By Benjamin T. Ladd | The Miriam Hospital
Ronald, a cardiopulmonary rehabilitation patient, rushed to the internet after recently noticing subtle twitches and contractions in his neck and shoulders. The information he gathered online convinced Ronald that he might be in the early stages of muscular or neurogenerative disease – a concern he brought up with his case manager at rehab the next day. Was it safe to continue exercising there and at home, he asked, or was he at increased risk for a fall?
While being a steward of your own wellness is important, some people – including cardiopulmonary rehabilitation enrollees – fret over their health so much that it negatively impacts their mental and even physical well-being. Previously known as hypochondriasis, Illness Anxiety Disorder (IAD) involves worrying excessively about becoming seriously ill. Those affected tend to interpret innocuous bodily sensations as a sign of an emergency. While most people’s health anxiety is proportionate to the threat of their concern, individuals with IAD develop a disproportionate and counterproductive preoccupation with physical symptoms that harms functioning and emotional well-being.
IAD in the Cardiopulmonary Population
Cardiopulmonary disease patients face unique health-related stressors and can benefit when case managers identify their health anxiety and provide strategies to address it. Unchecked health anxiety can derail adherence, threaten rehabilitation progress, increase likelihood of over-accessing or avoiding healthcare and/or reduce quality of life.
IAD has two distinct clinical presentations: care seeking and care avoidant. Care-seeking types spend excessive time in healthcare settings, meeting with providers over unfounded concerns. They attend extra healthcare appointments or consult with unsubstantiated web resources as a safety behavior to ease their worry. In contrast, care-avoidant types distrust providers and sidestep medical care. They may avoid care because they are afraid of being diagnosed with a serious illness, or they find that medical professionals downplay or disregard their symptoms. Both clinical presentations are rooted in an excessive fear of developing a serious condition.
The two primary treatments for IAD are Cognitive Behavioral Therapy and antidepressants. Even if your background is not in behavioral health, you can educate your patients and guide them in the right direction for treatment. Many of your patients likely present subclinical IAD symptoms and would still benefit from your education on coping skills for anxiety.
At times, patients’ health anxiety can discourage them from adhering to recovery-promoting or self-management behaviors. For example, patients worried that exercise could trigger another myocardial infarction may avoid physical activity altogether. Previous research has also suggested that generalized anxiety and excessive worry are associated with both fatal and non-fatal cardiovascular diseases; anxiety may be a modifiable target for secondary prevention. Programs with behavioral health or a linkage to community providers are uniquely positioned to assist with this, but every case manager has the skills to tune in to their patients and respond to these concerns with a validating, psychoeducational conversation.
Recognizing and combatting IAD in cardiopulmonary rehabilitation patients poses a unique challenge because these patients must remain vigilant to bodily sensations that may predict another cardiac or pulmonary event. Thus, the first step in addressing health anxiety is to determine if their concerns signify imminent threat or one that requires medical treatment. Begin with the assumption that their concerns are well-founded. However, if they are medically cleared, direct them to stress-reduction techniques. At the bottom of this article, you will find resources that include explanations and instructions for how to engage in specific relaxation techniques. If their anxiety is not responsive to these coping strategies, refer them to a mental health professional who can determine the best course of action.
Cardiopulmonary rehabilitation patients must balance developing agency over their own health with acceptance of factors they cannot control, lest excessive worry about their health becomes counterproductive to their overall well-being. These patients must balance being mindful of signs of another health event and understanding when their health anxiety should not keep them from doing what is important to them, like caring for themselves. You are the front line for identifying health anxiety in your patients and helping them change the nature of their mind-body connection.
Stress Management Techniques and Resources
Journaling: Prior research has indicated that journaling can serve as an effective stress-management technique among medical populations; in this study, individuals in the journaling condition reported reduced depressive symptoms and anxiety after journaling three days a week for 12 weeks. When teaching anxious patients about the potential benefits of journaling, they may find it helpful to journal in response to specific prompts.
Mindfulness: Meditation and other mindfulness practices can serve as a powerful stress-management tool. You can incorporate guided meditation videos into education sessions or make your patients aware of the numerous mindfulness applications that can be downloaded for free on a smartphone. Some of the most popular smartphone-based mindfulness resources include Headspace, Calm and Insight Timer.
Ben Ladd is a research assistant at the Weight Control and Diabetes Research Center – part of The Miriam Hospital in Providence, Rhode Island.