Health Anxiety & Medical Professionals: A Treatment Primer

Health anxiety is a well-known form of mental distress. Individuals with health anxiety tend to be hyper-attuned to the way their body feels at any given time and are chronic WebMDers (or, nowadays, chronic ChatGPTers). Health anxiety is frustrating for many healthcare professionals. Patients with health anxiety tend to become Doctor’s office regulars. No matter how many times a doctor reassures a patient that they’re ok — that they don’t have cancer, or that no further tests are warranted — odds are they’ll be back. In a week, or a month, something else will feel off. Something else will feel wrong. They’ll notice a new symptom, plug it into ChatGPT, and decide that, this time, it’s serious. How should health care professionals handle these chronic patients? What will satisfy these patients that, really and truly, everything is ok? To answer this question, we first need to understand what’s going on. We need to understand what health anxiety is and what maintains it.

What is Health Anxiety?

Health anxiety is a form of OCD, a mental disorder characterized by an intrusive experience (most often an intrusive thought) that the individual experiences as distressing, and repetitive physical or mental behaviors (compulsions) enacted to relieve this intrusive experience. Compulsions bring temporary relief, but do not permanently relieve obsessions. This causes individuals with OCD to get stuck in a loop, where they enact their compulsion over and over again in an attempt to make their obsessions go away. This obsessive-compulsive cycle can easily be identified in individuals experiencing health anxiety. It starts with a perceived health symptom. As an example, let’s say the symptom is a headache. The patient wonders what this headache is, and whether or not it might portend a serious illness. This is the intrusive thought, and it might sound something like, “I have a headache. What if that means I have brain cancer?” The patient runs to the most readily available resource — the internet — in an attempt to answer this question. Of course, they find that headaches are indeed sometimes a symptom of brain cancer. This spikes their anxiety and so they dig deeper, hoping to find relief in some corner of the internet. They find plenty of information telling them it’s ok, and that most headaches are benign. But, this only reassures them briefly. The next Reddit horror story is just around the corner. And so, finding no lasting relief on the internet, they turn to the last resort for reassurance — their doctor. They come to the doctor full of worries needing relief. The doctor offers relief, and it feels better than WebMD, but it’s not enough. The what ifs remain. Doctors have been wrong before, and will be wrong again. What if this is one of those times? What if I have something so rare that only a specialist could recognize it? What if the tech mixed up lab results? The patients pushes up the reassurance ladder, asking for another appointment, a referral for a specialist, a different test. This is why reassurance does not work with individuals who have OCD. OCD seeks certainty, and complete certainty is not something any human being can provide. As mentioned above, even the best doctors in the world are wrong sometimes. An individual with OCD will find these small chances of “wrong”, and blow them up to catastrophic proportions. They’ll then seek for higher and higher levels of reassurance. Unfortunately, the only kind of reassurance that would satisfy them, 100% certainty, is an impossibility. Even if, after their race up the reassurance ladder, they actually do feel reassured, and are able to put the worries about brain cancer to bed, that lasts only until the next “new” symptom pops up. The cycle then repeats all over again. But, there is a way out of the cycle, and medical professionals have an important role to play when it comes to breaking it.

As discussed above, reassurance gives oxygen to the fire that is health anxiety. It is important for medical professional to notice this, and actively avoid reassuring their hypochondriac patients. This might look like telling a patient something like, “The test came back negative, but you’re right, tests can be wrong sometimes.”, or “All the medical expertise in the world tells me you don’t have cancer. But, I could still be wrong.” It is, of course, important for patients to understand why you’re doing this, why you aren’t giving them reassurance (beyond what is reasonable for a “normal” patient). You’re doing this because stopping compulsions is the best way out of the OCD cycle. Otherwise, the patient will remain trapped in a world of “what ifs”.

Anti-reassurance alone is not sufficient to combat health anxiety. This is where therapy comes in. We have excellent therapies for health anxiety. My preference, and what I find works best with most patients, is value-based exposure therapy (ACT-informed ERP). Exposure therapy is the classic cognitive-behavioral therapy used to treat OCD, anxiety, and phobias. It is predicted on the idea that the way out is through. We move past our fears by confronting them. This allows our brain to learn that the thing we feared is actually not as scary as we thought, and- even if it is- we are the kind of people who can stand it. However, exposure therapy is hard. It asks patients to do the opposite of what every fiber of their being is telling them to do. This is why values are an important addendum to exposure therapy. Patients need identifiable reasons to do exposure therapy, reasons so important to them that it makes willingly walking towards their fears “worth it”.

What it might look like

Exposures look different for every patient, but some general areas of exposure for a patient with health anxiety might be interoceptive and existential exposures. Individuals with health anxiety tend to be big somaticizers- meaning they have a hyper-awarenesss of the physical sensations in their body. Interoceptive exposures are essentially designed to help somaticizers tolerate the discomfort associated with these bodily sensations. A common interoceptive exposure might ask a client to spin in place for thirty seconds, abruptly stop, and then practice tolerating the experience of dizziness. Over time, intercopetives help patients learn to see somatic sensations as nothing more than the errant, meaningless quibbles of the human body that they are.

Existential exposures have to do with what Irvin Yalom termed the “givens” of existence, the inescapable aspects of human existence that plague most of us during a dark night of the soul. Perhaps the greatest of these givens is the fact of death. Human beings die. You are a human being, and one day you too will die. This is a fact many patients with health anxiety have a very difficult time tolerating. It could be argued that the theatrics of health anxiety are nothing more than a desperate attempt to reassure the patient against death. Existential exposures are about confronting, and learning to tolerate, these sorts of fears. This could be as simple as a patient writing the word “DEATH” or the sentence “I WILL DIE” over and over again, and tolerating the feelings that come up. This will not make the fear or discomfort surrounding death go away. But, overtime, it will make it tolerable.

Values come into play early on in this process, as part of the intention-setting for exposure therapy. Usually, I see values as the proverbial carrot I’m offering to patients. As an example, let’s say a patient identifies family as their top value. I would spend time with this patient pointing out all the ways in which their health OCD moves them further away from this value. It leads to countless hours spent querying chatGPT, hours that could be spent with the family. And, on top of that, the hours that are spent with family are probably spent by the patient in a fog of anxiety. It’s hard to be fully present with our loved ones when we’re anxious. Exposure therapy, then, becomes about not only “treating” anxiety, but also about moving closer to that which really matters in life.

I hope this helps paint a fuller picture of healthy anxiety, both in terms of its presentation and treatment. If you have any questions about health anxiety, please do not hesitate to reach out. I’m always happy to chat.

Jacob Weissman, Licensed Professional Counselor

jacob@journeysbridge.com

281-241-8172