Exposure and response prevention.
There is an old joke about doctors:
“Doc, it hurts when I do this.”
“So, don’t do that.”
A version I hear frequently:
“Doc, I get upset when I read about all the side-effects of these drugs.”
“So, don’t read about the side-effects.”
Neither response makes much sense. Someone who tries to avoid learning about the side-effects of drugs would have to turn away whenever a drug commercial is shown on television. Other things that would have to be avoided include:
The science section of the newspaper. New drug treatments are reported all the time, along with the drugs’ side-effects.
The druggist, who may think it is his job to inform the patient of possible drug interactions and other potential problems.
People who are sick—or have been sick—since they are likely to mention drug side-effects they have experienced.
And isn’t it sensible for patients to know about the possible side-effects of drugs they take? If there is, in fact, a danger in doing something, isn’t it sensible to know about those possible dangers? On the other hand, does it make sense to avoid a drug because it may cause a side-effect?
The idea of avoiding learning something because the process of learning is painful would not be accepted in most other contexts. A child afraid of going alone to kindergarten is encouraged to go anyway. Indeed, children are told they must accommodate themselves to the idea that they will attend school whether or not they are afraid. They are also told, truthfully, that when they get used to going to school, they will no longer be afraid.
Children who have irrational (unjustified) fears are routinely encouraged to confront their fears—sometimes a little at a time and sometimes with a supportive parent standing by. A child afraid of dogs is encouraged to approach dogs a little at a time, perhaps a puppy to start with, then a bigger dog, or a less familiar dog—and so on until the fear of dogs has evaporated. A child afraid of the monster under the bed is helped to look under the bed and discover that there is no monster there. Sometimes such a child has to look under the bed repeatedly before that fear is gone forever. If a parent decides to take such a frightened child into his/her own bed instead of looking with the child under the child’s bed, that fear will never go away. Similarly, a child afraid of sleeping in the dark should be led a little at a time to sleep in an increasingly dark room. Otherwise the child grows into an adult who still needs a light on in order to fall asleep—and this problem is seen not infrequently in people who have other phobias.
Similarly, a child who is afraid of falling off a bicycle, or afraid of going on a sleep-over date or away to camp, or, in later years, afraid of driving a car, will be encouraged by everyone to confront those fears rather than retreat into a way of living that may be more comfortable initially, but will terribly limit life and in the long run allow those fears to persist. There are, indeed, people who never learn how to drive a car.
The various anxiety disorders are treated with a program of graduated exposure to the fearful situation. An adult afraid of snakes, for example, is treated very much like the child who is afraid of dogs—exposure to the snakes a little at a time, closer and closer, over and over again. Agoraphobia, the most common and debilitating kind of phobia, is really a fear of the panic attack, which comes on unpredictably when patients are in a situation from which they cannot exit—or think they cannot exit. They not only have to go into those phobic situations repeatedly, they have to experience the panic attack over and over again in order to come to believe finally that it is only a feeling and will not lead to loss of control. If someone is afraid of bridges, no one would say, “Well, then, stay off bridges.” Everyone recognizes that the proper approach is to go on bridges over and over again, until they are no longer frightening. But, of course, when the bridge phobic first goes on to a bridge, his/her anxiety level goes up! No one regards that as too high a price to pay for getting over the phobia. Nobody expects that fear to stay at an elevated level with more experience.
The treatment for obsessive-compulsive disorder (ODC) is called “exposure and response prevention.” The patient is helped to confront whatever is upsetting to him or her—let’s say germs—without being permitted to avoid the accompanying shuddery feeling by washing or in any other way escaping that feeling. With time, the feeling, and the urge to avoid that set of circumstances, will go away. But initially, when the patient’s hands are covered with dirt, the anxious, shuddery feeling gets worse.
There is an underlying principle at work here: the more you experience a situation you think is dangerous—but which is not dangerous—the less afraid you will become. But, of course, when you initially put yourself in that situation, you become more afraid.
The condition we call health anxiety is manifested typically by patients imagining the worst possible disease to explain their physical symptoms. It appears along with exaggerated and inaccurate ideas about laboratory testing and the fear of drugs’ side-effects. And there are other such distortions. Among them is a misreading of the odds of an illness occurring. (See my book, “Worried Sick?”)
The Anxiety and Phobia Center at White Plains Hospital runs a clinic for health worriers. I tell the patients that in order for them to get better, they must read the drug inserts that upset them so much. They must read about the diseases they fear, even if they have been told they do not suffer from those conditions. They tell me, almost always, that whenever they do either, their fears get worse! I understand that, I try to explain, but getting more anxious initially is the first step in overcoming these fears. Usually, they say that they do read about these matters over and over again, and they still get worse. The problem is—they read the same things over and over again and never go further to learn what they need to learn to overcome these fears. It is not that they know too much, they know too little.
In the matter of drugs’ side-effects, they need to know how common a particular adverse reaction is. And they need to know just how these lists of drug reactions are compiled. (It is not the case that all the side-effects listed are, in fact, side-effects of those drugs.) They could be a placebo response. These patients need to know how commonly these reactions occur on the placebo arms of the medical studies that underlie these reports. I try to convince them that possible side-effects are not a reason to avoid a drug; they are, if they occur, a reason to stop taking them.
In the case of the serious illnesses they worry about, they have to get past their initial scared feelings when they read about how awful these conditions can be. They need to learn whether or not they have all the other symptoms of these conditions and whether or not the particular symptom they think they have occurs by itself in that illness. Very often it does not. Similarly, some of the conditions they worry about are actually impossible in their circumstances. When I had health anxiety in medical school, for instance, I discovered that a particular disease I was worrying about occurred only in middle-aged women. (Students worrying about having serious illnesses is called “medical students’ disease,” not “doctors’ disease,” because, unlike doctors, students, know enough to worry, but not enough not to worry.)
An example of an impossible condition: a man worrying about having had a heart attack because he had a pain in the left foot. (He knew a pain in the left arm could be a sign of a heart attack.) Another example: a woman worrying about the possibility of ovarian cancer when her ovaries had been removed. Other worries are less outlandish, but still far-fetched: a brain tumor because of a sudden, transient pain in the jaw, pancreatic cancer because of constipation, and so on. These can be discovered by the patients to be irrational and unreal.
Patients are only convinced after a considerable period of time that they need to learn more, not avoid learning. They come grudgingly to believe that is true only after I have demonstrated to them over and over again that the particular illnesses they worry about are not consistent with their symptoms. Over and over again, I can show them that something is missing from their symptoms that would have to be there for such a terrible diagnosis to be made. They can discover these discrepancies themselves.
And I ask them to read also about the much more common, and much less serious, illnesses that may, indeed, explain their symptoms—the conditions they really have. (c) Fredric Neuman