Health anxiety moderates the effects of distraction versus attention to pain
Introduction
Health anxiety has been conceptualized as a dimensional construct that is characterized by extreme health anxiety or even hypochondriasis (excessive preoccupation with disease in the absence of supporting medical evidence or despite medical reassurance) at one extreme and complete lack of concern about one's health on the other Warwick, & Salkovskis, 1990, Hitchcock, & Mathews, 1992. A Cognitive-Behavioural Theory (CBT) of health anxiety has been proposed (Warwick & Salkovskis, 1990). According to this theory, health anxious individuals form dysfunctional assumptions and beliefs about symptoms and disease based on past experiences and become health anxious when these dysfunctional schemata are triggered by critical incidents (e.g. hearing about illness, experiencing bodily sensations). Cognition is not only predicted to be prominent in the development of health anxiety, but is also expected to play an important role in the maintenance of the condition as well. Once health anxiety ensues, the theory further predicts that the health anxious person will manifest an attentional bias to notice illness information. Moreover, they will have a tendency to misinterpret somatic information as catastrophic and personally threatening (i.e. cognitive reaction). Considerable support for the cognitive response style among health anxious patients has been found through clinical observation (Salkovskis & Warwick, 1986), questionnaire studies (Kellner, Abbott, Winslow & Pathak, 1987; Jones, Mabe & Riley, 1989), studies examining cognitive biases (Hitchcock & Mathews, 1992), and quasi-experimental studies examining cognitive responses to experimentally induced pain (Hadjistavropoulos, Craig & Hadjistavropoulos, 1998).
Recently, it has been suggested that health anxious individuals may not only have a bias to negatively attend to and interpret somatic sensations, but they may also be deficient in strategies that protect them from health anxiety. Hadjistavropoulos et al. (1998), for instance, found that in a non-clinical sample health anxious individuals were deficient in their capacity to objectively monitor somatic sensations while experiencing experimentally induced pain. Non-health anxious individuals, on the other hand, utilized an objective monitoring style (i.e. a focus on the objective, concrete and nonemotional aspects of the symptoms as manifested in cognitions such as “it is a tingling sensation”) when exposed to pain. Previous research shows that those who use such an objective monitoring strategy during a noxious event experience benefits including increased pain tolerance and threshold as well as improved recovery from pain Blitz, & Dinnerstein, 1971, Ahles, Blandard, & Leventhal, 1983, Cioffi, & Holloway, 1993. Hadjistavropoulos et al. (1998) proposed an extension to the CBT and suggested that health anxious persons may be deficient in their ability to engage in objective somatic monitoring. Here, the question remains whether this finding would hold in a clinical sample.
A further cognitive strategy that could be predicted to play a role in the experience of health anxiety is cognitive avoidance or suppression. The cognitive-behavioural theory of health anxiety (Salkovskis & Warwick, 1986) suggests that health anxious individuals will physically avoid information or situations that evoke health anxiety. Whether this would extend to the usage of cognitive avoidance, such as distraction or the suppression of anxiety provoking thoughts, in order to avoid health anxiety is unclear. If cognitive avoidance is present among health anxious individuals it could actually serve to increase health anxiety in the long run. Counter to what might be expected based on common sense (Leventhal, 1992), cognitive avoidance/distraction as a coping strategy seems to lose its advantages after a brief period and tends to be associated with greater disability and pain in those who favor this approach (Mullen & Suls, 1982). Suppression of thoughts, that relate to physical sensations, tends to result in a longer recovery period from pain and increases the probability that innocuous physical sensations (e.g. vibration) will be perceived as unpleasant (Cioffi & Holloway, 1993). Moreover, efforts to suppress such thoughts increases the likelihood of unwanted cognitions (Wegner, Schneider, Carter & White, 1987). Based on these findings, it could be predicted that efforts to avoid pain through suppression or distraction may prolong it and, thus, exacerbate health anxiety. To date, no research has explored this possibility within a clinical sample.
Overall, there appears to be a need to study cognition further among health anxious persons, particularly in a clinical setting. A clinical context that was thought to be useful for the examination of health anxiety is the study of musculoskeletal pain patients who are undergoing physical therapy. Preliminary research suggests that health anxiety may be important in understanding the way people respond to chronic low back pain. Low back pain patients who score high on health anxiety report greater somatic awareness, depressive symptoms and disability (Main & Waddell, 1987). Research also suggests that physical therapy and examination elicit considerable anxiety in patients (Hadjistavropoulos & LaChapelle, in press).
One goal of the present study was to explore more systematically the role of health anxiety in chronic pain. In particular, it was of interest to explore whether non-health anxious and health anxious patients would show variable cognitive responses during physical therapy. In line with the CBT and extrapolating from existing literature the following hypothesis was made:
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Health anxious patients were predicted to report greater pain, more somatic symptoms, higher anxiety and worry about health and injury, more catastrophic thoughts about pain, greater cognitive avoidance (e.g., attempts to ignore, distract from pain), greater negative somatic monitoring of symptoms, and lower usage of concrete objective somatic monitoring of pain than non-health anxious patients.
A second goal of this study, was to explore the impact of varying attentional focus either away from pain (distraction) or toward pain (attention) on response to pain, anxiety and cognition among health anxious and non-health anxious patients. Little attention has been given to how health anxiety may interact with cognitive coping strategies in determining one's response to pain. We attempted to disentangle the relation of distraction versus attention to sensations and health anxiety through the experimental manipulation of cognitive coping strategy in a sample of musculoskeletal patients differing in health anxiety. An interaction between health anxiety and cognitive coping strategy was hypothesized.
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Among health anxious patients, it was predicted that distraction would result in negative consequences for patients since previous research has shown that this strategy quickly becomes ineffective and results in increased pain and a greater number of negative intrusive thoughts (Cioffi & Holloway, 1993). Attention was also predicted to be detrimental because health anxious patients were predicted to respond to this instructional set by focusing on the negative somatic experience and by having catastrophic thoughts about injury.
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We further hypothesized that among non-health anxious individuals, the attentional condition would result in greatest benefits for patients since non-health anxious patients were expected to focus on concrete objective somatic symptoms rather than on negative aspects of the experience. This strategy has been found previously among non-health anxious individuals (Hadjistavropoulos et al., 1998) and typically aids coping with pain (Cioffi & Holloway, 1993).
In summary, this study examined the way health anxious and non-health anxious individuals respond while undergoing active physical therapy. Pain levels, control, anxiety and cognitive activity were studied under three conditions: (a) attention/monitoring, (b) distraction/avoidance and (c) a control condition. The control condition was thought to provide information regarding typical patterns of responding, while the experimental conditions were expected to provide information regarding the specific effects of coping responses on pain, anxiety and cognition.
Section snippets
Participants
Participants were attending a multidisciplinary pain treatment program over a 10 month period. All participants met the following criteria: (a) they had a routine, active, 45 min independent physiotherapy session as part of their treatment program; (b) they had approval from their physiotherapist to participate in the study; (c) they had experienced pain for at least a 3 month duration and (d) they rated their pain or discomfort during physiotherapy as at least a three on a Likert scale question
Preliminary analyses
The chi square statistic and multivariate analysis of variance (MANOVA) were used to examine whether patient groups (i.e. health anxious versus non-health anxious) and experimental conditions (attention versus distraction versus control) differed on background variables. Chi squares were used for categorical variables (i.e. marital status, sex, availability of job to return to, third party payer, multiple diagnoses, surgery as a result of the injury, previous injuries) while MANOVA was used for
Health anxiety
The present study clearly demonstrated that health anxiety has a substantial impact on how patients respond to physical therapy. This extends previous work on the relationship between health anxiety and chronic pain that has relied on self-report questionnaires (Main & Waddell, 1987). Clinicians can expect that during physical therapy health anxious patients are more likely to report higher anxiety, worry about health, worry about injury and catastrophic cognitions than non-health anxious
Conclusions
The results of the present study are important in two regards. First, they suggest that the CBT of health anxiety (Salkovskis & Warwick, 1986) can be applied to chronic pain patients. There was strong support for the prediction that health anxious pain patients would be more likely to attend to sensations and catastrophically misinterpret these same sensations than non-health anxious patients. Second, the results have implications for findings regarding the role of distraction versus attention
Acknowledgements
The research was supported by a grant to HDH from the Saskatchewan Health Services Utilization and Research Commission. The assistance of staff and patients of the Functional Rehabilitation Program, Wascana Rehabilitation Centre, is gratefully acknowledged.
References (25)
- et al.
Cognitive and behavioral responses to illness information: the role of health anxiety
Behavior Research and Therapy
(1998) - et al.
Interpretation of bodily symptoms in hypochondriasis
Behaviour Research and Therapy
(1992) - et al.
Psychometric construction of the Illness Behaviour Questionnaire in British patients with chronic low back pain
Pain
(1987) The McGill Pain Questionnaire: major properties and scoring methods
Pain
(1975)- et al.
The effectiveness of attention and rejection of coping styles: a meta-analysis of temporal differences
Journal of Psychosomatic Research
(1982) - et al.
The use of coping strategies in chronic low back pain patients: relationship to patient characteristics and current adjustment
Pain
(1983) - et al.
Morbid preoccupations, health anxiety and reassurance: a cognitive-behavioural approach to hypochondriasis
Behaviour Research and Therapy
(1986) - et al.
The factor structure of the Coping Strategies Questionnaire
Pain
(1994) - et al.
Hypochondriasi
Behaviour Research and Therapy
(1990) - et al.
Cognitive control of pain: attention to the sensory aspects of the cold pressor stimulus
Cognitive Therapy and Research
(1983)
An inventory for measuring clinical anxiety: psychometric properties
Journal of Consulting and Clinical Psychology
Role of attentional focus in pain perception: manipulation of response to noxious stimulation by instructions
Journal of Abnormal Psychology
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