Confronting fears is critical–as it is in the treatment of the other anxiety disorders.
It is easy to set down in a few sentences the principles underlying the treatment of health anxiety, but implementing these principles in a practical program of treatment is not simple. Sometimes, as in any treatment program, one sets out to do one thing and ends up doing other things — sometimes unawares. Years ago, psychiatric residents were taught that the purpose of all psychotherapy was simply to make the unconscious conscious. It took years of training to discover what this formula meant and then how to use it in actual therapy. And then it turned out to be wrong.
There are many different schools of psychotherapy. They have different theoretical rationales that grow out of different theories about the etiology of emotional and mental disorders; but in practice, viewed from the other side of a one-way mirror, or through the prism of supervision, they all end up doing the same thing. They take issue systematically with certain incorrect assumptions patients have about themselves or about the world in general. The settings may be different, even the methods may be different, but the purpose remains the same. For example, a woman may come to therapy because she is embittered and unhappy. She feels everyone treats her disrespectfully just because she is a woman. Consequently, she fights with everyone.
Surely, it is true that someone may look down on this woman simply for being a woman; but surely not most people. The psychoanalyst listening to her may express doubt in her prejudice by raising an eyebrow or asking a question. The cognitive therapist may ask the patient to think of other possible explanations for the behavior she usually interprets as showing contempt for her and, as an exercise, to write them down. The purpose of both is to get the patient to see things more realistically. The success of either treatment may depend on the relationship between the patient and the therapist, an imponderable. Similarly, there are different programs that can he designed reasonably to attack health anxiety.
In part because of reports in the media of new and threatening diseases, and, also, new forms of treatment, there are a great many people who are preoccupied by matters of health. Health worriers–people who worry too much about their health—make up a large portion of the medical practice of most physicians. They over-utilize medical services, particularly diagnostic procedures, and, nevertheless, remain anxious, even when they are perfectly well. It is very difficult to reassure them.
Health worriers may be diagnosed with obsessive-compulsive disorder or depression, or a number of other illnesses, but their condition is really better defined by the mistaken ideas they have about how and why people get sick. Similarly, they have Bad Ideas about drugs, doctors, and other related matters. Bad Ideas are incorrect, but self-confirming, prejudices which lead people to behave in ways that worsen their fears. Treatment is directed to changing these behaviors so that health worriers can see the world and themselves more accurately. This kind of treatment is called cognitive-behavioral, or exposure therapy. The underlying principle is confrontation. It is necessary to confront one’s fears in order to overcome them. This is not easy to do.
Health anxiety is disturbing not only to the health worrier, but often to all the members of his or her family. Often others in the family are dragged into a stereotyped and repetitive interchange in which they are required to answer the same questions over and over again. “Do I look pale? (or paler?).” “Does this mole look weird? (or weirder?)” “Does this bump look red to you? (or redder?)” “Do you think I’m running a fever?” Although couched in the form of requesting medical information (from people who are not medically informed), these questions are really designed to seek reassurance. Like any other kind of compulsive checking, such reassurance comforts only momentarily at the price of focusing the health worrier’s attention even further on the possibility of a medical calamity.
These nagging questions reduce family members finally to halfhearted, distracted replies that do not serve to reassure even temporarily. Such questions should be resisted by family members—sympathetically, but firmly. Health worriers should be reminded that obsessional checking aggravates their condition, It is much better to frustrate the health worrier in this way than to end up angry and exasperated. Ridicule, however good-natured, is, of course, not helpful. It is possible, although difficult, for family members to help with the process of treatment, even though it is hard for them to be firm and dispassionate when someone they love is feeling bad.
Every once in while a health worrier is so persuasive, or family members are so suggestible, that they start to worry also. They are more likely to calm down, though, once they talk to the patient’s doctor. It is a good idea for them to accompany the patient to the doctor’s office for this reason and because patients, unaccompanied, are often too agitated to understand or remember exactly what the doctor said.
Another family problem attendant upon health anxiety is the tendency for these concerns to pass on to the next generation. Ideas are contagious. All of the Bad Ideas that underlie health anxiety can be conveyed in subtle ways or, sometimes, directly. It is hard for parents who worry excessively about their own health not to worry too about their children’s health. It is still harder to worry without the children knowing. Constant admonitions to stay away from people who are sick exaggerate the danger of being sick. Talking about the importance of eating properly or getting a good night’s sleep suggests the precariousness of good health. Some parents warn very explicitly about germs as if human beings had not evolved effective ways of warding off infection.
When judging which precautions are reasonable, one should be guided by the advice of a pediatrician rather than what seems to be obvious as a matter of “common sense.” It is very hard for someone who is naturally fearful to avoid becoming overprotective. Other family members can help. Remember, each of us has certain irrational fears that seem at first glance to be ridiculous to other people. However outlandish the ideas of a health worrier may seem, they follow logically from the person’s experience. They may be wrong, but they must be understood in detail. It must become clear to the health worrier that his or her concerns are truly appreciated. It does no good, even at that point, to tell someone ‘You’re wrong. The doctor says you’re wrong. Stop worrying.” Someone who feels bad should not be embarrassed or in other ways made to feel worse. (More specific features of treatment are described in previous blogs and in “Worried Sick.”) © Fredric Neuman