about health-care behaviours, such as “When you experience something unusual in body, you should not waste time going to the doctor since it can otherwise be too late.” Beliefs about one’s perceived personal weaknesses or vulnerability to a certain sickness may work in a similar way. Examples include, “Cancer runs in my family,” “my father died when I was young,” or “I have a weak heart”. Critical occurrences, such as a loved one’s diagnosis or a well publicised health concern, might activate such beliefs in vulnerable people.
With relation to underlying erroneous health-related attitudes and assumptions, severe HA develops when insignificant physical signs and symptoms are misunderstood as suggesting serious illness. The presence of a perceived health concern may thus prompt an individual to visit a medical professional and get themselves checked.
What leads to persistence of health anxiety despite reassurances?
It’s normal to be concerned about bodily symptoms now and again, and most of the time, this is alleviated once you realize there’s nothing severely wrong with the functioning of your body. People with severe HA, on the other hand, have persistent health concerns despite what appears to be compelling confirmation that their anxieties are baseless. It’s as though something is interfering with the reassuring effects for these people. I will try to explain why it happens by describing the physiologic, cognitive, and behavioural variables that prevent patients with HA from recognizing that they don’t have to be so concerned about the physical indications and symptoms they’re afraid of.
Physiological (biological) Factors:
As previously stated, anxious arousal (increased heart rate, sweating, hyperventilation, vasoconstriction, and other symptoms) aids in the organism’s defense against danger and readiness to respond quickly (i.e., fight back or flee). Although most individuals understand that elevated heart rate is a sign of autonomic arousal, other cardiovascular effects are less well understood. Less understood consequences of being in such situations include increased blood flow to major muscle groups (to prepare for action) and decreased blood flow to the skin, fingers, and toes (to guard against blood loss). As a result, when you’re anxious, your skin may seem pale or feel chilly, and your fingers and toes may go numb or tingly.
Hyperventilation, is another sign induced by autonomic arousal, which increases the supply of oxygen to the muscles. Breathlessness, suffocating or choking feelings, and even discomfort or tightness in the chest are the consequences of increased breathing speed and depth. With sustained hyperventilation, the ratio of oxygen to carbon dioxide in the brain is somewhat offset if no real activity happens. While entirely safe, this may cause temporary lightheadedness, blurred vision, disorientation, sense of unreality, or hot flashes for a short time. Profuse sweatiness, dry mouth, pupillary dilatation (resulting in blurred vision), and a reduction in digestive function (frequently causing nausea or constipation) are some of the other side effects. Finally, muscle strain, a part of being anxious can cause bodily pains, tremors, and shaking, as well as an overall feeling of exhaustion.
What is the relation between these physiological effects of autonomic arousal and Health Anxiety (HA)?
Although insignificant, the emergence of such symptoms may be misinterpreted by the HA patient as suggesting a serious condition that results in emergence of more threatening symptoms as one becomes anxious or stressed about one’s health. This causes further increase in anxiety, which exacerbates the “inexplicable” symptoms of autonomic arousal, resulting in severe HA and a desire to seek medical help for a suspected medical condition.
The way people think about health-related information they receive also contributes to the development of HA. Unexplained physical sensations, for example, naturally prompt a search for proof to corroborate or disprove one’s worst concerns. Because the cost of making a false negative decision (assuming good health when an illness exists) is higher than the cost of making a false positive decision (assuming sickness when one is well), people with HA prefer to be cautious than to ignore something that might be dangerous. This, however, leads to a biased focus on evidences that might prove (rather than disprove) the presence of illness (thus, headache Equals brain tumour, heart palpitations equal heart attack). Furthermore, data that suggests good health (e.g., symptoms that are similar to previous headaches and respond to usual medicines taken for headache) is frequently overlooked. This type of selective attention can also affect the impact of doctor’s reassurance; evidence that supports a diagnosis enhances the dread of being sick, while disconfirmatory information is dismissed as insufficient or irrelevant. This selective attentional bias explains why, even after medical tests reveal that there is no sickness present, people still continue to seek second opinions.
Body vigilance—the inclination to pay great attention to and monitor even minor physiological sensations based on concerns about such feelings—is another cognitive element implicated in the maintenance of HA. Indeed, expecting one’s body to produce dangerous indications and symptoms would inevitably increase sensitivity to notice any such phenomenon quickly. However, excessive body vigilance may result in the misinterpretation of typical bodily changes and perturbations as “new” signs of being seriously ill.
Along with body vigilance, people with severe HA have an intolerance for uncertainty—indeed, anything short than total certainty when it comes to personal health is exceedingly anxiety inducing for such people. While most individuals accept a certain level of uncertainty in everyday life (including issues relating to their health), those with HA interpret any doubts about their health as highly unpleasant. Health-conscious people seek reassurance by asking doctors for more evaluation, describing symptoms to others, going through medical references, or evaluating one’s own physiological signs or symptoms (e.g., taking one’s own blood pressure, checking for lumps in any part of their body, such as breasts etc.) in order to eliminate any possible source of threat to their health and thus trying to be certain about their health; however the more they try to eliminate every source of uncertainty, the more uncertain they become about their health.
Taking action to reduce the risk of harm is a natural (and adaptive) response for someone who feels threatened. This type of “safety-seeking” behaviour also leads to a reduction in fear. If the threat is misperceived, however, the individual’s safety-seeking response prevents them from noticing that their fear is unfounded. The most overt safety behaviour in HA is reassurance-seeking, which is considered a core feature of hypochondriasis. Because of the rapid reduction in doubt/distress, reassurance, whether derived from a doctor or another source, becomes habitual. As a result, the person will learn to rely on such confirmation to alleviate HA; for example, “hearing Dr. X tell me that I don’t have a brain tumour is the only way I can stop worrying.”
Some safety behaviours can cause an increase in the very symptoms that one considers dangerous. Body-checking, for example, is a common symptom of HA: patients who are concerned about specific symptoms (e.g., a raised patch of skin) may do repeated examinations of affected areas requiring manipulation of a specific body part. Such behaviour, on the other hand, may result in a rise in bodily symptoms, which are then mistaken as a sign of sickness.
Another type of safety seeking behaviour is avoiding fear cues. E.g., a guy stopped exercising because he believed it would overstrain his lungs and may lead to lung cancer. Covert avoidance is also seen, like in the example of a teacher who wore cotton in her ear all the time because she was afraid that “the crying youngsters might lead to increasing deafness.” When feared bad outcomes do not occur, avoidance limits self-correction of erroneous beliefs, which would otherwise occur naturally.
In the scenario above, the teacher incorrectly ascribed her ability to never lose her hearing to her habit of wearing cotton whenever she was around loud children. As a result, even slight avoidance of this insignificant noise kept the teacher from realizing that typical exposure to loud youngsters would not result in hearing loss. This reinforced her erroneous belief and unreasonable dread of hearing loss from screaming youngsters.
In conclusion, HA has a scientific physiological, cognitive as well as behavioral underpinnings which if understood by a patient may lead to change of approach towards this type of anxiety. Otherwise health anxiety can have paralyzing on one’s every day functioning in life.
In next article I will discuss the treatment part of this type of anxiety from a psychological point of view. Stay tuned!
- The author is a licensed clinical psychologist (Pass out from Government Medical College Srinagar) and works as a child and adolescent mental health therapist at Child Guidance and Wellbeing Centre-IMHANS Kashmir and can be reached at [email protected]
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