Health anxiety audio transcript

­Health Anxiety – An NHS self help guide

“I am always at the doctor’s surgery. That is because at the time I am quite sure there is something seriously wrong with me. Last time it was tingling in my hands and arms. I thought it was the first sign of something like M.S. and before I knew it I was picturing the worst. The doctor did some tests and said it was nothing to worry about. At first I felt better, but this week I have had a headache too, maybe I should go back just to make sure…”

“I often have worrying symptoms that must be the sign of something serious. The doctors have found nothing yet. I make sure that I rest a lot so I don’t strain myself. I don’t travel away from my own town, I want to be near our own doctors. My wife tells me nothing is wrong but that only makes me feel better for a few minutes. I just feel I must keep checking how I am every day…”

These are the thoughts of two people who suffer from health anxiety. That means that they worry a lot about their health. This focus on health makes their symptoms seem worse. Much of their time is taken up with these worries. Reassurance from a doctor that nothing is wrong doesn’t seem to help for long.

If you find yourself with many troublesome worries about your health you may be experiencing health anxiety. This guide can help you to work out if health anxiety is a problem for you. It describes the signs of health anxiety and suggests ways of managing this difficulty which may help you overcome the problem. You may already know you have a problem with health anxiety, but hopefully this guide may help you understand it and manage it better.

Isn’t it normal to worry about health?

We all worry about our health from time to time. For example, if we had to go into hospital for an operation, or if we are recalled by our doctor following tests. Worrying about our health can lead us to improve our lifestyle, for example, to give up smoking or to eat a healthy diet. In fact, looking after our health by having regular health checks and being aware of changes in our body is very important.

When does worrying about our health become a problem?

Health worries become a problem when they begin to get in the way of normal life even though any serious physical cause for symptoms has been ruled out. Severe health anxiety can also be a sign of a serious depression. I you are also very depressed then please speak to your GP about this.

This guide may also help people who do have a physical health problem but find that they worry too much about it.

What are the signs of health anxiety?

You may be experiencing health anxiety if you worry about your health a lot of the time when there is no medical reason to do this, and how you lead your life is affected by this. You may often seek comfort or reassurance from other people that everything is alright. This may be from family, friends, or your doctor.

You may find you are checking your body for symptoms, and that the more you check, the more you seem to notice strange feelings or lumps in your body. You may avoid certain activities as if you were ill, and you may avoid anything to do with illness e.g. information or medical programmes on the television.

On the other hand some people with health anxieties find themselves drawn to any information about illnesses and can begin to notice the signs of such illness in themselves.

Am I suffering from health anxiety?

Anxiety of any sort can affect us in at least four different ways. It affects:

• The way we feel
• The way we think
• The way our body works
• The way we behave

In order to check out whether you may be suffering from health anxiety, please write down any of these symptoms you experience regularly:

How you feel

• Anxious, nervous, worried, frightened
• A feeling of dread
• Tense, stressed, uptight, on edge, unsettled
• Unreal, strange, woozy, detached
• Panicky
• Feeling tired or unwell
• Angry that people think your symptoms are ‘all in your head’

 How you think

• Constantly worrying about health
• Picturing upsetting things in the future, such as being diagnosed with a serious illness and the effect of this on your loved ones
• Imagining the worst and dwelling on it
• Thinking about illnesses and symptoms
• Concentrating on parts of your body and symptoms
• Thinking that the doctor may be able to help
• Thinking that if you don’t worry, you are tempting fate
• Worrying that the doctor may have missed something
• Believing that unless you keep an eye on things you may miss signs of a serious illness
• Believing that you may have something terribly wrong, but you don’t want to think about it
• Thinking that your family/friends may know if this symptom seems serious
• Wishing you could visit the doctor but fearing you are now thought of as a time waster or someone not to be taken seriously

Common thoughts and images

• “This must be cancer”
• “I feel so unwell it must be serious”
• “Surely a headache like this can’t be just stress”
• “That tingling seems like it may be the first sign of a stroke”
• “I may die if I don’t do something”
• “Doctors often miss illnesses despite examinations and tests”
• “Some new symptoms have come since I last spoke with the doctor, it may be more serious than he thought”
• A picture in my mind of the doctor telling me that I have a terminal illness
• A vivid image of my own funeral

What you do

• Go to the doctor’s surgery frequently
• Ask family and friends for reassurance about your symptoms
• Frequently check your body for symptoms such as lumps or bumps, tingling and pain
• Focus on one area of the body for changing sensations
• Avoid any information on serious illnesses e.g. turn the TV off if a hospital programme is on
• Seek out any information on serious illnesses, and check for those symptoms (books, Internet, TV)
• Act as if you were ill, for example, avoiding exertion or exercise, keeping near to home, resting

 What happens to your body?

These symptoms are typical in all types of anxiety

• Odd sensations in various parts of body
• Body aching
• Breathing changes
• Chest feeling tight or painful
• Dizzy, light headed
• Feeling jumpy or restless
• Having to go to the toilet frequently
• Headache
• Heart pounding, racing, skipping a beat
• Stomach churning, butterflies
• Sweating
• Tense muscles
• Tingling or numbness in toes, fingers or arms

If you are regularly suffering from some or all of these symptoms, then it is possible that you are suffering from health anxiety.

What causes health anxiety?

There can be many reasons why someone starts worrying too much about their health. If you are suffering from health anxiety: you may have had a period of ill health or a serious health problem which has left you fearing the worst; or you may have gone through a particularly difficult period of your life which has resulted in a lot of stress related symptoms, which can be worrying; there may have been illness or death in your family, possibly where early symptoms were missed; or another family member may have worried a lot about their or your health when you were young.

All of these can make it more likely that someone will develop health anxiety.

What keeps health anxiety going?

People with health anxiety have their normal day-to-day life badly affected by their worries about health. This often continues despite tests and reassurances that nothing serious is wrong.

In health anxiety, a vicious circle keeps the problem going:

• It starts with triggers such as illness or death in the family, being ill, noticing normal body sensations, stress, information in the papers or on television, long term beliefs about your health.
• You might have feelings of tension and threat leading you to focus on bodily symptoms which may cause worrying thoughts like “is my heart failing?” “this is cancer” and “this might kill me”
• These thoughts can lead to behaviours such as checking for symptoms, focusing on the body, asking for reassurance from your doctor, family or friends, stopping going out, staying off work. These behaviours can result in your anxiety being reduced in the short term.
• But after the initial reduction in anxiety you may go on to experience further anxiety and increased symptoms such as shakiness, shortage of breath, headache, tingling/chest pains leading you to focus again on bodily symptoms

From this vicious circle of health anxiety we can see that there are certain things that keep a health anxiety going.

What are the things I might be doing that keep health anxiety going?

Everyone has different worries but there are six main things that you may tend to do that will keep health anxiety as a major problem for you. We will describe each in turn and you may want to write down your own particular difficulties in each area. This will begin to help you to be clear what difficulties you need to work on with the help of later parts of this guide.

Focus on symptoms and the body, checking and monitoring
When we focus on one part of the body, we tend to notice physical sensations and symptoms that we were unaware of before, and even bumps and lumps in that body part. The more you focus on one area or symptom, the more you notice it. Think of what happens when someone mentions head lice! People with health anxiety tend to find these normal symptoms and sensations worrying and check them very frequently. This focus can also include squeezing, prodding, scratching and mirror gazing. Which of course makes the symptoms worse.

Do you have a symptom, sensation, body part, lump or bump that you have focused on a lot?  It may help to write it down.

Worrying thoughts about symptoms and health information
People with health anxiety tend to have unhelpful thoughts and pictures in their mind about bodily symptoms and other health information. These thoughts are very repetitive, occurring again and again, though not often accurate. Here are some examples of common unhelpful thinking styles in people with health anxiety:

 Jumping to conclusions:

• “If the doctor sent me for tests she must be really worried”
• “A headache like that must be something serious”

Do you ever think like this, if yes jot down your thoughts.

Catastrophising:

• “It could kill me in months”
• Picturing how my children will be left without a mother before they are at school
• Imagining my wife and children at my funeral

If you ever think like this jot down those thoughts or images.

All or nothing thinking:

• “If I have any symptoms then there must be something seriously wrong with me”
• “I need to have all possible tests or else something may have been missed”

If you have had similar thoughts jot them down.

 Emotional Reasoning:

• “I feel something is wrong so there must be something wrong”
• “I just know this symptom must be caused by a serious illness”

 If you have had similar thoughts jot them down.

Ruminating or repetitive thinking:

• Thoughts going round and round in your mind with no solution
• The same worries coming back again and again

Getting reassurance or comfort from others
It is common for people to seek reassurance from others if they are worried. People with health anxiety often seek comfort from friends and family or their doctor. This reassurance works at first and they feel a little less worried. This does not last and the worry is soon back. People can get into a habit of asking for reassurance very often. This keeps the symptoms very much in their mind and usually makes them feel even worse in the long term. If reassurance does not work for you the first or second time it may actually be keeping your worry going.

Write down who you ask to give comfort and reassurance for health worries and how often you ask them to reassure you.

Finding out about illness
Sometimes finding out too much information about illness can increase worries and make people focus on new symptoms or body areas. Books, magazines, partial information from your doctor and particularly the internet can lead to this.

Write down some times you may have done this.

Avoidance
Sometimes avoiding things to do with illness can keep your worries going, for example, you may turn the TV over as Casualty comes on, or shut a newspaper that describes AIDS. Sometimes people also avoid exercise or activity because of a fear that it will bring on illness. This can lead to low mood and an increase of symptoms because of loss of fitness.

Can you think of times when you may have avoided information or activities because of worries about your health?

Deeper beliefs that make you likely to worry about health
Certain long held beliefs can lead us to have health anxieties. Some examples are:

• Bodily changes are always a sign that something is wrong.
• If I worry about it, then at least I’m prepared for the worst.
• I’m prone to cancer/heart problems/stroke; we have a family history of it and I’m sure to get it.
• Doctors often make mistakes.
• Extensive tests are the only way to know you are well.
• If I’m not 100% sure that I am well, then I am likely to be ill. I can’t risk that.

To summarise:

• Worrying about health is quite normal from time to time.
• Health anxiety becomes a problem when it gets in the way of normal life, even though there is no evidence to suggest anything is seriously wrong.
• People with health anxiety often:
  – Seek comfort or reassurance from others
  – Frequently check their body for symptoms
  – Avoid information about health or seek out too much information
  – Avoid activity as if they were ill
  – Have unrealistic worrying thoughts and beliefs about health
  – Have pictures in their mind of what being diagnosed with a serious illness would mean to them and their loved ones

 The next section suggests some ways of managing health anxiety.

How can I manage my health anxiety?

It may help you to draw up a ‘vicious daisy’ of health anxiety to begin to understand and cope with your difficulty.

• Imagine, or draw, a flower with nine petals with space to write on. At the centre of the daisy is the belief that something is wrong with your body.  The petals represent the different things you do when you are worrying about your health. Write down any thoughts or feelings associated with these issues on each of the nine petals.
• The first petal is for checking your body.
• The next is about worrying thoughts.
• The next is something in your background that makes you worry about health.
• The next is about going to the doctor.
• The next is about who you ask for comfort or reassurance from regarding health worries. Fill in the names or roles of people here.
• The next is for things you don’t do in case you are ill.
• The next is about avoiding information about health.
• The next is about focussing on particular parts of your body for symptoms.
• The final petal is about looking on the internet and in books for health information.

Why should I try and stop worrying about my health, isn’t that dangerous?

• It is true that we all need to take good care of our health and seek help where appropriate but.
• You can never be 100% sure that your health is perfect.
• Living with some uncertainty is normal and healthy.
• You can waste a lot of time worrying that something is seriously wrong and picturing the outcome if it is.
• Imagine that you are 90 years old and looking back on your life. Think how you might feel about all those years wasted in worry about health if your fears turn out not to be true!
• What good things could you do if you were not worrying about health?
• If you think about one part of your body for too long you are bound to notice strange sensations. Try focusing on your throat for a few minutes – swallow three times. Notice how this focus brings on difficulty in swallowing and sensations in that area.
• If you start prodding or pressing a particular area you may cause yourself pain and discomfort.

Try making a list of the advantages and disadvantages of continuing to worry about your health. For example:

Advantage – ‘I get relief in the short term when my husband says no, that doesn’t feel like a lump to him’

Disadvantage – ‘In the longer term I have to ask him again and again if I am alright and I get very tense, and he gets cross with me’

How can I stop asking for reassurance from the doctor and other people?

Asking for comfort or reassurance including going to the doctor for tests makes you feel better in the short term, but tends to make you think more about your health and become more anxious in the longer term.

Try to keep a record of how many times you ask for reassurance and how worried you felt each day.

Here is an example of a record made by John, who has begun to reduce the number of times he asked for reassurance or comfort that he did not have cancer.

Number of times he asked for reassurance or comfort each day
Monday – 10 times
Tuesday -10 times
Wednesday – 6 times
Thursday – 6 times
Friday – 2 times
Saturday – 2 times
Sunday – 1 time

How worried he felt each day on a scale from zero-10 where zero is no worry and 10 is very worried
Monday – 9
Tuesday – 9
Wednesday – 7
Thursday – 6
Friday – 6
Saturday – 3
Sunday – 2

Reducing the number of times you ask for reassurance or comfort will make you less anxious in the long term.

It may help to distract yourself, try to do something active such as going for a walk. Keep busy; you can try to delay asking for reassurance or comfort. You can try to ask for comfort a little less each day over a week.

How can I stop my focus on symptoms and the body?

Focus on the body including squeezing, prodding, scratching and mirror gazing can lead to increase in symptoms and will make you feel very anxious.

You can make a plan to gradually reduce the number of checks you allow yourself to do each day. Here is an example of a plan made by Mary who checks her skin for lumps 30 – 40 times each day.

Monday – 35 checks
Tuesday – 30 checks
Wednesday – 20 checks
Thursday – 15 checks
Friday – 10 checks
Saturday – 5 checks
Sunday – 2 checks

As you reduce the number of checks you should begin to feel less anxious about your health.

How can I stop myself finding out too much about illness?

We know that too much focus on illness can lead people to focus on their own body and symptoms.

This can increase health anxieties. If this is something you do, you may try to stop this by:

• Not reading medical books, looking at medical internet sites or reading medical articles in magazines.
• Not searching out lists of symptoms on the internet looking for a diagnosis.
• Not watching medical programmes on TV.
• Getting your family or friends to support you in this.
• Finding other ways of coping with your anxiety.

Keep a record of the number of times you looked for illness information.

This is an example of a plan made by Jill who is trying to reduce the number of times she looks at information on cancer.

Week 1
Internet – 30 times
TV – twice
Books – four times

Week 2
Internet – 15 times
TV – one time
Books – three times

Week 3
Internet – seven times
TV – not at all
Books – once

Week 4
Internet – not at all
TV – not at all
Books  – not at all

How can I stop behaving as if I am ill?

Some people who worry about their health stop doing things because they worry it will bring on illness. This has the effect of making you less healthy and fit. In the long run it will lower your mood and increase health risks.

It is important to return to normal activities.

Start by making a list of things you have avoided because of health anxiety. Peter worries about his heart. Here is his list:

 Things he avoided

• Going to the pub at night
• Walking the dog
• Walking into town
• Sex
• A game of football with friends
• Fast walking up stairs

Next make a step-by-step plan to introduce activity. Here is Peter’s plan to begin to get more active:
Week 1
Step 1
Each day
Walk faster up stairs, walk the dog

Week 2
Step 2
Each day
Walk into town twice, go to the pub

Week 3
Step 3
Each day
All of the previous plus sex

Week 4
Step 4
Each day
All of the previous plus football

You can try a similar plan.

How can I alter worrying thoughts about my health?

We have already explained that some ways of thinking can make health anxiety worse. These thoughts can also be pictures in your mind.

The best way to stop these worrying thoughts is to think other less anxious, more balanced thoughts.

Here are some examples of how you can do this:

Worrying thought or picture 
“Any new body change/symptom is a sign of something serious… I seem to have a lot of headaches just now…”

 Balanced thought
“People have body changes and symptoms all the time, it is normal and it is rarely a sign of serious illness… headaches are often a sign of stress or dehydration…”

Worrying thought or picture 
“Lots of tests are the only way to know you are well…I may be unwell and don’t know it…”

 Balanced thought
“You cannot have tests all of the time… there is no way to be 100% sure you are well … better not to waste time worrying about it…”

Worrying thought or picture
“My family has a history of heart problems… I’m just waiting and watching for when it happens to me…”

Balanced thought
“I have discussed this with my doctor and she tells me I am fine. Constant checking is just stressful and bad for my health, I should just try and relax…”

Worrying thought or picture 
“Picture in my head of family around my hospital bed and I am seriously ill…”

Balanced thought
“What is the point in thinking this way… yes someday I will die but is it useful to think about it all the time now?

Remember if you have health anxiety you will tend to view any information, however neutral, as a sign that something is seriously wrong! Watch out for this and challenge this habit.

It can help to keep a diary of worrying thoughts and more balanced thoughts. Think back to recent health worries and try to do this now. Give reasons for your new more balanced thought.

It can be helpful to become more mindful of how your health anxiety affects you and how you typically react. It is important to focus on the here and now and notice if your thoughts are frequently moving to pictures of future sad events, notice how this makes you feel. Try to bring your thoughts back to the here and now.

You can accept that you tend to have these worrying thoughts but that they do not mean these worries will come true. Try and distance yourself from the thought rather than focusing on it.

Mindfulness meditation courses are now widely available and can further help you to learn to cope with the distress of health anxiety, as well as some websites which offer free downloads of relaxation and mindfulness meditations. Becoming serene, relaxed and gaining a state of inner peace can be helped by mindfulness and relaxation training. This can in turn help you to reduce focus on health anxiety and reduce distress.

Where can I find further help for health anxiety?

We hope you will use the advice in this guide and find it helpful. If you feel you need more help you should discuss this with your GP who will tell you about alternative treatments and local services. There are a number of organisations that provide information and support for anxiety. There are also many self help books that people have found helpful, as well as internet based materials.

A list of useful contacts, books and references are available in the written version of this guide.

Written by

• Dr Lesley Maunder and Lorna Cameron, Consultant Clinical Psychologists
• Gail Young, GP and Counsellor
• Maureen Leyland, Counselling Manager and Counselling Psycologist

Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust has developed this resource with the support of NHS healthcare staff, service users and local voluntary sector groups.