Helping Health Anxiety
Helping Health Anxiety

Helping Health Anxiety
Module 5
Re-evaluating Unhelpful Health
Related Thinking
Introduction

2

The Mind-Body Connection

2

How to Address Unhelpful Health Related Thoughts

4

Thought Diary - Example

6

Thought Diary - Worksheet

7

Summary of My Thought Diaries

8

An Important Word on Factual Evidence

9

Module Summary

11

About the Modules

12

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 3, we talked about how our health anxiety can remain dormant for some time, but when
triggered is likely to negatively affect the way we think about our bodily symptoms or sensations, andhealth-related information. In Module 4, we practiced disengaging our attention from these distressing
symptoms or worries by first building up our attention muscle and then learning to put off or “postpone”
our worries until a later time. In this Module, we will examine what you can do with these negative andoften unhelpful thoughts once you get to your elected “worry period”. We will examine these thoughts inmore detail, and discuss ways of evaluating and overcoming them.

The Mind-Body Connection
What you think, and the thoughts that go through your mind, are very important in determining how you
feel. Stop for a moment and think: when you are feeling good, what sorts of thoughts roam around in yourhead? Conversely, when you are feeling bad, what sorts of thoughts are you having?
It makes sense to most people when we say that:
It is not the situation you are in that determines how you feel,but the thoughts, meanings, and interpretations you bring to that situation.
Here is an example of what we mean. Imagine you are in bed at night and hear a loud noise. Below are
three different ways of thinking about this same situation and the different emotions, physical sensations,and behaviours that could result from thinking in these different ways.
Example event: In bed at night, hear a loud noise
Emotions

Physical

Behaviour

AmusedSmiling, quite
relaxedLaugh, call for cat

AnxiousHeart racing,tense, sweating

Concentrate on further
noises, grab phone andbegin to dial for police

NeutralQuite relaxed

Go back to sleep

Thought 1
I bet that was my naughty little
cat. I wonder what kind ofmischief he has just got up toThought 2
Oh no, someone must be trying to
break in!!

Thought 3
Hmm. The neighbours must be
putting their bins out.

Because we are usually not aware of these thoughts, we may not realise just how much they are affecting
us. Can you now see how what we think can be so important in determining how we feel emotionally andphysically, and can influence what we do?
Overall, having our thoughts influence our emotional and physical state is usually a fairly
helpful process. After all, if someone really is breaking in to our house – having youranxiety response kick in, including having your heart beat faster and starting to sweat
means you are physically more prepared to deal with that threatening situation.
However, people with health anxiety often perceive that there is a greater threat to theirhealth than there actually is. This doesn’t mean that you are imagining the symptoms –forCentrelinical
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Helping Health Anxiety

those symptoms are real! But if you interpret or think about the symptoms in a catastrophic way, this willoften bring about intense negative feelings and sensations in your body.
People with health anxiety tend to:• Overestimate the likelihood that they have or will develop a serious health problem• Overestimate how bad things will be• Ignore or discount other possible (and often less catastrophic) explanations for their symptoms ortheir doctors response, and• Underestimate their ability to treat, cope with or manage a health problem
Here are some examples of common thoughts experienced by people with health anxiety:I’ve been so tired and run-down - I could have leukaemia
My mother had cancer so there’s a pretty good chance I’ll get it too
My heart is racing - I am going to have a heart attack
I could get a serious illness and die
I’m sure I have diabetes as I’ve been to the bathroom four times today
My side is aching - this could be ovarian or stomach cancer
I’ve been having weird thoughts - I could be schizophrenic and not know itThis operation could kill me
I’ve never seen this mole before - it could be a melanoma
I’ve had diarrhoea for three days - this could be colon cancer
I have a headache - this could be a brain tumour or an aneurism
My knees hurt - I must have arthritis
I keep forgetting things - this could be the start of dementia
I’ve been feeling really weak lately - this could be a sign of multiple sclerosis

As each of these health related thoughts are about a potential threat to one’s health and well-being, it will
likely trigger our anxiety response. This is the mind-body connection in action! Unfortunately, this can thenbecome a vicious cycle of worrying about our health, triggering more anxiety sensations, noticing thesesensations as well and then worrying even more.
Healthanxiety
Even more worry
More anxiety sensations
More worry
About original issue + new anxiety sensations

Anxiety sensations

Worry about health

Trigger(e.g., notice a sensation or symptom, waiting for test results)

Fortunately, something can be done about this vicious cycle. This Module will explore how we can begin to
break this cycle by identifying and challenging those worrisome thoughts you are having about your health.
Note: While we have touched on the idea of behaviours that come about from these thoughts, we will come back tothese in Modules 6 and 7

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Helping Health Anxiety
How to Address Unhelpful Health Related Thoughts
One way to help address unhelpful health related thoughts is to challenge them head on. Remember that
our thoughts are just that, thoughts. Sometimes our thoughts will be accurate, sometimes they will only bepartially correct, and sometimes they will not represent the reality of the situation at all. The only way wecan work out how accurate our thoughts really are is to question, dissect and evaluate them.
A helpful way to think about this is to imagine that you are a detective - collecting evidence for and against
a case, considering other possible causes and explanations, and trying to work out the most accurate andlikely explanation. Evaluating these thoughts isn’t something you should try to do in your head as this canget messy and confusing. The best way is to write it down and we suggest using a Thought Diary to help
you through this process. Thought Diaries are designed to guide you through the evaluation process stepby step, on paper, making things clearer and more helpful for you.
On the next few pages are instructions and an example of how to complete a Thought Diary. Followingthat is a blank Thought Diary for you to practise on.
The Thought Diary will first ask you to Identify Your Unhelpful Health Related Thoughts. To help
you do that, first ask yourself:• What triggered off this episode of health anxiety?
Then:• What am I worrying about?
• What am I predicting?
• What conclusions am I jumping to?
After you have written these down, underline the most bothersome of these thoughts and rate thestrength of your belief between 0 and 100%.
You’ll then need to ask yourself – when I am thinking like this, what do I feel?
• What emotion(s) am I feeling? (e.g., worry, fear, sadness, concern, anxiety)• Rate the intensity of your emotion(s) between 0 and 100%
• What physical sensations(s) do I notice? (e.g., heart racing, muscular tension, fatigue)
Once you have completed the first section, you are ready to begin to Challenge Your Unhelpful
Health Related Thoughts. Here are the questions asked in your Thought Diary to challenge thesetypes of thoughts:• What is the factual evidence for this thought?
• What is the factual evidence against this thought?
Note: Be sure to include only good quality evidence – see pages 9-10 for a summary• How does it affect me when I expect the worst?
• What could I do to cope if ‘the worst’ did happen?
• Are there any other possible explanations for my symptoms, or for my doctor’s
response?
• What is the most likely explanation?
• What can I do to cope with this symptom or situation right now?
The ultimate aim of doing this Thought Diary is for you to Develop more Realistic Health Related
Thoughts. Once you have explored the answers to the above ‘challenging’ questions in your Thought
Diary, ask yourself:• What would be a more realistic thought about this symptom or situation?

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Helping Health Anxiety
The final step is then to:• Re-rate how much you now believe your original thought,• Re-rate the intensity of the emotions that you were originally feeling,• Rate whether there has been any change in your physical sensations.
If you experience only a few unhelpful health related thoughts per day, and they are not taking up asignificant amount of your time or interfering with your daily activities, we recommend that you start topractice using a Thought Diary whenever you notice you are feeling anxious or worried about your health.
However, if you experience numerous unhelpful health related thoughts throughout the day, and theamount of time spent thinking about your health is interfering with your daily activities, we recommendthat you combine the worry postponement exercise from Module 4 with using these Thought Diaries. Thismeans that whenever you catch yourself worrying about your health, you postpone any further thoughts
about your health until a later specified time and place. When you get to this specific time and place, then
you can spend time completing the Thought Diary to evaluate your thoughts.
If you work through the entire Thought Diary for challenging your unhelpful health related thoughts, it islikely that you will experience a decrease in the strength of your belief and therefore a decrease in theintensity of your emotions and physiological sensations. While it will take some effort and practice, we
recommend that you continue to use the thought diaries until it becomes second nature to stop andquestion your thoughts.

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Thought Diary – Example
Identify Unhelpful Health Related Thoughts
What triggered off this episode of anxiety?
Received a negative test result for an iron deficiency after feeling tired and run-down for several weeks.
Doctor said to just monitor my symptoms and come back if it gets worse.

What am I worrying about? What am I predicting? What conclusions am I jumping to?
If it is not an iron deficiency, it must be something much worse
My doctor hasn’t tested for more serious problems
This tiredness could mean something serious, like leukaemia

Underline the most bothersome thought and then rate how much I believe it (0-100%)? 80%

When I am thinking like this, what do I feel?
Emotions (Rate the intensity 0-100%):

Physical sensations:

Worried (90%)

Heart rate increases, chest feels heavy

Challenge Unhelpful Health Related Thoughts
What is the factual evidence for this thought?
- I have been feeling tired- I have looked on the internet and tiredness andfatigue are symptoms of leukaemia- The test results showed it is not an iron deficiency- My doctor didn’t specifically test for leukaemia

What is the evidence against this thought?
- My doctor said tiredness and fatigue are very
common and may be related to stress- I don’t have the other symptoms of leukaemia(swollen lymph nodes, frequent infections,bruising easily, unexplained weight loss, or pain
in my joints and bones)

How does it affect me when I think about the worst?
Makes me feel anxious and a bit angry at my doctor for not doing some more tests
Find it hard not to focus on the tiredness

What could I do to cope if ‘the worst’ did happen?
I would have to start treatment. This would probably involve chemotherapy and a bone marrowtransplant if a match could be found for me. I would have to think about the possibility of death. The
entire experience would probably be quite difficult but I would have the support of family and friends.

Are there any other possible explanations for my symptoms, or for my doctor’s response?

Have I recently changed my routine, diet, medications, or activity levels? Do I need to improve these? Have I been experiencing increased stresslately, or have I experienced a minor medical ailment – such as a cold, that could account for what I am feeling?
I have been quite busy and stressed at work lately. I probably haven’t been looking after myself or sleeping
as well as usual. My doctor probably sees a lot of people who are feeling this way, who don’t haveleukaemia, so isn’t too concerned about it.

What is the most likely explanation?
I am just run down and need to look after myself a bit better

What can I do to cope with this symptom or situation right now?
I will make sure I buy some fresh fruit and vegetables to eat, rather than just getting by on coffee. I will
also take some time out for myself to relax by having a bubble-bath, will go to bed a little earlier, and will
ask for some help to manage a big project at work.

Develop Realistic Health Related Thoughts
What’s a more realistic thought about this symptom or situation?
This is probably just a sign that I am stressed and run down. I don’t have any other symptoms so my
doctor probably isn’t very worried about this tiredness.

How much do I believe my original thought now (0-100%)
How intense are my emotions now (0-100%)
How intense are my physical sensations now (Circle)
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40%
30%

More intense

Same

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Less intense

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Helping Health Anxiety
Thought Diary
Identify Unhelpful Health Related Thoughts
What triggered off this episode of anxiety?

What am I worrying about? What am I predicting? What conclusions am I jumping to?

Underline the most bothersome thought and then rate how much I believe it (0-100%)?

When I am thinking like this, what do I feel?
Emotions (Rate the intensity 0-100%):

Physical sensations:

Challenge Unhelpful Health Related Thoughts
What is the factual evidence for this thought?

What is the evidence against this thought?

How does it affect me when I think about the worst?

What could I do to cope if ‘the worst’ did happen?

Are there any other possible explanations for my symptoms, or for my doctor’s response?

Have I recently changed my routine, diet, medications, or activity levels? Do I need to improve these? Have I been experiencing increased stresslately, or have I experienced a minor medical ailment – such as a cold, that could account for what I am feeling?

What is the most likely explanation?
What can I do to cope with this symptom or situation right now?

Develop Realistic Health Related Thoughts
What’s a more realistic thought about this symptom or situation?

How much do I believe my original thought now (0-100%)
How intense are my emotions now (0-100%)
How intense are my physical sensations now (Circle)
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More intense

Same

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Less intense

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Helping Health Anxiety
Summary of My Thought Diaries
Once you have completed several thought diaries, you can complete this worksheet as a quick reference
guide to remind you of your new realistic health related thoughts. That way, if the same or a similar
unhelpful and distressing thought pops up, you can simply review this worksheet rather than trawl backthrough all of your completed thought diaries. However, if you feel like when you read something from the“New Realistic Health Related Thought” column that you don’t actually believe it, you may need to go backand complete another thought diary on that issue.

Original Unhelpful Health Related Thought

New Realistic Health Related Thoughte.g., This could be something serious, likeleukaemiaThis is probably just a sign that I am stressed andrun down. I don’t have any other symptoms so my
doctor probably isn’t very worried about thistiredness.

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An Important Word on “Factual Evidence”
With the wealth of information readily available to us via the media and internet search engines, it isimportant for us to remain smart consumers of the information we receive. When completing thesethought diaries we are asked to consider “factual evidence” both for and against our thoughts. But how
can we tell whether the information we have is “factual” or not?
Unfortunately, not all health information available in magazines, newspapers and on the internet goes
through a quality control process. Some websites, for example, may look quite convincing on the surface,
but not actually represent the best practice and most up to date health-related information. This can beboth confusing and dangerous for us.
It can be confusing when we receive mixed messages about whether or not we need tomake changes to important things such as our diets, medications, or other lifestyle choices. It
can also be confusing when we receive mixed messages about the importance of particularsymptoms, their relevance to serious health problems, and the need to continue to seek help
from health professionals. It can be potentially dangerous when we do make decisions
about our health or changes based on information that is not reliable or factual.
While we will talk a lot more in the next module about seeking information from various sources, bychanging the way we search for and evaluate health information, we can start to reduce any confusion andrisks and begin to take a more helpful and critical stance.
Information seeking
Quite often we can turn the very thing we are thinking about into the phrase we type into an internet
search engine. For example, if we are concerned about the impacts of worrying on our potential for aheart attack, we may type “worry and heart attacks” and hit Search.
This type of searching can be problematic as it can lead to biased results. That is, you will most likely• filter in web pages that do talk about there being links between worry and heart attacks, and• filter out any that do not talk about or debunk such links.
This unhelpful searching can therefore reinforce your worrisome belief that there is a link!!
There are two steps you can take to change the way you gather and filter information from the internet.
Step 1: Practice using more helpful and less biased search phrases to find out what you want to know.
For example,
Instead of:“Worry and heart attacks”

You could try:
“What causes heart attacks?” or “Leading causes of heart attacks”

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More helpful
Less biased filtering

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Step 2: Look for ways of filtering in alternative view points. You can do this by typing in mismatchingstatements. For example, you could try: “Is coffee bad for you?” and “Is coffee good for you?”
These strategies can lead to you coming up with some very different health information!

If you are someone who has or is thinking about using the internet to search for health information, take amoment to think about some alternative ways you could search for that information:
Instead of:
I could (also) try:

Evaluating health information
Even with good search strategies we will often come across unhelpful or even conflicting information (e.g.,
one magazine article stating that coffee is good for you whilst another states that coffee is bad for you).
Unfortunately, in this day and age, anyone with access to the internet can send
information around the world and claim it to be factual. Some website or magazine
articles can also appear to contain useful information from reputable sources. So how do
we know what is good information and what is not so good?
Ten questions to ask...
 Is this written by a qualified and registered health professional (e.g., GP, Psychologist)?
 Does the author represent an established and reputable health organisation (e.g., government
body, university, major hospital)?
 Is the author free of commercial interests (i.e., they are not trying to sell you a product or
sensationalise a story to sell a magazine)?
 Does the article include multiple pieces of evidence to back up it’s claims (i.e., discusses theresults of several research studies conducted by reputable organisations rather than anecdotal
stories or one-off studies)?
 Is enough information provided for you to check the background research for yourself?
 Was the background research based on people similar to yourself (e.g., similar age, height/weight,
gender, diagnosis, comorbid problems etc)?
 Was the background research based on many people?
 Are statistics clearly explained?
 Is this information consistent with health information you have read from other reputablesources, (e.g., other government bodies, universities, major hospitals)?
 Is a review date provided so that you can tell the information is up-to-date?
The more ticks you have above, the better your health information is likely to be. However, it isimportant to remember that information from the internet and media is one resource only, andshould never alone be used to diagnose a medical or psychological condition, or to makeimportant changes to your medication, diet, or other lifestyle choices. Your GP or local
health clinic can assist you in understanding the specific risks and benefits of such changes
based on your full personal medical and/or psychological history.

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Module Summary•

Our thoughts influence our emotional state and the presence of some physical sensations in our bodies.
This is known as the mind-body connection.

•

People with health anxiety tend to:- Overestimate the likelihood that they have or will develop a serious health problem- Overestimate how bad things will be- Ignore or discount other possible (and often less catastrophic) explanations for their symptoms ortheir doctors response, and- Underestimate their ability to treat, cope with or manage a health problem•

When we think there is a threat to our health, we can trigger off our anxiety response. This gives us
more physical sensations, which we may then also worry about. This can lead to a vicious cycle ofhealth anxiety.

•

One way to overcome this vicious cycle of health anxiety is to challenge our unhelpful health related
thoughts head-on using a Thought Diary. This involves identifying what you are predicting or worried
about, challenging your predictions or expectations, and developing more realistic health related
thoughts.

•

If we are using evidence from the internet or media to weigh-up the likelihood of our health-related
thoughts being true, we need to ensure that we access information from established, reputable, andunbiased health organisations.

Coming up next …
In the next module, we will start
exploring ways to reduce excessive
checking and reassurance-seeking
behaviours.

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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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