Useful Resources

CBT Session One The information here is provided by a trained CBT therapist through the National Health Service of Great Britain. These modules are useful for my own personal anxiety and for information purposes only. They may also be useful for yourself as they are for generic health anxiety, but please consult a doctor or trained therapist to ensure you get the best treatment possible as I am not qualified in the field of CBT in any way and you may be advised to seek different treatment.

This is the first module of my cbt course. I shall update weekly or as and when I have something new!

Helping Health Anxiety

Helping Health Anxiety

Helping Health Anxiety

Module 3

What Keeps Health Anxiety Going?

Introduction 2
How Health Anxiety is Triggered 2
How Health Anxiety is Maintained 3
Unhelpful Health Related Thinking 3
Increase in Anxiety Symptoms 3
Focussing on Symptoms 4
Checking & Reassurance Behaviours 5
Avoidance & Safety Behaviours 6
Putting it All Together 7
Model of Health Anxiety Maintenance 7
Worksheet: How My Health Anxiety is Maintained 10
The Good News 11
Module Summary 12

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In Module 2, we explored how our past experiences may lead us to feel more vulnerable, increasing our concern about our health and making us more sensitive to bodily symptoms and changes. We also identified the concept of “dormant” health anxiety – where unless we are confronted by something that

“activates” or triggers off our health anxiety, it may not bother us for periods of our life. In this module, we

will discuss potential triggers to health anxiety, and explore how health anxiety is then maintained in the longer-term.

How Health Anxiety is Triggered

If you ask any friend or family member whether they have ever worried about their health, most people will probably admit to having some health-related concerns from time to time. Interestingly, the same things

that would make any other person worry about their health could trigger off an episode of health anxiety. It is usually when these triggers are combined with a set of inflexible and inaccurate health rules or assumptions that health anxiety is triggered. These triggers can be something internal within us or external in our environment.

Internal triggers

Remember in the last module we talked about our bodies as being like old cars. Over time they will develop some strange noises and start to run a bit rougher.

All-in-all, it is normal to feel some symptoms and sensations in your body. This can include stomach discomfort, tingling or numbness in parts of your body, ringing in your ears, sensitivity to heat or cold in your teeth, increases or decreases in your heart rate, changes in your saliva production, and variations in your energy levels. Sometimes new or unfamiliar symptoms may begin for you, such as the onset of headaches or development of a rash. Many women whilst pregnant will also report a range of new and sometimes bizarre sensations in their bodies. You may even have unusual sensations, such as developing a strange taste in your mouth or a muscular twitch under one of your eyes.

External triggers

Besides things happening within your body, a number of external things can draw your attention towards

possible health problems and therefore trigger off episodes of health anxiety. For example: Health scares in the news

Upcoming medical appointments

Being in contact with people who are unwell

Hearing about someone who has been diagnosed with an illness

Receiving inconclusive results on a medical test

Being told you do have a health condition

Being away from known health-care systems (e.g., travelling overseas)

Take  a moment to write  down any triggers you have  experienced in relation to health anxiety.

Internal triggers

External triggers

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How Health Anxiety is Maintained

Unhelpful Health Related Thinking

If your unhelpful health rules or assumptions are activated by the types of triggers just mentioned, they are

likely to negatively affect the way you think about sensations or variations in your body, and how you interpret health information from medical professionals or other sources. In general, people with health anxiety tend to overestimate the likelihood that they have a serious health problem and underestimate their ability to cope with such a problem. They also tend to discount other factors which suggest that things will not be as bad as they have predicted (e.g., overlook their doctor’s reassurance that a serious illness is unlikely, focus on the most negative potential outcomes rather than the chances of cure or good

management). As such, all health-related experiences are viewed as a ‘catastrophe’ or ‘worst-case’ scenario.

Catastrophic interpretation of bodily sensations

If you hold an unhelpful health assumption such as “All discomfort and bodily changes are a sign of serious

illness”, and are then faced with the trigger of experiencing pain in your joints, you may come up with catastrophic interpretations of what the pain means. You might say things like: “This could be arthritis”, “I probably have bone cancer”, “This problem will be the end of me”, or “This could be something incurable”.

Catastrophic interpretation of health related information

You may also misinterpret health information as indicating that you are at higher risk

than you really are. For example, imagine that your doctor tells you that your blood test showed a low white blood cell count but that it is “…probably just due to a common cold”. If you hold the unhelpful health assumption “If my doctor doesn’t know exactly what the problem is, then it must be really serious” you are more likely to come up with thoughts such as “Maybe it is actually leukaemia”, or “My doctor hasn’t tested for really serious problems like HIV or Lupus, so there is a chance that

is what I actually have”.

Take  a moment to write  down some of the unhelpful thoughts you have  experienced in regard to your health. What kinds  of things are you saying to yourself about your health or about any health information you have  received?

Increase in Anxiety Symptoms

As you can probably imagine, if you start having catastrophic thoughts about your bodily sensations, you are likely to be firing up your fight/flight response in reaction to this perceived threat to your health. Your

fight/flight response is designed to protect you by helping you survive a battle (“fight”) or to run away to save yourself (“flight”) and can include the following changes:

muscular tension, tiredness or exhaustion

skipping, racing or pounding heart

changes in breathing rate / breathlessness, chest pain or pressure

dizziness, light-headedness, blurred vision, confusion, feelings of unreality and hot flushes

numbness and tingling in your fingers and toes

an increase in sweating

widening of the pupils, blurred vision, spots before the eyes, a sense that the light is too bright

a dry mouth, nausea or an upset stomach

You may notice one, some or all of these symptoms in varying degrees of intensity.

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These physical alarm responses are important when facing real danger, but they can also occur when there is only a perceived danger. If you say things to yourself like: “This could be something incurable”, “I may

have cancer”, or “My doctor may have missed something important”, it is likely that these perceived dangers

will set off your fight/flight anxiety symptoms.

Unfortunately, people who have a tendency to notice and worry about health signs and symptoms can then also start to worry about some of these fight/flight anxiety symptoms – jumping to the conclusion that they are another sign that something really is wrong!

This can lead to a vicious cycle where real symptoms trigger catastrophic thoughts about health problems, which in turn trigger anxiety symptoms. These anxiety symptoms can then lead to more catastrophic thoughts about health problems, which

trigger more anxiety symptoms… and so on. Although driven by your catastrophic thinking, you experience real physical symptoms.

Focussing on Symptoms

In Module 2, we discussed how a useful part of our fight/flight response is to focus on the thing by which

we feel threatened, and also, on ways of possible escape. We also talked about how hard it can be to draw our attention away from that threatening thing.  We used the example of coming across a snake in the bush from which we find it hard to look away.

Unfortunately, focussing your attention on something can sometimes amplify the intensity with which you experience that thing. Going back to our snake example, if you were to focus your attention on the snake you will become more aware of the size, colour and shape of the snake. You may also notice the sound of the snake as it moves across the ground. Overall, focussing more intensely helps you to evaluate and monitor the threat before you.

Similarly, the more you focus on your symptoms, the more aware you will become of the peculiarities of that symptom. Unfortunately, focussing on a symptom can also amplify the intensity of that symptom and, in turn, create more concern about the symptom and increase your desire to focus on the symptom.

Try this exercise. Focus in on your stomach…notice all the tiny sensations you can feel…it might be tightness or gurgling or fluttering or something else…really hone in on any symptoms or sensations you notice in your stomach.  Stay with this for 1 minute. Now ask yourself whether you had noticed any of these sensations before you purposely focused on yourstomach?  Also as the time spent focusing on your stomach dragged on, did the

sensations get more or less noticeable?  Usually people find they notice a whole bunch of sensations they had not previously been aware of, and that these sensations seem to grow over the minute, as they pay more and more attention to them.

Take  a moment to write  down any symptoms, sensations or areas of your body that  you tend  to focus on regularly. When you are paying attention, what  do you notice most about that  symptom, sensation or body area? Is it the intensity? The level  of pain or discomfort? Whether it is staying the same or changing?

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Helping Health Anxiety

Checking and Reassurance Seeking Behaviours

To check on or ask for reassurance about things we are worried about is a normal human behaviour. Most people have thought to themselves “I’m not sure I locked the door properly”, then walked back and

checked or even asked a companion “Did I lock the door when we left?” Usually, this will lead to us feeling less anxious, and allow us to continue on with our everyday lives.

In terms of our health, we are actually encouraged to check our bodies and seek reassurance. For example, we are often encouraged to monitor moles for any signs of change, and women are frequently encouraged to check their breast regularly. We are then encouraged to contact a medical professional if we are concerned about our health, or notice any changes in our general wellbeing. Just like the previous example of checking whether we’d locked the door, checking or obtaining reassurance about ourhealth status will usually lead us to feel less anxious, and allow us to continue on with our everyday lives.

However, people who experience health anxiety tend to continue worrying about their health, continue to feel anxious, and therefore continue to engage in checking and reassurance seeking to try to reduce their concerns and unpleasant feelings.

People with health anxiety have reported engaging in frequent and repeated:

Checking in the mirror for signs of asymmetry, areas of discolouration, or new moles or lumps Poking, palpating or pinching of the skin, breasts, stomach or other areas of the body Examination of bodily excretions (e.g., saliva, urine, faeces) for signs of blood or infection Measuring parts of their body (e.g., using tape measure or callipers)

Monitoring of bodily processes (e.g., taking pulse, checking blood pressure) Weighing of their body or bodily excretions

Asking family members, friends, and health care providers about their symptoms

Researching their symptoms on the internet or in medical texts

Posting of their symptoms on internet sites to obtain others opinions about their symptoms

Requesting of medical tests or evaluations, and second opinions

In some cases, the efforts to check for an illness can bring about new and painful symptoms themselves. For example, when performing a breast self-examination, Sally noticed a bumpy area that she had not noticed before. Over the next two weeks, she continued to worry and began to push on and even squeeze the area to see if any of the lumps were getting any bigger. She also informed her boyfriend and mother about her concerns, getting them to also feel the lumpy area and asking them for their advice. Each day, the area became more and more tender and painful to touch, thus increasing her concern that something was seriously wrong.

Take  a moment to write  down any checking or reassurance seeking behaviours you have  engaged in. What were you looking for? What did you find?  Were  there any negative consequences of the checking or reassurance behaviours?

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Avoidance and Safety Behaviours

Whilst checking and reassurance seeking are designed to decrease feelings of anxiety that are already present, avoidance and safety behaviours are strategies used to try to prevent us from experiencing anxiety.

People who experience health anxiety will generally try to avoid the internal and external triggers we identified earlier in this module. To avoid internal triggers, you may avoid engaging in things that lead to changes in your physiological state. This could include: exercising, walking up stairs, drinking coffee, having sex, eating spicy foods, and drinking fizzy drinks.

To avoid external triggers, you may avoid a large range of potential people, places or situations which remind you of health issues. To name a few, this can include avoiding:

medical professionals or check-ups doctor’s surgeries

watching the news or reading the newspaper walking past funeral homes

writing a will

phoning for test results

eating foods close to the used by date

visiting a friend who has a non-infectious disease using public restrooms

watching medical dramas on TV

visiting a relative who has recently been sick not reading information provided by a Doctor

Avoidance means that in the short term, there are fewer reminders of health related issues and therefore less chance of feeling worried and concerned. However, in the longer term avoidance can keep your fears going, or even make them worse.

The term “safety behaviours” refers to a more subtle form of avoidance. To use safety behaviours means that you may not outrightly avoid something, but will only approach that feared place, person or activity if certain back-up plans are in place. For example, someone who fears contracting meningococcal disease may still goout in public and even attend medical appointments , but only if they are carrying hand sanitiser and antibiotics in their bag. Similarly, someone who is fearful of having a heart attack may continue going about their daily business, but only if they are around others and are carrying a mobile phone at all times in case

an ambulance needs to be called.

Engaging in safety behaviours only temporarily reduces your health worries and concerns. The next time you are confronted with a similar situation, you will feel the need to use them again and never learn that you can survive without them.

Take  a moment to write  down the things you might be avoiding because of your health fears. This  could include certain people, places, activities, objects, or even  foods. Also,  are there any behaviours you engage in to increase your sense  of safety in these situations?

Note: Although they could seem like opposite behaviours, you may engage in checking and avoidance at the same time. For example, you could be engaging in daily breast self-examinations, yet avoid telling others about your concerns or

going to the doctor to have them check you over. Alternatively, you may engage in only checking or avoidance, or a little of each of these. The combination of

checking and avoidance behaviours will vary from person to person.

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Putting It All Together:

Helping Health Anxiety

Model of How Health Anxiety is Maintained

It is quite normal to experience both internal and external triggers. So how do these triggers lead to health anxiety? Remember from Module 2, if you have already experienced a number of negative health experiences, you may be more sensitive or “tuned in” than others to noticing these internal and external triggers. This in turn increases your chance of “setting off” health anxiety.

Generally speaking, when confronted with an internal or external trigger, your health rules and assumptions become activated. By “activated” we mean that they move from being dormant to being switched on like a light switch. Once activated, your health rules and assumptions can start to affect how you think, feel, and behave in response to those triggers.

If you hold flexible and realistic rules and assumptions about your health, these internal or external triggers probably won’t worry you too much. For example, let’s say you notice pain in your joints, plus you hold the rule “If this pain gets worse or is still there in another week, then I will get the Doctor to check it out”. Such a rule is:flexible, in that it allows you to experience what may be normal bodily sensations, without excessive worry, checking, or medical opinion seeking, and is

realistic, in that it doesn’t discount the possibility that there may be a problem that could need medical attention.

However, imagine that you notice pain in your joints, plus hold the unhelpful health assumption “All discomfort and bodily changes are a sign of serious illness”. How might

you then respond to that pain in your joint? What might you start to think about that pain? How would you

be feeling each time you thought about that joint pain? How would you rate your chance of a good outcome should you even visit the doctor?

All-in-all, when you experience a combination of unhelpful health rules or assumptions plus internal or external triggers that draw your attention to health related issues, you are at increased risk for experiencing health anxiety. You are more likely to interpret bodily sensations or changes as a sign of serious illness, to misinterpret health related information, and to set off more physiological sensations each time you worry.

You may then engage in unhelpful efforts to control your anxiety or reduce your risk of disease. You may focus on your symptoms in an effort to monitor and evaluate any potential health threats. You may check or seek reassurance to increase your sense of certainty over your health status. You may also engage in avoidance or safety behaviours to stop your health anxiety from being triggered in the first place.

In the short term, these behaviours may provide a temporary sense of relief or control over your health concerns. However in the long term there can be negative consequences. For example, focusing on your symptoms can enhance the intensity of those symptoms. Checking behaviours may lead to tenderness or inflammation. Seeking and then being given medical tests may reinforce your belief that something is wrong. Researching your symptoms can alert you to catastrophic yet unlikely explanations for your symptoms. All of these behaviours create more worry and therefore keep your health anxiety going.

Also, avoiding or using safety behaviours can limit your ability to learn anything new about your health. For example,

If you don’t go to the doctor for a check-up, you don’t find out whether you do or do not have a health problem. You may therefore continue to worry about your health.

If you avoid people or places that you believe may make you sick, you never get to find out if this really does occur. So in the longer term you feel that you must continue to avoid it.

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The following case illustrates how this can develop in to a vicious cycle of anxiety.

Sarah was a 30yo woman who continued to visit her doctor complaining  of a sore throat. Sarah had read a magazine article about a person who had developed throat cancer despite never being a smoker. Sarah had worried ever since that she may develop or even already have this problem, and had begun to notice some unusual sensations in her throat region (i.e., tightness, a dry throat). On multiple occasions her doctor informed her that her throat “looked inflamed” but that there were no current signs of actual cancer. Her doctor told her not to worry about the soreness but rather to come back and see him if the symptoms got worse.

Unhappy  with her doctor’s response, Sarah began engaging in daily forced coughing behaviours to try to “bring up” as much phlegm as possible so that she could check it for signs of blood or infection. She would sometimes use her toothbrush to push on the back of her tongue so that she could check for areas of tenderness, and also engaged in regular palpating of her neck, checking

it for lumps and areas of tenderness. Sarah had difficulty concentrating and performing her job as

she continuously focussed on the unpleasant  sensations and spent time researching her symptoms and potential treatments on the internet. Sarah began to switch off the television whenever medical dramas or documentaries came on the television, stating that she didn’t need to be reminded of what the future may hold.

On the following page we have collated this information into a model, so that it is easier to see how Sarah’s health anxiety is being triggered and then maintained.

As you can see, Sarah is caught in a vicious cycle of worrying about her health, setting off more physiological symptoms (including anxiety itself), and engaging in efforts to control her worry and

symptoms which in the long term can keep the problem going. On the following page, there is a worksheet for you to collate your own example.

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Helping Health Anxiety

How Sarah’s Health Anxiety is Maintained


– Reading magazine article about a person with throat cancer

– Noticing unusual sensations in throat region

Activates unhelpful health rules / assumptions

– I must be symptom free to be healthy

– If I miss an important symptom, it could kill me

Unhelpful health related thoughts

– This is cancer, I just know it

– My doctor said the area is inflamed and to keep monitoring, so something serious is happening

Anxiety symptoms

Increased muscular tension, racing heart, dry mouth and throat

Focussing on


– Pays close attention to sensations in throat

– Notice all minor changes/sensations

Checking & Reassurance Seeking

– Checking tongue, phlegm,

throat region

– Seeking reassurance from doctor and internet

Avoidance & Safety Behaviours

– Avoids medical

dramas or


Short term consequences

Sense of relief or control over symptoms

Long term consequences

Focus on symptoms may enhance the intensity of symptoms

Checking (i.e., using toothbrush, coughing up phlegm, pressing on neck) may

lead to further inflammation and tenderness

Doctor and internet cannot provide complete reassurance

Avoidance limits opportunities to change perceived threat of medical dramas or documentaries.

Worrying continues and may increase. Anxiety symptoms increase. Increased

desire to focus on symptoms, check and seek reassurance, and to avoid or use safety behaviours.

Vicious cycle keeps going

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How My Health Anxiety is Maintained


My internal or external triggers…

Activates unhelpful health rules / assumptions

My health rules & assumptions (can be copied from last module)…

Unhelpful health related thoughts

What do I tell myself about my bodily sensations and changes?

What do I say to myself about information my doctor gives me or that I hear from other sources?

Anxiety symptoms

Physiological sensations I experience…

Focussing on symptoms

What am I focussing on?

Checking & Reassurance Seeking

e.g., body checking, reassurance seeking

from Drs or the internet

Avoidance & Safety Behaviours

People, places, things I avoid…or things

I feel I must do to confront these…

Short term consequences

e.g., sense of relief or control over symptoms

Long term consequences

e.g., thoughts, rules and assumptions remain unchallenged, anxiety continues

increased desire to focus on symptoms, check and seek reassurance, and to avoid or use safety behaviours

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Helping Health Anxiety

More Good News…

At first, it may look overwhelming to see how your efforts to try to control or reduce your worrying and symptoms can actually lead to them increasing. However, being able to understand what is keeping health anxiety going on a day-to-day basis lets you see where you can start to make some changes to break this vicious cycle.

The remainder of these modules will cover a range of cognitive and behavioural strategies aimed at gradually breaking down the unhelpful thoughts, behaviours, and rules & assumptions that can keep this cycle going.

Looking at the model, you may wonder why we don’t start at challenging the unhelpful rules and assumptions first. The reason we leave these until later is that they can be somewhat harder to shift than your unhelpful thoughts and behaviours (after all, these rules and assumptions may have been there for quite some time). We therefore come back to these towards the end of the modules once you have started to “wear down” the old maintaining cycle. We encourage you to commit to working through the modules, in order, and completing all of the exercises and worksheets, as this will bring you the most benefit.

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Module Summary

Health anxiety can be triggered by a range of internal or external triggers

It is quite normal to experience these internal and external triggers. However, when they are paired with unhelpful health rules or assumptions, they can lead to:

– negative health related thinking

– increased anxiety symptoms

– a narrowing of attention on to the feared symptoms

– checking and reassurance seeking behaviours, and

– avoidance and safety behaviours

In the short term, these behaviours may provide a sense of relief or control over symptoms

In the long term, these behaviours may lead to:

– increased focussing on symptoms

– more worry and concern about symptoms

– more anxiety symptoms

– tenderness or pain in the area being checked

– an increased desire to check and seek opinions

– increased use of avoidance and safety behaviours

Understanding what keeps our health anxiety going is the first step towards breaking this vicious cycle.

Coming up next …

In the next module, you will learn

how to start decreasing your focus on your health symptoms and worries.

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Coping with health anxiety
Improving Access to Psychological Therapies (IAPT)
Dr Brendan Hogan
Clinical Psychologist
Section 1: About health anxiety
What is health anxiety? 3
Physical symptoms: Are they real? 5
What keeps health anxiety going? 7
Section 2: What can be done to decrease health anxiety?
List the ways you have tried to help yourself and how effective these
methods have been 10
Stop trying to prove that nothing is wrong with you 12
Dealing with worries about your health 13
Stop asking for reassurance 16
Stop checking and monitoring your symptoms 17
Stop finding out as much as you can about illness 18
Stop avoiding things to do with illness 18
What else are you avoiding? 20
Additional forms 22
Evaluation form 24
About health anxiety
Most people worry about their health at some time. Usually people worry when they
experience physical symptoms, and most of the time, these worries go away. For
some people, though, the worries do not go away. These people worry that they may
have a serious medical condition. These worries may affect their lives in very
significant ways, leading to intense anxiety, panic attacks, feeling as though they
cannot cope, or sometimes even depression.
This booklet focuses on how health worries come about and what keeps them going.
It provides specific guidelines about what you can do to help decrease the anxiety
associated with your health and begin to take control over your thoughts and
behaviour related to your health.
What is health anxiety?
Health anxiety – as one would expect – involves intense anxiety about one’s health,
usually to the point that it produces significant distress or interferes with one’s day-today
functioning. Health anxiety involves either the fear that one has a serious
physical illness or the belief that one has a serious physical illness.
People who experience health anxiety usually experience several of the symptoms
and exhibit many of the behaviours listed below:
• Physical symptoms. There is a great deal of variety in the kinds of physical
symptoms experienced, but some of the most common include chest pain,
general aches and pains, sweating, trembling, headaches, numbness, and
tingling. For some people, the physical symptoms may take the form of a noticed
bodily change – for example, a lump or a bump.
• Interpretation of body sensations as indicating severe illness. This is the
most important aspect of health anxiety – the physical symptoms that are
experienced (eg, chest pain, lump or bump) are either feared or believed to be an
indication of a very serious medical problem.
• Physiological arousal. Due to the increased anxiety and the perception of
threat, the body becomes more aroused, producing physical symptoms of anxiety
(eg, increased heart rate, sweating, trembling, gastrointestinal disturbance, and
so on).
• Checking behaviours and increased focus on the body. People with health
anxiety very often actively check their body for signs of illness. Focusing on the
physical symptom(s) and monitoring the body for any physical changes are
• Reassurance-seeking from doctors. Motivated by their concern that their
health is seriously in danger, people with health anxiety often seek medical
consultations and examinations in hopes of easing their fears. Medical
appointments may be made with increasing frequency, and the opinions of
multiple doctors may be sought.
• Reassurance-seeking from family and friends. People with health anxiety will
often mention their symptoms to their family and friends and ask for opinions
about whether they are really all right.
• Spending a lot of time finding out about illness. Some people are so
concerned about the possibility of illness that hey read a lot about illnesses and
check out their symptoms, for example in a medical encyclopaedia, or in
magazine articles, or on the internet.
• Avoiding things to do with illness. Quite frequently, people with health anxiety
will stop watching programmes on TV that might mention their feared illness, or
stop reading newspapers or magazines, or even stop talking about the illness
they are worried about.
• Other avoidant behaviours. Many people stop engaging in activities that they
fear may put their health at further risk. Behaviours such as walking, sports, and
other forms of exercises are avoided. Other people may go to bed or sit down
whenever they notice a physical symptom.
To give you a better idea of what health anxiety is all about, here is a case
Mary is a 36-year-old woman who works full-time as physiotherapist. She gave up smoking ten years
ago. Over the past six months, she has become increasingly concerned that she may have lung
cancer. The onset of her anxiety about her physical health seemed to coincide with an increase of
stress at work as her patient load was growing quite large.
Mary noticed that she was getting pains in her chest. Other times she noticed that it was becoming
more difficult to breathe easily. She went to her GP, who told her not to worry. When her symptoms
did not improve, she returned to her GP, who did some tests. When the results of the tests came
back, her GP told her that she was fine. She felt better for a few weeks, but then the pains and the
breathing difficulties returned. This worried Mary more, and she started to read about the symptoms of
lung cancer on the internet. She found that this increased her anxiety significantly, and that she could
not stop thinking about her chest pain and breathing difficulties, and spent a significant amount of time
worrying that she had cancer. She began to avoid reading about cancer in magazines, and would turn
off the television if she suspected that cancer might be discussed on a programme she was watching.
Mary returned to the doctor several times; this seemed to provide some immediate relief, but the
doubts would start to creep back a few days after the visits. She began to ask her husband whether
he thought she had lung cancer. She kept a very close eye on her symptoms. She would sit or lie
down whenever she noticed chest pain or breathing difficulties. She stopped exercising, and went out
less and less. Her level of distress increased as her worries about her health continued to plague her.
Mary had several of the above symptoms.
• She had physical symptoms (chest pain, difficulty breathing) and worried a lot
about them.
• She feared that her physical symptoms were an indication that she had a
serious medical problem – lung cancer.
• She focused on her physical symptoms and monitored them.
• She sought reassurance from her GP and from her husband.
• At first, she looked for information about lung cancer on the internet, but when
she discovered that this increased her anxiety, she started to avoid anything
to do with cancer at all.
• She stopped engaging in activities that she thought might risk her health or
aggravate her symptoms, and would sit or lie down every time she noticed the
physical symptoms.
Look again at the list of features of health anxiety. Put a tick beside any of the
symptoms you have experienced or behaviours that you engage in.
Physical symptoms: Are they real?
Physical sensations are very real. However, they may arise from a number of
different causes. One cause is illness. Other causes include normal changes in the
body, stress, and worry.
The human body undergoes lots of physical changes every day. Most people
experience aches and pains and unusual sensations at some point; these changes
are sometimes noticed, and sometimes not. When they are noticed, some people
attribute the change to the game of golf they played yesterday, or what they ate for
lunch. Or they brush it off as a normal change in their body that will probably
disappear in the near future. Sometimes physical changes and sensations that are
experienced are due to the effects of a relatively minor health problem, like a cold or
the flu – when people recognise this, they usually do not worry that these symptoms
are a sign of serious illness. However, some people interpret the physical changes
or sensations they experience as indicative of a serious health problem – this leads
them to focus on the symptom and to start to worry a lot about it.
When someone has been stressed or worried, they may experience symptoms that
are a direct result of the stress and worry. Some of the physical symptoms that are
caused by anxiety, stress, and worry are listed below:
If we think back to Mary’s example, she experienced chest pain and difficulty
breathing. These symptoms may have been the product of anxiety, but they were
interpreted as signs of a serious illness (e.g., cancer) and Mary’s thoughts were
something like “I am very ill”. These thoughts led to more anxiety, which caused
more physical symptoms….and so on, in a vicious circle.
Here is a diagram of “the vicious circle of health anxiety”:
Normal body sensations
Physical symptoms
(eg, chest pain, headache)
Anxiety (“I have cancer”,
“I am ill”, “I may die”
“I will be unable to work”
Symptoms of anxiety
• Heart rate increases (feels like the heart is pounding)
• Heart palpitations (feels like the heart “skips a beat” or “flutters”)
• Chest pain
• Breathlessness
• Perspiration (increased sweating, sweaty palms)
• Dryness of the mouth
• Dizziness
• Tingling sensations
• Aches and pains
• Tiredness
• Legs feel shaky, weak
• Trembling
• Digestive disturbance
• Headaches
Physical symptoms are very real. They may be caused by illness, or
by a normal bodily change, or by stress or worry. The symptoms
caused by stress and worry are just as real as those caused by
illness. They are not in your head! However, the way you interpret
the physical symptoms can become a major problem and may serve
to aggravate the symptoms you are experiencing.
What keeps health anxiety going?
Many of the things that people do to cope with health anxiety actually serve to keep
the anxiety going. Think back to the list of symptoms and behaviours associated with
health anxiety. Many of the behaviours listed there are really things that people who
worry excessively about their health do in an effort to cope with their anxiety. But do
these strategies work? Many, if not all, of these strategies are helpful in the shortterm
– that’s why people do them. Unfortunately, they actually serve to keep the
problem going.
Checking behaviours and increased focus on the body. Constant monitoring and
checking of physical symptoms may seem like a good idea – that way, you notice
even the slightest twinge, and you will notice a small change in the severity or
intensity of a physical sensation. While it is wise to be aware of how you are doing
physically, it is actually not helpful to pay close attention to your body at all times.
This is because your body naturally fluctuates during the day and the night, and over
time. Thus, noticing every little change provides very little useful information. And
worse – any change that is noticed is worried about, and as worry increases, physical
changes and symptoms tend to get worse, and as this happens, checking and
monitoring increases even more. In other words, checking and monitoring your body
feeds into the vicious circle of health anxiety.
The more you think about something, the more you notice it. Think about buying a
new car. You decide on a make and a model. You may suddenly find that you notice
that kind of car everywhere. Has the number of that kind of car increased? Probably
not – you are now noticing these cars because you are thinking about them so often.
The same thing can happen with physical symptoms – the more you think about
them, the more you notice them, even though they have been there all along.
Another problem that some people run into is that they engage in more than a just
“mental scan” of their body – in addition, they may poke and prod themselves to
check for changes, or do things like swallow repeatedly to assess the severity of
throat pain. These kinds of behaviours can also make the health anxiety worse by
aggravating the symptom that is worried about. For example, imagine repeatedly
touching and pressing on one spot on your arm. After a while, your arm would start to
hurt – even if it didn’t hurt in the first place. Keep touching and prodding, and the skin
may turn red and it may feel swollen. In this case, you would have produced the
symptom that you feared!
Reassurance-seeking. People with health anxiety are likely to seek reassurance
about their health from doctors, and they sometimes even check with their family and
friends. In most cases, these people are told that nothing is wrong. This quickly
makes them feel better. But…it doesn’t take long until the anxiety returns. The
reassurance doesn’t last. What happens in the long term? Reassurance tends to
encourage preoccupation with health. For example: You think about and notice
symptoms, they worry you, so you visit your GP. He or she tells you nothing is wrong,
so you feel better. But it isn’t long before you notice more symptoms, and the worry
returns. What happened to the original reassurance? It seems to have lost its
punch…so you go back to the doctor. And the vicious circle continues. No amount
of reassurance seems to be enough.
A question for you to think about: How much reassurance would it take to make you
stop worrying about your health forever?
It may be difficult to come up with a precise answer. This is because seeking
reassurance is a strategy that doesn’t work well in the long term – no amount of
reassurance is enough to convince you in any lasting way that nothing is wrong.
Spending a lot of time finding out about illness. Some people with health anxiety
read a lot about their feared illness (or illness in general) and check out their
symptoms, for example in a medical book, on the internet, or in magazines. This
kind of behaviour can be a problem for several reasons. First – it is another example
of paying too much attention to your health. Sooner or later you will find reference to
a symptom that you have – a symptom that is not due to you being ill, but due to a
normal body change or sensation, or a symptom that is produced by anxiety. The
more attention you pay to that symptom, the more you worry…and so on. In addition,
reading about illness can cause you to focus even more on your body, and notice
even more sensations. A second problem is that sometimes people read up on
illnesses as a way of seeking reassurance that they are not ill. And as we discussed
above, the benefits of reassurance are short-lived and tend to keep the anxiety
Avoiding things to do with illness. Avoiding information about illness can also be
a problem. Some people stop watching programmes on TV, or reading articles in
magazines or newspapers, about the illness they fear most. This can have the
immediate effect of stopping their worries. But what happens in the long term? The
worries persist. This is because they do not face what worries them and get the
worries into proportion.
Other avoidant behaviours. Some people avoid physical activities to protect
themselves from illness. Other people will go lie down every time they notice a
symptom. Not only does this kind of avoidant behaviour make your life less
enjoyable and interesting, but it contributes to you becoming less physically fit. As
your fitness declines, you become more likely to tire quickly from any sort of exercise,
and may tend to lose your breath more easily. This may end up confirming your
worries about your health, and lead to you reducing your activities further. This is
another example of a strategy to cope with health anxiety making the situation even
Here is a model of the vicious circle of health anxiety that takes into account these
In summary: The strategies that you use to cope
with anxiety about your health may actually be
making your anxiety worse and keeping the
problem going. You started using these strategies
for a reason: they work in the short-term. But what
about the long-term?
(illness, normal body sensations, stress, worry)
Physical symptoms
(eg, chest pain, headache)
Interpretation of bodily sensations Perceived threat
as indicating severe illness (Thoughts: “I may be ill”)
Leads to….
Physiological arousal
Preoccupation with perceived Increased focus on the body
alternation/abnormality of Checking and monitoring
bodily sensations Reassurance seeking
Seeking information
Avoidance behaviours
This model helps illustrate that your preoccupation and anxiety about your health is
aggravated by some of the things that you may be doing to cope (like reassurance
seeking and checking/monitoring your symptoms). Increasing your anxiety level can
increase your physical symptoms, which further convince you that you are seriously
ill…and the cycle continues.
What can you do to decrease health anxiety?
First and foremost, it is good idea to think about what it is that you want to change.
One very important thing to remember is that the aim of helping you cope with
your health anxiety is not to make the symptoms disappear. Remember that
changes in your body and a wide range of physical symptoms are perfectly normal.
In addition, anxiety produces a host of physical symptoms that can be misinterpreted
as an indication of serious illness. You cannot avoid the fact that is natural for your
body to undergo changes and for you to experience physical sensations, nor can you
completely eliminate anxiety from your life – as such, you will never be free of
symptoms. What is the aim, then? It is to help you become less worried about
your health. All kinds of symptoms may make you worry – and worrying may
produce lots of symptoms. If you can reduce the amount of worrying that you do, you
will very likely start to feel much better.
2.1 List the ways you have tried to help yourself and how effective these
methods have been
You have probably used many strategies in an effort to ease your anxiety about your
health. Make a list of things you have done to try and help yourself. After you have
made the list, think about how helpful what you have done was in terms of 1)
reducing your anxiety at the time, and 2) reducing your anxiety in the long-term. Give
each a rating between 0 and 10 for how effective the strategy was at the time, and in
the long-term (0 is not at all effective, and 10 is very effective.)
Here is a list using Mary’s example:
Ways I have tackled my
worry that there is
something wrong
How effective was this
strategy at the time?
How helpful was this
strategy in the long
Going to the doctor
Having tests
Talking about the
symptoms with my
Looking up symptoms on
the internet
Avoiding TV programmes
and magazine articles
about cancer
Avoiding exercise
Notice that most of the things Mary had done to try to help herself made her less
worried in the short term, but in the long term they didn’t seem to work at all. These
strategies did not really help her address her persistent worry about her symptoms.
Your list:
Ways I have tackled my
worry that there is
something wrong
How effective was this
strategy at the time?
How helpful was this
strategy in the long
Stop trying to prove that there is nothing wrong with you
Look again at the list and rankings you just made. Your efforts at proving there is
nothing wrong really aren’t working for you in the long term, are they? In fact, these
strategies actually help keep the problem going.
No one can say with absolute certainty that nothing is wrong with you. Your doctor
can tell you that you are definitely ill – medical exams and laboratory tests can prove
this. But can any doctor or any laboratory test avoid ever making a mistake?
Unlikely. Can they guarantee that you will never become ill? No. We all have some
chance of developing illness at some point in our lives. But the chance of this may
be much less than we think.
The question you must ask yourself is:
Do you want to spend your time worrying about the possibility of illness, or do
you want to get on with your life?
There will always be uncertainty about your heath. But just because something
might happen, does not mean that it will.
Take a pen or pencil and write down your answers to these questions:
What are your worries about your health? (For example: “I am worried that I
have cancer” or “I am worried that I will get heart disease and then be unable
to take care of my family”)
Do you know for certain that you have this illness? (Being certain means that
your doctor has told you so.)
If your answer is Yes: follow your doctor’s advice. If you want, keep
reading – some of the strategies here may still help you.
If your answer is No: (if you are uncertain or know that the answer is
no) then move on to the next question.
Is there anything I can do about my worry – for example, change my diet or
If your answer is Yes: then start now. Move on the next step.
If your answer is No: it’s time to work on reducing your worrying. Move
on to the next step.
Dealing with worries about your health
A very important first step is to start thinking about other possible explanations for
your physical symptoms. Is it possible that these symptoms are a sign of something
other than illness? Remember – rather than there being something seriously wrong
with your health, the problem very well may be that you are very worried that
something is wrong. The worry in itself may be causing you a lot of problems. So – a
useful strategy may be to move the focus away from worrying about whether or not
you have a disease and toward the worry.
The symptoms you have may be a sign that you have a serious illness. More likely is
that they are not. Many symptoms can be caused by changes in your body that are
normal, not dangerous. Being worried and anxious can cause you to feel quite ill,
and cause you to experience lots of physical symptoms.
Try this exercise.
Write down all the evidence that indicates that you are seriously ill. Then ask
yourself whether the symptoms could be caused by something else (like worry or
anxiety). Write down all the other possible explanations of your symptoms. When
you are done, think about which explanation you think is the most likely. Give a
percentage rating of how like you think each explanation is.
Mary’s example:
Evidence that I am seriously ill. Evidence that I am not seriously ill.
I have chest pain.
I’m very stressed at the moment – maybe
this is causing the chest pain.
The chest pain goes away if I lie down or
focus on breathing deeply – lung cancer
pain wouldn’t go away so easily.
Just because cancer was on the news
tonight does not make it any more likely
that I have cancer.
There is a chart for you to record your evidence at the back of this booklet.
What exactly are your worries about your health? Worries about health anxiety tend
to have certain characteristics.
• Worrisome thoughts tend to overestimate the likelihood of danger
• Worrisome thoughts tend to overestimate the severity of any possible problem
• Worrisome thoughts tend to underestimate our ability to cope with the problem
For example, Mary might worry think that she was very likely to get cancer (in fact, in
her mind, it might be a certainty), that her symptoms were a sure indication that she
did have cancer, that that if she did get cancer, it would be the very worst and most
incurable form of cancer, and that the cancer would incapacitate her and she would
lead a lingering and painful death and be unable to take care of herself, both
emotionally and physically. Not surprisingly, extreme thoughts such as these cause
more anxiety – which can cause more symptoms – which makes the anxiety even
worse and more out of proportion.
You have had some practice looking at evidence for and against you having a
serious illness. Now you may want to try to challenge some of your thoughts about
Follow these steps in completing a “thought chart”.
1. Write down exactly what your worrying thoughts are.
2. Rate (on a scale of 0-100) how much these thoughts worry you.
3. Go through evidence for and evidence against each thought, and then come
up with an alternate thought that is more realistic.
Have a look at Mary’s thought chart:
Worrying thought How worried was
I? ( 0-100)
Alternate, more
rational, thought
New rating of
worry (0-100)
My chest pain
means that I have
lung cancer.
100 My chest pain is
probably due to
anxiety, not lung
cancer. I’m more
aware of it right
now because I saw
a bit of a TV
programme on
There is a thought chart for you to complete at the back of this booklet. It is a very
good idea to keep a diary of your worrying thoughts and your alternative thoughts.
You should bring the diary with you wherever you go, and practice challenging your
worrisome thoughts as often as you can.
Need some proof that your physical symptoms may be due to something other
than a serious illness?
Here are some strategies:
1. Give a physical symptom that is bothering you a severity rating from 0-100.
2. Spend five minutes focusing on nothing but the physical symptom that is
concerning you. Keep all your attention on the symptom.
3. At the end of five minutes, record what happened to the symptom. Did it get
worse? Better? Give it a rating from 0-100.
4. Spend five minutes doing something else completely different. For example, try
taking out a piece of paper and writing down, in detail, what the room you are
sitting in looks like.
5. At the end of five minutes, record what happened to the symptom. Did it get
worse? Better? Give it a rating from 0-100.
6. Compare the ratings. What happened when you were concentrating on your
symptom compared to when you concentrated on something else?
Many people find that their symptoms increase in severity and/or that they notice the
symptoms more when they are focusing on them. When they turn their attention to
something else, they stop noticing the symptom or it seems to feel less intense.
What does this tell you about focusing on your body sensations?
Some questions to ask yourself:
Am I overestimating the risk here?
Could my symptoms be related to something else besides illness?
Am I underestimating my ability to cope?
What would I say to myself if I was not so worried?
What would you tell a friend if they had this worry?
What would a friend tell you about this worry?
Stop asking for reassurance
We all need reassurance about our health sometimes. When people feel ill or notice
unusual changes in their body, it is appropriate to seek advice from a doctor or to
mention the symptoms to a friend or family member. Having a doctor tell you that
there is nothing to worry about, or talking over worries with friends and family can be
very reassuring. However, too much reassurance means:
• You become preoccupied with your health.
• You no longer believer the reassurance, and as a result, you need
more and more reassurance to reduce your worry.
• You look to others to reassure you, when it is more helpful to
reassure yourself.
In the long run, reassurance does not work for people with health anxiety. Most of
the time, it makes things even worse.
How do you stop? First of all, when you feel worried about your health, try not to ask
for help from anyone else. You might even want to talk to your friends and family
about this decision before you take action – let them know that if you do ask for
reassurance, they should help you by not “reassuring” you. Perhaps you could ask
them to change the subject if you ask, or remind you that you made an agreement
that they would not answer you. This may make you feel more anxious in the shortterm,
so it may be important to plan for another way to deal with your worrying
thoughts. A good idea for distraction is to do something else: go for a walk, clean the
house, or read a book. Find something that works for you – something that you can
easily do when you re tempted to talk about your health.
It is a good idea to keep a record of how often you ask for reassurance or talk about
your health. If you are not given reassurance, you will discover that you gradually
stop asking for it less often, and start to feel less worried.
Mon. Tue. Wed. Thu. Fri. Sat. Sun.
Number of
times I ask
How worried
I felt (0-100)
Keep a diary like this for several weeks, and review what happens to your level of
worry as you refrain from asking for reassurance.
Stop monitoring and checking your symptoms
Monitoring and checking your bodily state is sensible, as long as it is not done in
excess. For example, doing monthly (not daily!) checks for lumps in breasts is a
procedure recommended by doctors. It is not helpful to pay attention to your health
at all times. You have seen how worrying about your health can make you aware of
even the smallest change in your body and make you notice every sensation. It is
also not reasonable to check every lump and bump on your body multiple times a
day – remember, poking, touching, or squeezing a lump can make it swollen and
sore, and chances are that this will make you even more worried!
How to stop monitoring and checking your symptoms:
1. Decide how much checking is reasonable. Ask your doctor for some
advice, or check with friends or family to see how often they check or monitor
their bodies.
2. When you are tempted to check – DON’T! Not checking and monitoring
your body will probably make you more worried in the short-term. This is a
good time to use your distraction strategies, to help take your mind off your
1. Checking may be like a bad habit for you. If so, you may need some practice at
stopping. You may want to ask your family or friends for help – perhaps they can
remind you if they see you checking your symptom, or maybe that help distract
you when you find yourself starting to worry.
Too much information about your health can make you more aware of every
symptom and change in your body. Most symptoms can be caused by many
different things – and many symptoms are nothing to worry about at all. Trying to
diagnose yourself can be incorrect and very worrying.
• Stop reading medical books or encyclopaedias, and stop looking up your
symptoms on the internet.
• This may increase your worry in the short-term – but remember, it will help
decrease your worry in the long-term.
• When you feel the urge to “research”, use distraction to help take your
mind off it.
• Ask your friends and family to remind you stop.
Again, keeping a diary can be helpful. As you spend less time finding out about
illness, you will find that you worry less about your health.
Mon. Tue. Wed. Thu. Fri. Sat. Sun.
Tips for distracting yourself
• Do something else. Physical activity may be helpful – try going for a walk or a swim, or do
some gardening or cooking. Whatever you like to do! Reading a book or listening to the
radio may also be helpful.
• Pay attention to something else. Notice what is around you, either in the room or outside.
Describe the picture in great detail, or try something like counting how many green things
that you see. The more detailed the task, the more distracting it will be.
• Do a mental exercise. Mental arithmetic works for some people – try counting backwards
from 500 by sevens. Think of a fun holiday you have had, or imagine your favourite place.
• Talk to someone else. Get them to help distract you! If you need to, call a friend or family
member. You don’t need to tell them that you want them to distract you – as long as you talk
about something other than your health, it may help take your mind off your worries.
Number of
times I
found out
worried I felt
Try keeping this diary for a few weeks, and watch what happens to your anxiety as
you stop spending so much time finding out about illness.
Stop avoiding things to do with illness
While some people spend too much time finding out about illness, other people avoid
any information at all about health (or their feared illness) because it increases their
anxiety. You may find that you avoid TV programmes about your feared illness, or
avoid reading articles in the newspapers or magazines. Again, this decreases
anxiety in the short-term, but increases it in the long-term. So what can you do?
Make a list of the ways in which you have been avoiding information about your
feared illness. Rate for each how strong your avoidance has been (0 = not very
strong at all, 100 = very strong avoidance). Start with the one you have avoided the
least, and plan to spend a little bit of time doing just this. When this one feels more
manageable, move on to the next one, and gradually work your way up the list.
Here is Mary’s example:
What I have avoided How much I avoided it
Watching TV programmes about cancer
Reading articles about cancer in the
newspaper or in magazines
Listening to other people talk about
Mary would start this exercise by not walking away when she hears other people
talking about cancer. For example, at first, she might try to stay in the conversation
for five minutes, then move up to five minutes. When this feels manageable, she
might try to read a short article on cancer in the newspaper, and then try a longer
one. And so on. When she finds a task to be anxiety provoking, she may have to
challenge her worrisome thoughts about anxiety (see section C).
Make your own list here:
What I have avoided How much I avoided it
It is a good idea to keep a record of your anxiety levels as you tackle each of these
What else are you avoiding?
Are you avoiding physical activity or exerting yourself? Are you sitting or lying down
whenever you notice a particular symptom? The trouble with stopping your normal
activities is that it decreases your fitness level – this can make you feel unwell, tired,
and aching. When you try to exert yourself, you will feel even worse. This is not due
to illness, but do to you becoming less fit – but when you notice these things (eg,
fatigue, breathlessness when you increase your activity level), you may misinterpret
them as signs of illness. This may make you slow down even more – and the vicious
circle continues.
• Resume physical activities slowly. If you have been inactive for a while, you
won’t be able to as much as you once could. You will have to ease back into it.
• Make a list of the things you used to do that you would like to do again. Put them
in order, with the one requiring the least energy first, and finish with the one that
requires the most effort.
List of activities I have been avoiding
• Spend a little bit of time doing the activity you put first on your list. Do this gently
– for example, if you wanted to go for a walk, you may want to start with a five
minute walk. When you feel comfortable, take a longer walk.
• When you feel comfortable with that activity, move on to the next one on your list.
Remember to ease yourself into it.
• Go through the list of activities, one by one.
This booklet has provided you with information about health anxiety, and what
you can do to help reduce this anxiety. Getting over health anxiety takes a lot of
work. It is a good idea to work through these exercises slowly – at your own
pace. Keep a record of your progress (for example, a record of your daily anxiety
levels) – this way, you can look back at what has happened as you complete
more and more of the exercises. Challenging your thoughts about illness can be
very helpful – this is a skill you can use when you are trying the other practice
exercises. Remember that you are not trying to get rid of the physical symptoms
– the goal is to reduce your anxiety about these symptoms.
Evidence that I am seriously ill Evidence that I am not seriously ill
Worrying thought How worried was I? ( 0-
Alternate, more rational, thought New rating
of worry

Manual evaluation
We would be very grateful to hear about what you think of this manual. It is an
evolving document and we will attempt to incorporate people’s suggestions.
Are there any parts of the manual that are unclear or difficult to understand?
Are there any parts that were very useful for you?
Do you have any suggestions that would make the manual more effective?
Any other comments:
Please detach this page and send it to:
The Primary Care Psychological Treatment Service
(Panic Manual)
Department of Psychological Treatment Services
Box 190 – S Block
Addenbrooke’s Hospital
Cambridge CB2 2QQ
Thank you.
The Patient Advice and Liaison Service (PALS) provides service users, their carers and
families with help, information and support to resolve concerns quickly and efficiently.
Freephone: 0800 376 0775
Tel: 01223 726774
Cambridgeshire and Peterborough NHS Foundation Trust
HQ Elizabeth House, Fulbourn Hospital, Fulbourn, Cambridge CB21 5EF
T 01223 726789
F 01480 398501
Reprinted January 2010


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