Helping Health Anxiety
Helping Health Anxiety

Helping Health Anxiety
Module 8
Adjusting HealthRules and Assumptions
Introduction2

Helpful vs Unhelpful Rules & Assumptions

2Identifying My Unhelpful Health Rules & Assumptions

2

Adjusting Health Rules & Assumptions

4

Worksheet (Example)

6

Worksheet

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Following Through8

Module Summary

9

About the Modules

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Introduction
You have now learned strategies to decrease the amount of time spent worrying about and focussing on
health symptoms, to directly challenge unhelpful health related thoughts, and to decrease unhelpful healthrelated behaviours. We hope that you are finding these strategies helpful in improving how you think andfeel about your health, and how you behave in relation to your health on a day-to-day basis. Now that youhave some experience in working with strategies to manage your health anxiety, it is also important totackle some of the more difficult underlying reasons that you started to worry about your health in the firstplace. In this module, we will discuss adjusting the underlying health rules and assumptions that gave rise to
your health anxiety.

Helpful vs Unhelpful Rules & Assumptions
As we mentioned in Module 2, we all have rules and assumptions by which we live our lives. Although wearen’t specifically taught “the rules”, we learn them through our early experiences and from observing
other people who influence us in our earlier years. You may not even be aware that you developed theserules or assumptions, but they consistently influence your thoughts and behaviour anyway.
As we’ve mentioned earlier, some rules and assumptions are helpful and some are not. We all needguidelines for living to help us make sense of the world and to cope with our everyday lives. So having
rules, in itself, is not a bad thing.
Helpful rules and assumptions are realistic and somewhat flexible. An example of a healthy rule is, “drivers
should stop at red lights”. This is a helpful rule because there is evidence to suggest that not stopping at a
red light may result in a car accident. So keeping this rule can help ensure our survival!
Helpful rules are also flexible and adaptable, and this helps us to adapt our behaviour to different situations.
For example, having the rule that “it is good to try to eat healthy food” is helpful because there is evidence
to support the fact that you will have fewer health problems if you eat healthy foods. But there is also
flexibility in this rule so that it takes into account occasions when it may be preferable to eat foods that areless healthy without feeling guilty (e.g., birthdays or Christmas).
Unhelpful rules are those that are inflexible and unreasonable. For example, holding
the belief “my doctor should be able to explain each of my bodily sensations andchanges” is unreasonable in the sense that it is unlikely that your doctor will be able tomaintain this standard every time you see them. It is not possible or reasonable toexpect your doctor to know exactly what is happening within your body at all times.
Therefore, this type of unhelpful rule will only keep you worried about your health,and dissatisfied or perhaps even frustrated with your doctor.

Identifying My Unhelpful Health Rules & Assumptions
Let’s now take some time to identify what unhelpful rules and assumptions you might have developed
regarding your health. You might already have an idea of these from the work you have completed in
Module 2. If you are unsure, there are several ways that you can start to identify these rules orassumptions.
Take a moment to record some responses to the following questions:• How have people around me responded to health concerns in the past? What might I have learned
from them?
• What standards do I expect myself to meet regarding my health?
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What standards do I expect my doctor or other health professionals to meet?
What symptoms do I allow myself to experience without worrying?
What symptoms or sensations do I never allow myself to experience?
What negative predictions do I repeatedly make about my health? (Note: you may want to review
your thought diaries from Module 5 for any repeated themes)

Health rules and assumptions can be in the form of statements such as:“I must / should / have to always…”“My doctor must / should / has to always…”“I must / should never…”“My doctor must / should never”“If…, then…”

e.g., “I must take all symptoms and bodily changes
seriously”, “I must be symptom free to be healthy”
e.g., “My doctor must be certain”, “My doctor should be
able to explain each of my bodily sensations and changes”
e.g., “I should never ignore a symptom”
e.g., “My doctor should never discount a symptom until all
possible tests have been conducted”
e.g., “If my doctor doesn’t know exactly what the problem
is, then it must be really serious”, “If I don’t persist, thenmy doctor could miss something important”

Now that you have read this section on identifying your health rules and assumptions, have you been able
to identify any that are operating in your life? What are some of those health rules and assumptions? Take afew moments to write them down.

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Adjusting Health Rules and Assumptions
By now, you might have been able to identify those health rules and assumptions that have been guiding
your everyday health-related thoughts, feelings and behaviours. Just as in the previous modules, you canwork at challenging your health rules and assumptions by asking yourself specific questions, and using oneof our worksheets to guide you through this step-by-step. If you have worked through the previousmodules, you will probably find that changing these rules and assumptions will be a little easier. After all,you will have already tackled those health-related thoughts, feelings and behaviours that have been fuellingyour health rules and assumptions day-to-day.
The goal of completing the Adjusting My Health Rules & Assumptions Worksheet is not to get rid of yourhealth rules or assumptions, but rather to adjust them into more realistic and flexible health guidelines.
Before completing the worksheet, read through the following steps:
1. Identify the health rule or assumption you would like to adjust
You may have a number of rules or assumptions that you would like to work on. There is no right orwrong place to start with this. Some people like to tackle the one that is impacting on them the most.
Others like to start on the rule or assumption they think will be easiest to challenge, so that they canbuild up some confidence. Either of these strategies is fine.
2. Ask yourself “Where might this rule / assumption have come from? Why is it still
here?”The purpose of the first question is to think about why you developed this rule or assumption. As
mentioned before, these rules and assumptions have often developed as a way to protect ourselves andto make ourselves feel less vulnerable. It is therefore quite possible that the rules or assumptions madesense at the time you developed them. The purpose of the second question is to examine why you arestill holding on to these rules or assumptions. Ask yourself, “What advantages are there to living by thisrule or assumption? What benefits do I obtain? What do these rules or assumptions protect me fromnow?”
3. Ask yourself “What impact does this rule / assumption have on my life?”
Take a moment to record how holding this rule or assumption has affected yourthinking, feelings, and behaviours. How has it impacted on your relationships with others,including with health professionals? How has it impacted on your ability to do things thatyou value, and that give you a sense of enjoyment or satisfaction?
4. Ask yourself “In what ways is this rule / assumption unreasonable, unrealistic orunhelpful?”• Is your rule actually achievable? (E.g., if you believe “I must be symptom free to be healthy” –can you actually ever be symptom free?)• Can you or your doctor really live up to this standard? Is it possible that your doctor is holding
a different set of rules or assumptions to yourself? (E.g., if you believe “my doctor should beable to explain each of my bodily sensations and changes” – does the doctor know yourrules/assumptions? Does your doctor hold the same rules or assumptions? If not, what rules orassumptions might they be operating under? Can doctors always explain everything?)• Do the disadvantages of this rule / assumption outweigh the advantages? If there are moreadvantages than disadvantages, then maybe you don’t need to challenge this rule / assumption. If
however you decide that the rule / assumption is unhelpful, then let’s move on to the next step
5. Now, think carefully about what might be a more balanced and flexible rule orassumption.
Consider using less extreme terms than “musts” and “shoulds”, such as “sometimes”, “I’d prefer itif…”, “I would like…”, “It would be nice if…”. For example, instead of the unhelpful rule “I should
never ignore a symptom”, consider the alterative “I will sometimes need to pay attention to symptoms,forCentrelinical
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such as pain, fever and signs of infection. However most symptoms will improve over time and it ispretty normal to experience various sensations, including aches and pains.”

You may also consider changing the ending of any “If… then…” statements to a less worrisomeconclusion. For example, instead of the unhelpful assumption “If my doctor doesn’t know exactly what
the problem is, then it must be really serious”, consider the alternative “If my doctor doesn’t know
exactly what the problem is, then maybe it is nothing to worry about”.
Balanced rules and assumptions might end up being more lengthy in their wording than your old rules
and assumptions. This is because they are more sophisticated – you are making it realistic, flexible andadaptable. If you find it difficult to think of an alternative rule or assumption that is more balanced,don’t worry. Continue with the strategies your have learned in the previous Modules to address yourday-to-day health related thoughts, feelings and behaviours. By doing this, more balanced rules andassumptions may become apparent to you over time.
6. Finally, ask yourself “What can I do to put this rule / assumption into practice on adaily basis?”Why do you think it might be important to do this? Remember that your old rule or assumption may
have been in operation for some time, and has guided how you behave in relation to your health. So it
is important that you not only have a new rule, but new behaviours to accompany this rule so that thenew rule can be “house-broken” and become part of your new way of operating.
On the next page is an example of how an Adjusting My Health Rules & Assumptions Worksheet can becompleted. On the page after that, there is a blank worksheet. After you have a chance to look at theexample, try working through a worksheet yourself to adjust one of your unhelpful health rules orassumptions.

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Adjusting My Health Rules & Assumptions(Example)

Rule or assumption I would like to adjust
I must be symptom free to be healthy

Where might this rule / assumption have come from? Why is it still here?
My family have always worried about their health.
My mother took us to the doctor for antibiotics even if we had just the slightest cold.
If we told her about any aches or pains, she would get really concerned and worried.
I guess that even now I am still worried that if I drop this standard, I am exposing myself toillness

What impact does this rule / assumption have on my life?
I’m always thinking and worrying about sensations in my body
I feel the need to go to the doctor every time I notice something weird or new in my body
I don’t like to feel tired, so I don’t do much. I miss out on lots of fun things my friends do.
I find it hard to concentrate at work, especially if there is something going on in my body

In what ways is this rule / assumption unreasonable, unrealistic or unhelpful?
When I say to myself, “I must be symptom free to be healthy” I am setting a pretty
unachievable standard.
It is impossible to be symptom free and it is normal to feel some aches and pains from time totime.
Even some “healthy” people will have aches and pains occasionally.

What is an alternative rule / assumption that is more balanced and flexible?
I would prefer not to feel any discomfort or strange sensations in my body, but it is unlikelythat I will always be symptom free.
It is probably more helpful if I think about trying to maintain a healthy lifestyle thanworrying about all the different symptoms and sensations in my body.

What can I do to put this rule / assumption into practice on a daily basis?
I will start doing more things with my friends and letting myself feel tired occasionally
I will ensure I buy fresh fruit and vegetables each week to improve my diet
I will use my attention strategies and postponement to keep getting on with life, even if I feelsome strange sensations in my bodyforCentrelinical
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Adjusting My Health Rules & Assumptions
Rule or assumption I would like to adjust
Where might this rule / assumption have come from? Why is it still here?

What impact does this rule / assumption have on my life?

In what ways is this rule / assumption unreasonable, unrealistic or unhelpful?

What is an alternative rule / assumption that is more balanced and flexible?

What can I do to put this rule / assumption into practice on a daily basis?

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Following ThroughNow that you have worked through the worksheet, be sure to keep a copy of this new rule or assumption
somewhere easily accessible. After all, those old health rules are likely to pop up from time to time, as they
can take a while to wear out. Until your new rule or assumption becomes ‘worn in’, you may need to keep
reminding yourself of it.
Importantly, keep putting your new rule into practice by carrying out those daily actions you have planned.
Although it might seem difficult to you now, it will get easier as you keep doing them, and eventually it will
become the new way of living your life.
Remember that the goal is not to rid yourself of helpful health rules (e.g., “if I have worsening pain, I should
see a doctor”), but rather to adjust those unrealistic, unhelpful and outdated rules.

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Module Summary•

We all have rules and assumptions by which we live our lives. Although we may not be aware of them
they consistently influence our thoughts and behaviours.

•Helpful rules are those that are realistic and somewhat flexible. They are designed to help us function
and to keep us safe.

•Unhelpful rules are those that are inflexible and unreasonable.

•Although we may develop health rules and assumptions to try to protect ourselves, if they are inflexible
or unreasonable they can keep our health anxiety going.

•To adjust any health rules or assumptions you have identified, you can:
••
•
•
•

Consider where the rules or assumptions came from and why they might still be here
Identify the current impacts of the rule or assumption
Consider the ways that the rule or assumption might be unreasonable, unrealistic or unhelpful
Develop a new balanced and flexible rule or assumption
Think of new ways of behaving that would put the new rule or assumption into practiceComing up next …
In the next module, we will develop ahealthy living self-management plan foryou to keep everything going that you
have learnt throughout thesemodules.

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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: Centrefor Clinical Interventions.
ISBN: 0 9757995 6 8forCentrelinicalC Interventions• Psychotherapy • Research • Training

Created: August 2011

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