Reasons to worry
Private Practice, June 2021

Health anxiety was a big problem even before COVID-19, affecting up to nine per cent of patients in UK general medical practice.¹ Defined by the NHS² as ‘…when you spend so much time worrying you’re ill, or about getting ill, that it starts to take over your life’, and synonymous with hypochondria, it is commonly treated with CBT, which, while effective,³ doesn’t appeal to everyone.^4–6 It’s a pressing issue that counsellors should be more sensitive to, especially now we are in a pandemic, with a virus that may or may not be within our bodies, with symptoms that are still being understood and are common for a number of other reasons, and with a prognosis that can vary wildly between people who catch it.

Because there is little in the literature on the lived experience of health anxiety, the first author of this article (David) conducted a research project, under supervision from the second author (Sheila), to give voice to three women who struggle with this problem. Specifically, it looked at how these women articulated their self-concept, an idea relevant to most psychotherapy theory, including within psychodynamic, person-centred and cognitive therapy,⁷ but which is in any case central to the presentation and language of clients. We chose to recruit only white cis British women because self-concept varies across cultures and genders, and interviewed them each for 60–90 minutes before finding common themes using interpretive phenomenological analysis. Names of participants have been changed and their permission obtained for publication. This research was for a dissertation that partly fulfilled requirements for David’s MSc in person-centred psychotherapy and it was later presented at BACP’s Research Conference 2021.

The complexity of being health anxious

We found that health anxiety is a more psychologically complex phenomenon than people seem to realise. Analysis of the interview data led us to summarise this phenomenon into three central themes: ‘living with health anxiety’, ‘questioning health anxiety’ and ‘anxiety among others’. What follows is a brief description of participants’ experiences, thoughts and feelings under these principal areas. 

Living with health anxiety

All participants identified with the label ‘worrier’. One of them, Jacqui, said, ‘…[being a worrier is] not something I really noticed until my mum said it’. In contrast, Rebecca said of her daughter, ‘She’s secretly a worrier. She has a drawer full of tablets and stuff by her bed. So I know I’ve transferred it to her a bit.’ Here, worrying is not just something one does, but who one is.

At the same time, each participant found their anxiety to be appropriate to some extent, given what has happened to them and their loved ones – unlikely things do happen, people do die unexpectedly and doctors do make mistakes. For example, Rebecca said that a doctor practically told her that she had breast cancer after a biopsy, but after ‘eight weeks of hell’, this was found to be wrong, and this experience has put her off complying with any routine screening since.

Questioning health anxiety

Health anxiety takes a toll, and the women had a rejecting attitude towards it. Jacqui reminisced about university days when she wasn’t worried because she was ‘…so busy living my life’, and Rebecca also talked about a time when ‘I used to live the life’, saying, ‘I look back then, and I just can’t believe I was that person.’ There is a sense here of something or someone lost. Kate looked to the future and ‘…the kind of person that I want to be like, you know, that, yes, you’re aware stuff happens but don’t worry about it, it happens when it happens’, as compared with now, where ‘I’m one of those people who worries about all the things that can happen’. The more we talked, the deeper the interviews seemed to become, and each participant wondered why they were health anxious. ‘I don’t really know why I’m like it,’ Kate said. Jacqui said she was thinking, ‘Where has all this come from really?’

Rebecca noted that she had tried everything to find a way out and then wondered if she really wanted things to change because it was ‘… like an escape clause to not have to live my life’.

Anxiety among others

When asked to describe themselves at the start of the interview, two participants began by talking about their concerns about what other people think about them, but they both also held conflicting beliefs about themselves. Jacqui agreed with her boyfriend that she’s outgoing but also said she is not. Kate said, ‘I tell myself I don’t care about what people think of me, but obviously do.’ Rebecca began by describing herself as normally confident and outgoing but currently feeling ‘absolutely terrible’, but later described this ‘confident person’ in the past tense, saying, ‘I don’t know where it’s all gone.’

It was clear in the interviews that the label of ‘health anxious’ was a burden to carry. Talking about distrusting doctors, Rebecca said, ‘I know that is quite a health anxious thing… but to be honest, I’ve had a lot of reason not to [trust them].’ She seemed to feel the need to evoke her personal reasoning to stop me (David) dismissing her distrust as mere health anxiety. Jacqui similarly wanted to use her professional experience with medical terminology to have empowered conversations with doctors, but said she often gets the feeling the doctors think she’s ‘…just another girl’ who’s ‘…becoming a bit hysterical over something’. Kate pointed out that she does not actively look to find symptoms because she thinks that is ‘…what people think we do’

The participants all had to interact with people while being preoccupied with their health concerns. They often chose not to share their concerns for fear of negatively affecting their relationships, but had to carry the burden of this. Rebecca felt like she was lying to say she was fine. Jacqui felt she was having to play things down, which felt like a big deal to her, and Kate said she felt as though she was more fake now.

However, they had all selected some people that they could confide in – but they spoke about these interactions in a self-effacing way. Jacqui was concerned about ‘…being that person who sort of drones on and on and on’. Kate and her husband joked about her repeated requests for reassurance, and Rebecca found that her mother telling her to ‘shut up’ pulled her back ‘…from being an idiot’.

Thinking about health anxiety

Perhaps practitioners reading this have begun to think about how their therapeutic approach would make sense of these experiences. We will discuss some of the approaches here.

Person-centred theory conceptualises anxiety as occurring when an individual perceives incongruence within themselves.⁸ There are signs of incongruence in our participants – mainly in the ‘anxiety among others’ theme, which showed self-consciousness and impression management, the need to self-deprecate when being vulnerable with others and the feeling of not being authentic when hiding one’s health concerns – all of which is made more difficult by the consequences of being labelled ‘health anxious’ or ‘hypochondriac’. There is also a tension between wanting to reject the anxiety and having good reason to worry, perhaps another sign of incongruence. We have analysed our findings from a person-centred perspective in greater depth elsewhere.⁹

Solution-focused brief therapy avoids taking a view on what is normal for a person and instead works towards the client’s stated hopes for the work. A health-anxious client could therefore wish to only deal with one aspect of their problem, such as Googling symptoms less often, or getting on better with their partner, which may of course lead to other changes. Solution-focused therapists ask questions about interactions with others that may be particularly useful for the health anxious, given how it affects their relationships. They encourage clients to look for signs of their preferred future happening already, or for exceptions to their problems, so may encourage a loosening of clients’ fixed views of themselves, such as ‘being a worrier’. They offer no theory on problem causation, so may frustrate clients trying to understand why they are the way they are, though this question may become less important to a client if the therapy proves to be useful. The first author is preparing a paper discussing the data in more depth from a solution-focused perspective.

Warwick and Salkovskis’¹⁰ cognitive-behavioural model of health anxiety identifies three mechanisms that maintain it: selective attention to bodily sensations and health-anxious thoughts; misinterpretation of physiological arousal and bodily sensations; and safety-seeking behaviours. As this model focuses squarely on the problem at hand, they are all reflected in the experiences summarised as ‘living with health anxiety’. Their third mechanism, safety-seeking behaviour, of course profoundly affects the interpersonal lives of sufferers and can be seen in the ‘anxiety among others’ theme, which in turn can lead to the social construction of the ‘worrier’ role.

The psychodynamic perspective suggests that the fear, beliefs and ambivalent dependence on others for reassurance and comfort come from a need to disguise one’s unacceptable urges and perhaps to inflict self-punishment.¹¹ The interpersonal model hypothesises that somatising people display anxious attachment behaviour that derives from childhood experiences with caregivers, and that when under stress as adults, they use physical complaints to elicit care.¹² This study did not ask about childhood experiences, though through the above comments on incongruence, we see signs of that ambivalent dependence on others, tentatively approaching them to elicit care and reassurance – fraught with difficulty as this can lead to negative reactions.

Reflections for practice

Ociskova, Prasko and Sedlackova¹³ found that anxiety causes negative self-concept and self-stigma, and our findings support that. This self-stigma highlights the need for a good working alliance in which health-anxious clients would feel able to bring shameful material. A study¹⁴ on group-based, mindfulness-based cognitive therapy (MBCT) found that validation and normalisation were helpful – perhaps these can counter self-stigma. The paper found that clients increased their acceptance of their experiences and that some participants were more likely to try to take steps to be kinder to themselves when they noticed that they were feeling negative or were experiencing difficulties. This could be seen as an integration of conflicting aspects of the self-concept, such as considering oneself a worrier while rejecting that aspect of oneself, and it may be that most or all other approaches to therapy, when successful, facilitate a similar intrapersonally harmonising effect. 

Our master theme of ‘questioning health anxiety’ may show why health-anxious people come to therapy – a desire to reject health anxiety may bring them, and a desire to interrogate it may open up space for successful therapeutic work – for example, facilitating both a client’s processing and their willing consideration of therapeutic interventions, such as psychodynamic interpretations, recommended other ways to think or behave or suggested interpersonal strategies.

To close with some of our reflections: vast numbers of people are spending much of their lives in distressing fear of illness, a fear that for some has increased in these times of the COVID-19 pandemic.¹⁵ This fear itself may be diagnosed as illness. Doctors may be impatient towards them, and therapists may term them resistant to treatment. While people with health anxiety often yearn for reassurance from friends and family, they know there is a social cost to asking. If someone manages to resist asking for this reassurance, they may then feel inauthentic, talking to people while pretending they are not deeply worried about their health.

They may also long to be free of this worry, lamenting the apparent loss of their non-pathological selves or thinking scornfully of themselves. When they stop and think about it, they may be curious about why they suffer this affliction – and yet, when they look at the experiences of themselves and their loved ones, there may be every reason to fear disease and to distrust the reassurance of doctors.

If therapists can empathise with this phenomenologically complex plight, they will be better able to provide a helpful therapeutic meeting, providing a relationship that is both intrinsically helpful, going some way to countering previous attachment difficulties, and a sturdy basis from which to apply particular therapeutic techniques. They will provide a safe presence for clients to share a distress that can bring shame and stigma. They will also help themselves remain committed to their clients when times are tough – by staying in touch with the reality of the clients’ distress, and with the fact that while the client may be ‘in’ their worry in this moment, they also seek to overcome it and they are probably capable in other times of rationally and curiously interrogating it.

As therapists and counsellors, we may wish to consider the potentially harmful effects of applying a psychopathological label to this distress, and to bear in mind that a client’s personal lived history with health and medicine may make much sense of their fear. Practitioners who model a holistic acceptance of the person in front of them may help foster a curative self-acceptance in their clients that can work in the background of whatever other therapeutic activity may be happening.