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Key points
- Pathological health anxiety, or PHA, is health-related worrying that is disproportionate to true medical risk.
- Patients with PHA catastrophically misinterpret harmless bodily sensations.
- PHA can lead to other psychological conditions such as panic disorder.
- CBT and exposure therapy can effectively treat PHA.
Worrying about our health is adaptive and protects our survival. Concerns about a pervasive headache, throbbing pelvis pain, or heart irregularities compel the sufferer to seek medical attention. Getting an early diagnosis, in some cases, can save someone's life and decrease mortality.
Most of the time, however, these bodily symptoms are benign and not indicative of any underlying serious disease. Typically, the pertinent medical tests are sufficient to extinguish health anxiety in a healthy person.
However, a small group of people suffers from pathological health anxiety (PHA). For these people, getting repeated reassurance from medical professionals that an illness is not present does not arrest worries about their health.
Health anxiety can be defined as worry regarding health that is out of proportion to true medical risk (1). It can exhaust the medical system. A person with PHA repeatedly seeks medical attention—for example, a woman whose MRI scan shows no brain tumors may believe that the MRI technician made an error and request another scan.
Why Do Some People Develop PHA?
Health anxiety typically has an early onset.
Twin studies point to some genetic contribution to PHA. The environment is also crucial in the development of PHA. A child who struggles with an illness in childhood or witnesses a loved one suffer from a disease may continue to be extra attuned to their bodily sensations.
Parental style can also have an impact. Overprotective parents tend to excessively worry about the health of their children and may express health anxiety in their presence. For example, anxious parents may exaggerate the seriousness of their child’s benign stomachache. They may take the day off work, keep their sick child home from school, and spend long hours in emergency rooms. These behaviors can fuel “a disease conviction” that sets the stage for later PHA.
Disease conviction is the cognitive component of PHA. It is the belief that one has a serious medical condition despite repeated reassurances that the condition is not present. This cognitive component in the presence of physical symptoms contributes to catastrophic misinterpretation of these symptoms and pathological behaviors. These behaviors include reassurance-seeking and avoidance.
Negative Automatic Bias to Misinterpret Symptoms
Patients who endorse this cognitive bias attend to all disorder-related threats and elaborate on them. Many of these negative thoughts tend to be automatic and thus difficult to manage.
A few neuroimaging studies have examined these negative, automatic, disease-related thoughts in patients with PHA. In a recent functional neuroimaging study, participants were forced to categorize bodily sensations, such as headache or nausea, as harmless while being scanned (2). The results showed that PHA patients activated control, inhibition, and attentional brain areas more vigorously.
Perhaps control areas, such as the prefrontal cortex, were laboriously inhibiting an automatic association between these bodily symptoms and the belief that they are signs of serious conditions such as brain cancer. Disease conviction was so strong in the PHA group that the prefrontal cortex had to exert enormous effort to shift from the automatic association between symptom "headache" and "harmful" to the more difficult association "headache" and "harmless."
Another fMRI study compared patients with depression or PHA with controls who undertook a similar categorization task (3). Interestingly, PHA patients did not behaviorally differ from those with depression or controls. However, their brain activation differed from the other groups. PHA patients showed hyperactivation in the amygdala, right parietal lobe, and left nucleus accumbens compared to the other groups. They also showed different activation in the prefrontal cortex.
It seems like patients with PHA have an automatic bias to categorize bodily symptoms as dangerous and resist the re-conceptualization of these symptoms as benign. Resisting such automatic negative core beliefs require overactivation of control inhibitory systems such as the prefrontal cortex.
Health Anxiety is Not a Disorder
Health anxiety is not a diagnosis in the DSM-5 but rather a component of many psychological conditions. It is similar to an outdated diagnosis that is no longer part of DSM-5 called hypochondriasis. The diagnosis was replaced by somatic symptom disorder (SSD) and illness anxiety disorder (IAD), in which health anxiety is a core feature.
The newer diagnoses are more clinically reliable than the DSM-IV hypochondriasis diagnosis (1). Arguably, the differences between IAD and SSD appear to be due to severity. IAD is restricted to those with any somatic symptoms or mild symptoms, whereas SSD is diagnosed when significant moderate to severe somatic symptoms are present.
It is important to note that while physical symptoms are a part of the diagnostic criteria, it is the cognitive symptoms that determine the severity of SSD. Cognitive symptoms include persistent thoughts and feelings about these physical sensations—such as excessive worry and anxiety and even catastrophic thoughts about death.
PHA Can Lead to Other Psychological Conditions
Excessive fear of having a serious illness can lead to panic attacks. In turn, these attacks can lead to a panic disorder. As a result, a patient with PHA may engage in avoidance behaviors. For example, a man who is convinced that his heart palpitations are signs of cardiovascular disease may avoid hikes, gyms, or any activity that may increase his heart rate.
Excessive avoidance may escalate into agoraphobia and other anxiety and/or mood disorders. In addition to the economic burden of PHA, the sufferer's quality of life is severely affected.
Thus, effective treatments for PHA are crucial. The first step is to rule out any medical conditions. When serious illnesses are ruled out, then PHA can be ruled in. There are many standardized questionnaires available online to survey the patient’s thoughts about bodily sensations. Cognitive behavioral therapy is very effective at tackling the cognitive component of PHA, including "disease conviction." Behavioral techniques such as exposure therapy can address the misinterpretation of somatic symptoms.
References
(1) Bailer, J. Kerstner, T, Witthöft, Diener, C., Mier, D., and Rist, F. (2016). Health anxiety and hypochondriasis in the light of DSM-5. Anxiety Stress Coping, 29(2): 219-239.
(2) Mier, D., Witthöft, M., Bailer, J., Ofer, J., Kerstner, T., Rist, F. Diener, C. (2016). Cough is dangerous: Neural correlates of implicit body symptoms associations. Frontiers in Psychology, https://www.frontiersin.org/articles/10.3389/fpsyg.2016.00247/full.
(3) Yan, Z., Witthöoft, M., Bailer, J., Diner, C., and Mier, D. (2019). Scary symptoms? Functional magnetic resonance imaging evidence for symptom interpretation bias in pathological health anxiety. Eur. Arch. Psychiatry Clinical Neuroscience, 269, 195-207.
