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Anxiety

Confront Health Anxiety by Examining the Evidence for Your Thoughts

A tingling sensation may not be a sign of an impending stroke.

Key points

  • Up to 13 percent of adults in the general population and 20 percent of adults in outpatient medical settings have severe health anxiety.
  • Cognitive behavioral therapy (CBT) is a form of therapy that helps health-anxious people reshape dysfunctional beliefs about health and illness.
  • "Examining the evidence" is a CBT technique in which one uses critical thinking to examine the validity of thoughts about health concerns.

A new symptom popped up this week and sent you into a downward spiral again. Maybe you felt a pain in your side, got a headache, noticed some discoloration or experienced some dizziness or chest pain. Whatever it was, this sudden realization sucked the joy out of your day and took you from point A (noticing the symptom) to point B (envisioning yourself collapsed on the floor from a heart attack or in the hospital with cancer) in just a few short minutes. You know this probably isn’t accurate but that knowledge isn’t enough to stop yourself from spiraling.

Health anxiety is awful and, yet, not uncommon. Estimates suggest that up to 13 percent of adults in the general population and 20 percent of adults in outpatient medical settings have severe health anxiety.1 Not surprisingly, studies show that COVID-19 has even further exacerbated the prevalence and severity of health anxiety.2-3

Cognitive behavioral therapy (CBT) is the first-line treatment for health anxiety.4 One proven strategy we use in CBT for all types of anxiety is called "examining the evidence." I’ll explain what this is in a second. But first, keep in mind what the research says about people with health anxiety.5

Health-anxious people tend to:

  1. overestimate the likelihood of becoming ill;
  2. overestimate the severity of the illness if it were to happen;
  3. underestimate their ability to cope with the illness; and
  4. underestimate the adequacy of medical services to deal with the illness.

Examine the Evidence

Examining the evidence is a strategy used to evaluate specific thoughts or beliefs in order to better understand the accuracy of specific thoughts and beliefs. The whole goal of CBT is not positive thinking, but realistic and logical thinking. And, because our anxious minds can lead us to overestimate the probability and severity of a threat, it is critically important to put these thoughts to the test. Think of yourself as a scientist who is collecting data.

Now, let’s proceed with the cognitive intervention. In the context of health anxiety, this intervention is helpful to examine the evidence for and against dysfunctional beliefs, such as cognitive distortions about bodily changes or sensations. We will use an example to walk us through the exercise.

Let’s say you randomly notice some numbness or tingling in your leg. Your automatic thought is: This tingling is a sign of an impending stroke. Of course, this prompts you to spend the next couple of days searching for other stroke symptoms. So, let’s examine the evidence.

First, I would ask you: If you had 100 points to divide up between evidence in support of the thought and evidence against the thought, how would you divide it? Since you are feeling pretty anxious about this thought, my guess is you would allot more points to the evidence in support of the thought than evidence against the thought. So let’s say you allot 75 points in support of the thought and 25 points against the thought. We then move on to collaboratively examine the evidence.

Frightening thought: I am going to have a stroke.

Evidence in support of the thought:

  • I noticed tingling in my leg.
  • My grandfather had a stroke.

Evidence against the thought:

  • I had a physical recently and the doctors had no concerns about my cardiovascular health (and no concerns about my health in general).
  • I don’t have any other symptoms of stroke (sudden confusion, trouble speaking, trouble walking, dizziness, loss of balance, lack of coordination).
  • At the time I noticed the tingling, I was sitting on the couch with my legs crossed for a while.

After evaluating the evidence, I would have you again allot 100 points between the two categories. You might find that after this activity the numbers have changed a bit. You allot 30 points in support of the thought and 70 against the thought. This allows us to see whether this technique had any impact. Even if we only noticed a 10 point difference before and after the activity, I would conclude that it was a success.

Alternative Explanations

Next, I would ask you: Is there an alternative way of looking at things? What is a more accurate, non-catastrophic explanation for the tingling in your leg? Collaboratively, we would develop other non-catastrophic explanations for the tingling in your leg.

Perhaps, (a) your leg fell asleep while crossing your legs due to restricted blood flow to the area; (b) you have low levels of potassium, calcium or sodium; (c) you have an underactive thyroid; (d) it may be a side effect of a medication you are taking. And the list could go on.

There are often numerous potential non-catastrophic causes for your symptoms. However, in an anxious state, we often don’t even consider the non-catastrophic explanations. A great new habit to develop is to consider as many potential non-catastrophic explanations as you can think of and even try to conjure up evidence for them.

Please note that through this post, I am intending to provide a detailed picture of how this technique is carried out. However, this technique was designed for the therapist and the client to explore the evidence together in a collaborative way. Thus, it may be more effective if done in collaboration with a skilled CBT therapist — at least for the first few times. Of course, the long-term goal is for you to become skilled at using techniques like these so that you can implement them on your own throughout life.

References

1. Norbye AD, Abelsen B, Førde OH, Ringberg U. Distribution of health anxiety in a general adult population and associations with demographic and social network characteristics. Psychol Med. 2020 Oct 20; 1–8.

2. Sica C, Caudek C, Cerea S, Colpizzi I, Caruso M, Giulini P, Bottesi G. Health anxiety predicts the perceived dangerousness of COVID-19 over and above intrusive illness-related thoughts, contamination symptoms, and state and trait negative affect. Int. J. Environ. Res. Public Health 2021 May 8; 18:1933.

3. Pappa S, Ntella V, Giannakas T, Giannakoulis VG, Papoutsi E, and Katsaounou P. Prevalence of depression, anxiety, and insomnia among healthcare workers during the COVID-19 pandemic: a systematic review and meta-analysis. Brain Behav. Immun. 2020 88, 901–907.

4. Cooper K, Gregory JD, Walker I, Lambe S, Salkovskis PM. Cognitive Behaviour Therapy for Health Anxiety: A Systematic Review and Meta-Analysis. Behav Cogn Psychother. 2017 Mar;45(2):110-123.

5. Hadjistavropoulos HD, Janzen JA, Kehler MD, Leclerc JA, Sharpe D, Bourgault-Fagnou MD. Core cognitions related to health anxiety in self-reported medical and non-medical samples. J Behav Med. 2012 Apr 13; 35: 167-178.

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