The Treatment of Health Anxiety

Six principles

Health anxiety is, simply, a condition in which certain individuals (“health worriers”) worry too much about their health. They include patients who cross a number of theoretical and diagnostic categories, including generalized anxiety disorder, obsessive-compulsive disorder, and depression; but also, especially, somatization disorder—a condition in which anxious people present with physical symptoms, such as stomach ache, headache and palpitations—and hypochondriasis—a condition marked by the individual’s inclination to respond to physical symptoms by imagining the worst possible illness. The worst possible illnesses are those that might lurk silently but nevertheless, have the potential to kill. They include cancers of various sorts, particularly brain and pancreatic cancers, heart disease, degenerative neurological conditions, such as multiple sclerosis, brain aneurysms, and A.I.D.S. Health anxiety is a common condition that leads to considerable distress and over-utilization of medical services, including laboratory tests and procedures that are likely in the long run to worsen this psychological condition.

Doctors are well-aware of these unhappy persons. They see them every day. Some doctors are likely to be dismissive of their complaints, since their symptoms plainly do not reflect a medical disorder. They speak of such patients derisively as “crocks.” Most doctors, however, are sympathetic. They respond endlessly to the same questions in a vain attempt to reassure their patients. Then they typically do two things that are well-meaning, but likely to aggravate their distress:

1. They tell their patients to avoid looking at the drug insets they receive with medications that have been prescribed for them, since reading about potential side-effects makes them more afraid. And, indeed, that is what happens. For similar reasons they tell them to stay off the internet and stop reading about the illnesses they are afraid they may have.  These practices are antithetical to the proper treatment of health anxiety because they discourage the patients from confronting their fears. All irrational fears will be ameliorated in the end by confronting them. And that is the essence of treatment. Patients get upset when they learn a little about things they fear. When they learn more, they lose that fear. Since patients know very well that they get more upset—initially—when they read about their feared illness, it is hard to get them to so, and harder still when their physicians make them hesitate more. (Naturally, physicians have the obligation to correct any misconceptions and half-truths their patients pick up from the internet or from any other place.) 
2. Physicians agree to do special tests and procedures in order, once and for all, to prove to their patients that they do not have one or another disease. This is a bad practice. Health worriers  can no more be reassured by tests or further examinations than a patient with OCD who checks the front door over and over again to see if is locked is reassured by checking it just one more time. In fact, checking makes the underlying fear worse. It reminds the patient of the possibility of the feared condition really being present. Besides, laboratory tests and procedures are inherently ambiguous. The health worrier is likely to seize on some result just barely out of the normal range and worry still more. One ambiguous laboratory result is likely to lead to further tests and further concerns.

Physician need to acknowledge to their patients that these worries reflect an emotional problem which requires particular treatments of an emotional sort.

The therapy program for health anxiety instituted at the White Plains Anxiety and Phobia Center revolves about six principles. The patients are instructed:

1         A.  Learn the truth about yourself—the particular physical symptoms you characteristically develop, over and over again, in the face of stress.  For example, fatigue, back pain, panic attacks, palpitations, etc. These accustomed complaints are not likely to reflect some new physical disorder.

B. You need to learn about the illnesses you fear –Knowing a little is scary.—Knowing a lot is reassuring.

1.        2.    Confront your fears. Thinking the unthinkable diminishes fear. (This is an allusion to the “Nightmare Fantasy” in which patients are asked to imagine, in detail, the worst case scenario of their fears. It is possible to desensitize to a fear of illness and death by fantasizing.)
2.         3.   Avoid checking and the search for empty reassurance. (Patients are not allowed to ask the same question twice.)
3.         4.  Think of the odds against being desperately ill rather than the stakes. (“Wouldn’t it be awful if I died suddenly from a ruptured aneurysm?” “Yes, but what are the chances of that happening?”)
4.         5.   Do not seek absolute certainty or safety.
5.         6.   Live in a healthy way. (Including principles of eating properly and exercising.)

These summarize to certain “dos” and “don’ts”

Things to do                                                                  Things to avoid doing.

1.  Research diseases.                                             1. Do not examine yourself.
2. Construct and dwell on the Nightmare           2. Do not ask M.D. s for reassurance
3. (at the prescribed time)                 3. Do not ask your doctor to do tests or prescribe
4. Exercise.                                                                 drugs he does not think to do on his own initiative.

These principles and practices are elaborated on in detail in “Worried Sick?” which is a description of this program.(c) Fredric Neuman