Helping Health Anxiety
Helping Health Anxiety

Helping Health Anxiety
Module 3
What Keeps Health Anxiety Going?
Introduction

2

How Health Anxiety is Triggered

2

How Health Anxiety is Maintained

3

Unhelpful Health Related Thinking

3

Increase in Anxiety Symptoms

3

Focussing on Symptoms

4

Checking & Reassurance Behaviours

5

Avoidance & Safety Behaviours

6

Putting it All Together

7

Model of Health Anxiety Maintenance

7

Worksheet: How My Health Anxiety is Maintained

10

The Good News

11

Module Summary

12

About the Modules

13

The information provided in the document is for information purposes only. Please refer tothe full disclaimer and copyright statements available at www.cci.health.gov.au regarding theinformation on this website before making use of such information.

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Introduction
In Module 2, we explored how our past experiences may lead us to feel more vulnerable, increasing ourconcern about our health and making us more sensitive to bodily symptoms and changes. We also
identified the concept of “dormant” health anxiety – where unless we are confronted by something that
“activates” or triggers off our health anxiety, it may not bother us for periods of our life. In this module, wewill discuss potential triggers to health anxiety, and explore how health anxiety is then maintained in thelonger-term.

How Health Anxiety is Triggered
If you ask any friend or family member whether they have ever worried about their health, most people willprobably admit to having some health-related concerns from time to time. Interestingly, the same things
that would make any other person worry about their health could trigger off an episode of health anxiety.
It is usually when these triggers are combined with a set of inflexible and inaccurate health rules orassumptions that health anxiety is triggered. These triggers can be something internal within us or externalin our environment.
Internal triggers
Remember in the last module we talked about our bodies as being like old cars. Over
time they will develop some strange noises and start to run a bit rougher.
All-in-all, it is normal to feel some symptoms and sensations in your body. This can include stomach
discomfort, tingling or numbness in parts of your body, ringing in your ears, sensitivity to heat or cold inyour teeth, increases or decreases in your heart rate, changes in your saliva production, and variations inyour energy levels. Sometimes new or unfamiliar symptoms may begin for you, such as the onset ofheadaches or development of a rash. Many women whilst pregnant will also report a range of new andsometimes bizarre sensations in their bodies. You may even have unusual sensations, such as developing a
strange taste in your mouth or a muscular twitch under one of your eyes.
External triggers
Besides things happening within your body, a number of external things can draw your attention towards
possible health problems and therefore trigger off episodes of health anxiety. For example:• Health scares in the news
• Upcoming medical appointments• Being in contact with people who are unwell• Hearing about someone who has been diagnosed with an illness• Receiving inconclusive results on a medical test
• Being told you do have a health condition• Being away from known health-care systems (e.g., travelling overseas)
Take a moment to write down any triggers you have experienced in relation to healthanxiety.
Internal triggers
External triggers____________________________________________________________________________________________________________________________________________
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How Health Anxiety is Maintained
Unhelpful Health Related Thinking
If your unhelpful health rules or assumptions are activated by the types of triggers just mentioned, they arelikely to negatively affect the way you think about sensations or variations in your body, and how you
interpret health information from medical professionals or other sources. In general, people with healthanxiety tend to overestimate the likelihood that they have a serious health problem and underestimate
their ability to cope with such a problem. They also tend to discount other factors which suggest thatthings will not be as bad as they have predicted (e.g., overlook their doctor’s reassurance that a serious
illness is unlikely, focus on the most negative potential outcomes rather than the chances of cure or goodmanagement). As such, all health-related experiences are viewed as a ‘catastrophe’ or ‘worst-case’ scenario.
Catastrophic interpretation of bodily sensations
If you hold an unhelpful health assumption such as “All discomfort and bodily changes are a sign of serious
illness”, and are then faced with the trigger of experiencing pain in your joints, you may come up withcatastrophic interpretations of what the pain means. You might say things like: “This could be arthritis”, “Iprobably have bone cancer”, “This problem will be the end of me”, or “This could be something incurable”.
Catastrophic interpretation of health related information
You may also misinterpret health information as indicating that you are at higher risk
than you really are. For example, imagine that your doctor tells you that your blood
test showed a low white blood cell count but that it is “…probably just due to acommon cold”. If you hold the unhelpful health assumption “If my doctor doesn’tknow exactly what the problem is, then it must be really serious” you are more likely
to come up with thoughts such as “Maybe it is actually leukaemia”, or “My doctor
hasn’t tested for really serious problems like HIV or Lupus, so there is a chance thatis what I actually have”.
Take a moment to write down some of the unhelpful thoughts you have experienced inregard to your health. What kinds of things are you saying to yourself about your health orabout any health information you have received?

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Increase in Anxiety Symptoms
As you can probably imagine, if you start having catastrophic thoughts about your bodily sensations, you arelikely to be firing up your fight/flight response in reaction to this perceived threat to your health. Your
fight/flight response is designed to protect you by helping you survive a battle (“fight”) or to run away tosave yourself (“flight”) and can include the following changes:
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muscular tension, tiredness or exhaustion
skipping, racing or pounding heartchanges in breathing rate / breathlessness, chest pain or pressure
dizziness, light-headedness, blurred vision, confusion, feelings of unreality and hot flushes
numbness and tingling in your fingers and toes
an increase in sweating
widening of the pupils, blurred vision, spots before the eyes, a sense that the light is too brighta dry mouth, nausea or an upset stomach

You may notice one, some or all of these symptoms in varying degrees of intensity.
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Helping Health Anxiety
These physical alarm responses are important when facing real danger, but they can also occur when there
is only a perceived danger. If you say things to yourself like: “This could be something incurable”, “I may
have cancer”, or “My doctor may have missed something important”, it is likely that these perceived dangers
will set off your fight/flight anxiety symptoms.
Unfortunately, people who have a tendency to notice and worry about health signs andsymptoms can then also start to worry about some of these fight/flight anxiety
symptoms – jumping to the conclusion that they are another sign that something reallyis wrong!
This can lead to a vicious cycle where real symptoms trigger catastrophic thoughts
about health problems, which in turn trigger anxiety symptoms. These anxiety
symptoms can then lead to more catastrophic thoughts about health problems, which
trigger more anxiety symptoms… and so on. Although driven by your catastrophic thinking, you experience
real physical symptoms.
Focussing on Symptoms
In Module 2, we discussed how a useful part of our fight/flight response is to focus on the thing by which
we feel threatened, and also, on ways of possible escape. We also talked about how hard it can be to draw
our attention away from that threatening thing. We used the example of coming across a snake in the bushfrom which we find it hard to look away.
Unfortunately, focussing your attention on something can sometimes amplify the intensity with which you
experience that thing. Going back to our snake example, if you were to focus your attention on the snake
you will become more aware of the size, colour and shape of the snake. You may also notice the sound of
the snake as it moves across the ground. Overall, focussing more intensely helps you to evaluate andmonitor the threat before you.
Similarly, the more you focus on your symptoms, the more aware you will become of the peculiarities ofthat symptom. Unfortunately, focussing on a symptom can also amplify the intensity of that symptom and, inturn, create more concern about the symptom and increase your desire to focus on the symptom.
Try this exercise. Focus in on your stomach…notice all the tiny sensations you
can feel…it might be tightness or gurgling or fluttering or somethingelse…really hone in on any symptoms or sensations you notice in yourstomach. Stay with this for 1 minute. Now ask yourself whether you had
noticed any of these sensations before you purposely focused on yourstomach? Also as the time spent focusing on your stomach dragged on, did thesensations get more or less noticeable? Usually people find they notice awhole bunch of sensations they had not previously been aware of, and thatthese sensations seem to grow over the minute, as they pay more and more
attention to them.
Take a moment to write down any symptoms, sensations or areas of your body that you tend
to focus on regularly. When you are paying attention, what do you notice most about thatsymptom, sensation or body area? Is it the intensity? The level of pain or discomfort?
Whether it is staying the same or changing?

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Helping Health Anxiety
Checking and Reassurance Seeking Behaviours
To check on or ask for reassurance about things we are worried about is a normal human behaviour. Most
people have thought to themselves “I’m not sure I locked the door properly”, then walked back andchecked or even asked a companion “Did I lock the door when we left?” Usually, this will lead to us feelingless anxious, and allow us to continue on with our everyday lives.
In terms of our health, we are actually encouraged to check our bodies and seek reassurance. For example,
we are often encouraged to monitor moles for any signs of change, and women are frequently encouraged
to check their breast regularly. We are then encouraged to contact a medical professional if we areconcerned about our health, or notice any changes in our general wellbeing. Just like the previous example
of checking whether we’d locked the door, checking or obtaining reassurance about ourhealth status will usually lead us to feel less anxious, and allow us to continue on with our
everyday lives.
However, people who experience health anxiety tend to continue worrying about theirhealth, continue to feel anxious, and therefore continue to engage in checking andreassurance seeking to try to reduce their concerns and unpleasant feelings.
People with health anxiety have reported engaging in frequent and repeated:• Checking in the mirror for signs of asymmetry, areas of discolouration, or new moles or lumps• Poking, palpating or pinching of the skin, breasts, stomach or other areas of the body
• Examination of bodily excretions (e.g., saliva, urine, faeces) for signs of blood or infection• Measuring parts of their body (e.g., using tape measure or callipers)• Monitoring of bodily processes (e.g., taking pulse, checking blood pressure)• Weighing of their body or bodily excretions• Asking family members, friends, and health care providers about their symptoms• Researching their symptoms on the internet or in medical texts• Posting of their symptoms on internet sites to obtain others opinions about their symptoms• Requesting of medical tests or evaluations, and second opinions
In some cases, the efforts to check for an illness can bring about new and painful symptoms themselves. For
example, when performing a breast self-examination, Sally noticed a bumpy area that she had not noticed
before. Over the next two weeks, she continued to worry and began to push on and even squeeze the area
to see if any of the lumps were getting any bigger. She also informed her boyfriend and mother about her
concerns, getting them to also feel the lumpy area and asking them for their advice. Each day, the area
became more and more tender and painful to touch, thus increasing her concern that something wasseriously wrong.
Take a moment to write down any checking or reassurance seeking behaviours you haveengaged in. What were you looking for? What did you find? Were there any negative
consequences of the checking or reassurance behaviours?

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Avoidance and Safety Behaviours
Whilst checking and reassurance seeking are designed to decrease feelings of anxiety that are alreadypresent, avoidance and safety behaviours are strategies used to try to prevent us from experiencing anxiety.
People who experience health anxiety will generally try to avoid the internal and external triggers we
identified earlier in this module. To avoid internal triggers, you may avoid engaging in things that lead tochanges in your physiological state. This could include: exercising, walking up stairs, drinking coffee, having
sex, eating spicy foods, and drinking fizzy drinks.
To avoid external triggers, you may avoid a large range of potential people, places or situations whichremind you of health issues. To name a few, this can include avoiding:• medical professionals or check-ups• eating foods close to the used by date
• doctor’s surgeries• visiting a friend who has a non-infectious disease• watching the news or reading the newspaper• using public restrooms• walking past funeral homes• watching medical dramas on TV• writing a will
• visiting a relative who has recently been sick• phoning for test results• not reading information provided by a Doctor
Avoidance means that in the short term, there are fewer reminders of healthrelated issues and therefore less chance of feeling worried and concerned.
However, in the longer term avoidance can keep your fears going, or even makethem worse.
The term “safety behaviours” refers to a more subtle form of avoidance. To use
safety behaviours means that you may not outrightly avoid something, but will only
approach that feared place, person or activity if certain back-up plans are in place.
For example, someone who fears contracting meningococcal disease may still goout in public and even attend medical appointments , but only if they are carrying hand sanitiser andantibiotics in their bag. Similarly, someone who is fearful of having a heart attack may continue going about
their daily business, but only if they are around others and are carrying a mobile phone at all times in casean ambulance needs to be called.
Engaging in safety behaviours only temporarily reduces your health worries and concerns. The next time
you are confronted with a similar situation, you will feel the need to use them again and never learn thatyou can survive without them.
Take a moment to write down the things you might be avoiding because of your health fears.
This could include certain people, places, activities, objects, or even foods. Also, are there any
behaviours you engage in to increase your sense of safety in these situations?

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Note: Although they could seem like opposite behaviours, you may engage inchecking and avoidance at the same time. For example, you could be engaging indaily breast self-examinations, yet avoid telling others about your concerns orgoing to the doctor to have them check you over. Alternatively, you may engage in
only checking or avoidance, or a little of each of these. The combination ofchecking and avoidance behaviours will vary from person to person.
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Helping Health Anxiety
Putting It All Together:
Model of How Health Anxiety is Maintained
It is quite normal to experience both internal and external triggers. So how do these triggers lead to healthanxiety? Remember from Module 2, if you have already experienced a number of negative healthexperiences, you may be more sensitive or “tuned in” than others to noticing these internal and external
triggers. This in turn increases your chance of “setting off” health anxiety.
Generally speaking, when confronted with an internal or external trigger, your health rules and assumptions
become activated. By “activated” we mean that they move from being dormant to being switched on like alight switch. Once activated, your health rules and assumptions can start to affect how you think, feel, andbehave in response to those triggers.
If you hold flexible and realistic rules and assumptions about your health, these internal or external triggers
probably won’t worry you too much. For example, let’s say you notice pain in your joints, plus you hold therule “If this pain gets worse or is still there in another week, then I will get the Doctor to check it out”.
Such a rule is:• flexible, in that it allows you to experience what may be normal bodily sensations,
without excessive worry, checking, or medical opinion seeking, and is• realistic, in that it doesn’t discount the possibility that there may be a problem
that could need medical attention.
However, imagine that you notice pain in your joints, plus hold the unhelpful healthassumption “All discomfort and bodily changes are a sign of serious illness”. How might
you then respond to that pain in your joint? What might you start to think about that pain? How would you
be feeling each time you thought about that joint pain? How would you rate your chance of a goodoutcome should you even visit the doctor?
All-in-all, when you experience a combination of unhelpful health rules or assumptions plus internal orexternal triggers that draw your attention to health related issues, you are at increased risk forexperiencing health anxiety. You are more likely to interpret bodily sensations or changes as a sign ofserious illness, to misinterpret health related information, and to set off more physiological sensations eachtime you worry.
You may then engage in unhelpful efforts to control your anxiety or reduce your risk of
disease. You may focus on your symptoms in an effort to monitor and evaluate any
potential health threats. You may check or seek reassurance to increase your sense ofcertainty over your health status. You may also engage in avoidance or safety behaviours
to stop your health anxiety from being triggered in the first place.
In the short term, these behaviours may provide a temporary sense of relief or control over your healthconcerns. However in the long term there can be negative consequences. For example, focusing on yoursymptoms can enhance the intensity of those symptoms. Checking behaviours may lead to tenderness or
inflammation. Seeking and then being given medical tests may reinforce your belief that something is wrong.
Researching your symptoms can alert you to catastrophic yet unlikely explanations for your symptoms. Allof these behaviours create more worry and therefore keep your health anxiety going.
Also, avoiding or using safety behaviours can limit your ability to learn anything new about your health. For
example,• If you don’t go to the doctor for a check-up, you don’t find out whether you do or do not have ahealth problem. You may therefore continue to worry about your health.
• If you avoid people or places that you believe may make you sick, you never get to find out if thisreally does occur. So in the longer term you feel that you must continue to avoid it.
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Helping Health Anxiety
The following case illustrates how this can develop in to a vicious cycle of anxiety.
Sarah was a 30yo woman who continued to visit her doctor complaining of a sore throat. Sarah
had read a magazine article about a person who had developed throat cancer despite neverbeing a smoker. Sarah had worried ever since that she may develop or even already have thisproblem, and had begun to notice some unusual sensations in her throat region (i.e., tightness, a
dry throat). On multiple occasions her doctor informed her that her throat “looked inflamed” butthat there were no current signs of actual cancer. Her doctor told her not to worry about thesoreness but rather to come back and see him if the symptoms got worse.
Unhappy with her doctor’s response, Sarah began engaging in daily forced coughing behaviours to
try to “bring up” as much phlegm as possible so that she could check it for signs of blood or
infection. She would sometimes use her toothbrush to push on the back of her tongue so that she
could check for areas of tenderness, and also engaged in regular palpating of her neck, checking
it for lumps and areas of tenderness. Sarah had difficulty concentrating and performing her job as
she continuously focussed on the unpleasant sensations and spent time researching her symptoms
and potential treatments on the internet. Sarah began to switch off the television whenever
medical dramas or documentaries came on the television, stating that she didn’t need to bereminded of what the future may hold.
On the following page we have collated this information into a model, so that it is easier to see how Sarah’s
health anxiety is being triggered and then maintained.
As you can see, Sarah is caught in a vicious cycle of worrying about her health, setting off more
physiological symptoms (including anxiety itself), and engaging in efforts to control her worry andsymptoms which in the long term can keep the problem going. On the following page, there is a worksheet
for you to collate your own example.

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How Sarah’s Health Anxiety is Maintained
Triggers- Reading magazine article about a person with throat cancer- Noticing unusual sensations in throat region

Activates unhelpful health rules / assumptions- I must be symptom free to be healthy- If I miss an important symptom, it could kill me

Unhelpful health related thoughts- This is cancer, I just know it- My doctor said the area is inflamed and tokeep monitoring, so something serious is happening

Anxiety symptoms
Increased muscular tension, racing heart, dry mouth and throat

Focussing on
Symptoms

Checking &Reassurance Seeking

Avoidance &Safety Behaviours- Pays close attention tosensations in throat- Notice all minorchanges/sensations- Checking tongue, phlegm,
throat region- Seeking reassurance fromdoctor and internet- Avoids medical
dramas or
documentaries

Short term consequences•

Sense of relief or control over symptoms

Long term consequences
•
•
•
•
•

•

Focus on symptoms may enhance the intensity of symptoms
Checking (i.e., using toothbrush, coughing up phlegm, pressing on neck) may
lead to further inflammation and tenderness
Doctor and internet cannot provide complete reassurance
Avoidance limits opportunities to change perceived threat of medical dramas
or documentaries.
Worrying continues and may increase. Anxiety symptoms increase. Increased
desire to focus on symptoms, check and seek reassurance, and to avoid or use
safety behaviours.
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How My Health Anxiety is Maintained
Triggers

My internal or external triggers…

Activates unhelpful health rules / assumptions
My health rules & assumptions (can be copied from last module)…

Unhelpful health related thoughts

What do I tell myself about my bodily sensations and changes?
What do I say to myself about information my doctor gives me or that I hear from other sources?

Anxiety symptoms

Physiological sensations I experience…

Focussing on
symptoms

What am I focussing on?

Checking &Reassurance Seeking

e.g., body checking, reassurance seeking
from Drs or the internet

Avoidance &Safety Behaviours

People, places, things I avoid…or things
I feel I must do to confront these…

Short term consequences

e.g., sense of relief or control over symptoms

Long term consequences

e.g., thoughts, rules and assumptions remain unchallenged, anxiety continues
increased desire to focus on symptoms, check and seek reassurance, and to avoid or use safety behaviours

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More Good News…

At first, it may look overwhelming to see how your efforts to try to control or reduce your worrying andsymptoms can actually lead to them increasing. However, being able to understand what is keeping healthanxiety going on a day-to-day basis lets you see where you can start to make some changes to break thisvicious cycle.
The remainder of these modules will cover a range of cognitive and behavioural strategies aimed at
gradually breaking down the unhelpful thoughts, behaviours, and rules & assumptions that can keep thiscycle going.
Looking at the model, you may wonder why we don’t start at challenging the unhelpful rules andassumptions first. The reason we leave these until later is that they can be somewhat harder to shift thanyour unhelpful thoughts and behaviours (after all, these rules and assumptions may have been there forquite some time). We therefore come back to these towards the end of the modules once you havestarted to “wear down” the old maintaining cycle. We encourage you to commit to working through themodules, in order, and completing all of the exercises and worksheets, as this will bring you the mostbenefit.

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Module Summary•

Health anxiety can be triggered by a range of internal or external triggers•

It is quite normal to experience these internal and external triggers. However, when they are pairedwith unhelpful health rules or assumptions, they can lead to:- negative health related thinking- increased anxiety symptoms- a narrowing of attention on to the feared symptoms- checking and reassurance seeking behaviours, and- avoidance and safety behaviours•

In the short term, these behaviours may provide a sense of relief or control over symptoms•

In the long term, these behaviours may lead to:- increased focussing on symptoms- more worry and concern about symptoms- more anxiety symptoms- tenderness or pain in the area being checked- an increased desire to check and seek opinions- increased use of avoidance and safety behaviours•

Understanding what keeps our health anxiety going is the first step towards breaking this vicious cycle.

Coming up next …
In the next module, you will learn
how to start decreasing your focus on
your health symptoms and worries.

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About The Modules
CONTRIBUTORSDr Rebecca Anderson (MPsych1; PhD2)Centre for Clinical Interventions

Paula Nathan (MPsych1)
Centre for Clinical Interventions

Dr Lisa Saulsman (MPsych1; PhD2)Centre for Clinical Interventions
1

Masters of Psychology (Clinical Psychology)2

Doctor of Philosophy (Clinical Psychology)

BACKGROUND
The concepts and strategies in these modules have been developed from evidence based psychologicalpractice, primarily Cognitive-Behaviour Therapy (CBT). CBT for health anxiety is based on the approachthat health anxiety is a result of problematic cognitions (thoughts) and behaviours.

REFERENCES
These are some of the professional references used to create the modules in this information package.
Abramowitz, J., Taylor, S., & McKay, D. (2010). Hypochondriasis and severe health anxiety. In McKay, D.,
Abramowitz, J., S., & Taylor, S. (Eds.). Cognitive -behavior therapy: Turning failure into success (pp. 327-346).
Washington, DC: American Psychological Association.
Asmundson, 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: The Guilford Press.
Furer, P., & Walker, J. (2006). Health anxiety treatment manual. University of Manitoba: Manitoba.
Furer, P., Walker, J., & Stein, M. (2007). Treating health anxiety and fear of death. New York: Springer.
Papageorgiou, C., & Wells., A. (1998). Effects of attention training on hypochondriasis: A brief case series.
Psychological Medicine, 28, 193-200.
Salkovskis, P., Warwick, H., & Deale., A. (2003). Cognitive-behavioural treatment for severe and persistent
health anxiety (Hypochondriasis). Brief Treatment and Crisis Intervention, 3, 353-367.
Willson, R., & Veale, D. (2009). Overcoming health anxiety: A self-help guide using cognitive behavioural
techniques. London: Robinson.

“HELPING HEALTH ANXIETY”
This module forms part of:Anderson, R., Saulsman, L., & Nathan, P. (2011). Helping Health Anxiety. Perth, Western Australia: Centre
for Clinical Interventions.
ISBN: 0 9757995 6 8

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Created: August 2011

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