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Problems

Health Anxiety

A little bit of concern about our health is normal, and even healthy! For some people though, preoccupation with their health can take over their life and cause significant distress. People with health anxiety are preoccupied with having or acquiring a serious illness. They frequently seek reassurance about their health but fail to feel reassured. It is thought that between 1 and 10 people out of every 100 will experience health anxiety every year [1]. Cognitive Behavioral Therapy (CBT) and Acceptance and Commitment Therapy (ACT) are effective psychological treatments for health anxiety [2, 3].

What is it like to have health anxiety?

Polly’s fear that she had damaged her brain

Polly was in her mid-fifties and was worried that her brain was damaged. A few years previously she had been in a minor car accident – she was taken to hospital for a check-up but was more ‘shaken up’ than hurt. After the accident she became preoccupied with the idea that her brain had been injured. She noticed that she found it harder to concentrate and that she forgot simple things. She gave up her job in an office because she felt that she could not perform like she used to. She researched her symptoms on the internet and consulted a number of doctors. Despite extensive testing their results were inconclusive and she did not feel like her doctors really understood what was wrong with her. She often checked whether she had a feeling of being ‘mentally sharp’ or whether she was feeling ‘fuzzy’ and became concerned if she felt ‘fuzzy’. She experimented with a range of alternative therapies but did not find that anything helped very much.

Aspects of treatment that Polly found helpful

Polly was reluctant to see a psychologist because she believed very firmly that what she was experiencing had biological roots. Together with her therapist she began to develop two possible hypotheses about her difficulties. Theory A was that “I’ve damaged my brain and there is something really wrong with me”, and Theory B was that “Since my accident I’ve been preoccupied, anxious, and worried that I have damaged my brain”. They looked at which theory the facts of her case supported. Slowly, she began to entertain the possibility that her worry itself could be causing some of her symptoms and leading her to misinterpret normal experiences as problematic. Polly’s therapist encouraged her to monitor how much time she spent worrying about her symptoms, and how often she mentally checked how she was feeling. She experimented with ‘postponing’ her worries on some days and noticed that her habit of checking and paying attention to her symptoms tended to make them appear more prominent. She considered what was really important to her and slowly began to engage in activities which connected her to aspects of her life that she really valued.

Samantha’s fear that she would have a stroke

Samantha was in her early twenties and worked in a restaurant kitchen. She had a physical health condition called pulsatile tinnitus which meant that she was able to hear the blood ‘whooshing’ in the vein in her ear. Samantha had become very scared of this sound as she had come to believe that it meant that she would have a stroke and die. Samantha paid a lot of attention to this threatening sound in her ear and she would take precautions so as not to aggravate it. She would not exercise for fear of making her heart beat faster and raising her blood pressure – which made the sound louder. She refused to travel further than a few miles from her local hospital. She also preferred to be with her boyfriend or parents who could reassure her and make her feel safe. She spent a lot of time researching her symptoms on the internet.

Aspects of treatment that Samantha found helpful

When Samantha came to therapy she was absolutely convinced that she had thin veins and would have a stroke and die, and all of her safety behaviors were motivated by this belief. One of the things that her therapist helped her to do early in therapy was to construct an alternative, less-threatening, explanation for her symptoms. Her therapist called this ‘theory B’ and they spent time together gathering evidence for this alternative theory “I worry that I will have a stroke, but my worst symptoms might be caused by pulsatile tinnitus which isn’t dangerous”. Samantha and her therapist gathered information on the internet, and she was relieved to watch some videos of other sufferers describing symptoms similar to hers. Once Samantha was willing to entertain another possible explanation for her symptoms her therapist suggested that they find a way to test which theory might be true. Together they devised some behavioral experiments to test the belief “If I raise my blood pressure I will have a stroke and die”. Some of the experiments they did were running on the spot, running up and down a flight of stairs, and blowing up a balloon. Samantha noticed that the sound in her ears got louder, but none of her most feared worries came true. This was a turning point for Samantha. She became more confident and was able to drop more safety behaviors, and venture further from home.

What is health anxiety?

Symptoms of health anxiety include:

  • Preoccupation with having or acquiring a serious illness that persists despite receiving negative results on medical tests and reassurance from professionals.
  • Anxiety that is excessive and out of proportion to the actual likelihood of having a serious medical problem.
  • Repeatedly checking your body for signs of illness, frequently seeking reassurance about your health from medical professionals.

People who are healthy can develop health anxiety, as can people who have a diagnosed medical condition. To qualify for a diagnosis of health anxiety disorder your symptoms must have persisted for at least six months and must have caused you significant distress, or adversely affected your daily life. [1]

We can separate the effects of health anxiety into thoughts, feelings, and behaviors:

How you might think How you might feel How you might act
  • Worry that you are seriously ill.
  • Worry that you might become seriously ill.
  • Worry that someone close to you could become ill.
  • “Maybe I have cancer.”
  • “This feels so severe it can’t just be stress.”
  • “If doctors have missed something I could die.”
  • “I need to know what is causing this.”
  • Anxious, nervous, frightened, worried.
  • Fatigued, tired, unwell.
  • Body symptoms and sensations associated with your preoccupation, e.g. soreness, aches and pains, lumps and bumps.
  • Avoid situations which might trigger your anxiety (e.g. hospitals, medical programs on tv, exertion, ill people).
  • Repeatedly checking your body for signs of illness, or for changes.
  • Frequently seeking reassurance about your health (e.g. from medical professionals, family and friends, or from the internet).
  • Researching your health concern.

What causes health anxiety?

There is no single cause for health anxiety. When thinking about the causes of problems psychologists often consider:

  • Vulnerability factors: things that make you more likely to develop a problem.
  • Triggering factors: things that cause the onset of a problem.
  • Maintaining factors: things that act to keep a problem going.

Vulnerability factors that make it more likely that someone will experience health anxiety include:

  • Personality traits: having personality characteristics such as a propensity to worry or an intolerance of uncertainty can make it more likely that you will develop health anxiety.
  • Genetic factors: there may be genes which predispose people to developing emotional problems in general, but no specific genes which make your more likely to develop health anxiety.
  • Life experiences: psychologists think that life experiences are particularly important because they shape our beliefs, attitudes, and behaviors. Important life experiences might include experiencing a severe illness as a child, a member of your family being ill while you were young, or being overprotected from (not being exposed to) illness or death as you grew up. Beliefs, attitudes, and behaviors that might be important in health anxiety include:
    • How you respond to health concerns, such as how quickly you seek medical attention.
    • Your sense of how physically strong or robust you are, including any mental images you might have which reflect these qualities.
    • Your beliefs and attitudes about health, illness, and death. These might include your ideas about how awful illness might be, how careful you need to be, or how likely you are to contract a disease.
    • How much you pay attention to your body, and to illness.

Triggering factors for health anxiety might include:

  • internal triggers such as illness, or symptoms or sensations in your body,
  • stress, which can lead to physical signs and symptoms you might notice,
  • the death or illness of someone close to you,
  • learning about information concerning an illness (e.g. through the media, or through medical training).

We will consider the maintaining factors for health anxiety in the next section.

What keeps health anxiety going?

Cognitive behavioral therapy (CBT) is always very interested in what keeps a problem going. This is because if you can work out what is keeping a problem going, you can treat it by intervening to interrupt this maintenance cycle. Some of the things that psychologists think are important in keeping health anxiety going are:

  • The way that you pay attention to symptoms in your body.
  • Unhelpful beliefs and thoughts about health and illness.
  • Misinterpretation of harmless bodily sensations as a threat.
  • Thought suppression (trying to get rid of unwanted thoughts and doubts).
  • Checking and reassurance seeking.
  • Avoidance and safety behaviors.

Selective attention / focus on body sensations

Your ability to pay attention is an interesting thing. Most people are not very good at paying attention to lots of things at once, but once we are paying attention to something it can fill our awareness. This matters in health anxiety because the way that you focus on a symptom can easily amplify your experience of it. The more that you pay attention to a symptom the more you become aware of it, and the more intense it can seem to be. This can lead to a vicious cycle: the more intense and important a symptom seems, the more attention you will pay to it, and the more intense it will seem.

Unhelpful thoughts and beliefs about health and illness

Thought processes and beliefs play an important role in health anxiety.

  • Worry and repetitive thoughts mean that a concern is ‘on your mind’ and ever-present.
  • Intrusive (unwanted) thoughts and images can be very distressing.
  • Thoughts about symptoms can become amplified, distorted, or inaccurate. It can be hard to ‘think straight’. People with health anxiety often overestimate the probability that they have (or will develop) a serious illness, and underestimate their ability to cope with illness.
  • Some people with health anxiety find uncertainty (not knowing) uncomfortable. This can lead them to act in ways that are intended to increase their sense of certainty, but which may inadvertently prolong the problem.

Thought suppression

Trying to dismiss or suppress thoughts or feelings that bother you is entirely natural. Psychologists call this ‘thought suppression’ but unfortunately it is rarely completely effective. Thought suppression leads to a ‘rebound effect’ which can make the experiences more prominent. The result is that you have even more of the thoughts that you are trying to suppress.

Checking and reassurance seeking

Doctors and other health professionals often advise us to check our bodies and to seek medical advice if we notice changes. For example, women are advised to conduct self-examinations on their breasts, and men to check their testicles. Dermatologists advise us to monitor moles on our skin for any signs of change. For many people checking and seeking medical reassurance when they need to leads to feeling less anxious about their health. People who are high in health anxiety often fail to feel reassured though, and will engage in more and more checking and reassurance seeking. Too much checking can be problematic for a number of reasons:

  • Checking can lead to ‘false positives’ – seeing a problem where there is none,
  • Counterintuitively, checking often leads to an increase in doubt, which leads to more checking.
  • The process of checking can create symptoms. For example, repeatedly squeezing an area of skin can make it sore, which might then be misinterpreted as a serious health concern.
  • Checking means that you have ‘bought into’ the idea that there is something wrong in the first place.

Reassurance-seeking can feel good in the short term (it’s nice to be reassured). But in the long-term it can be harmful as it reduces our ability to self-reassure.

Avoidance and safety behaviors

Avoiding things that distress you, or which could cause harm, is normal and can often be sensible. For example, you might choose to walk home via a well-lit street and avoid a dark alley, or to eat fresh food and avoid food which smells ‘off’. People with health anxiety often apply these same strategies and try to avoid things that cause them to feel anxious. You might avoid:

  • Anything which makes you experience body symptoms that you worry about such as coffee, exercise, or particular foods
  • Things which remind you of health or illness such as hospitals, tv shows containing references to health or illness, or visiting people who are ill.

Safety behaviors’ are things that you do to help you to manage in situations which make you feel anxious. They are really a more subtle form of avoidance. Safety behaviors in health anxiety can include using hand sanitizer to reduce your chances of catching an infection, or making sure to have a mobile phone or companion with you in case you have a health emergency.

Avoidance and safety behaviors can make you feel immediately better, but they also lead to problems. One of the biggest obstacles is that they can prevent you from learning the truth about a situation. Consider a child playing the game of not stepping on the cracks in a sidewalk because they think “the bears will eat me”. What is the best way of the child learning that stepping on cracks doesn’t lead to getting eaten by bears? That’s right, they need to stop avoiding the cracks. The same is true of health anxiety. The things that you avoid, or which you do to prevent the worst from happening, prevent you from learning important facts about your condition.

CBT model of what keeps health anxiety going

Figure: Vicious cycles of health anxiety.

Treatments for health anxiety

Psychological treatments for health anxiety

Psychological treatments for health anxiety which have good research support include:

Medical treatments for health anxiety

There is a small evidence base indicating that medication can be helpful for reducing the symptoms of health anxiety. These include clomipramine, imipramine, fluoxetine, fluvoxamine, paroxetine, and nefazodone [5]. The effectiveness of medical treatments appears to be smaller than for cognitive behavioural therapy [6].

How can I overcome my health anxiety?

There are lots of things that you can do for yourself that will help you to recover from health anxiety. These include:

  • Develop ‘Theory A’ and ‘Theory B’.
  • Examine the costs and benefits of change.
  • Understanding more about the bodily sensations that people experience.
  • Working with your thoughts and images.
  • Behavioral experiments.
  • Working with reassurance seeking.
  • Working with your avoidance and safety behaviors.
  • Exposure to your worries.

Develop ‘Theory A’ and ‘Theory B’

Psychologists often invite people with health anxiety to try looking at their experience from different perspectives. The idea behind the CBT approach is that the way we interpret a situation (or symptoms) determines how anxious we are. People with health anxiety often believe that they have a serious medical problem. Psychologists call this belief ‘Theory A’. Theory B considers the alternative possibility “What if your problems were caused by how worried you are about your health rather than something actually being physically wrong with you?”.

Theory A Theory B
I have a serious medical condition. I need to take steps to monitor my health, keep checking for information, and seeking reassurance. I have an emotional problem where I am *worried* about having a serious medical condition. Some of the things that I do to manage my worry are causing me problems.
Consequences if theory A is true:

  • I really am in danger
  • It would be dangerous for me *not* to monitor my health for signs of change or deterioration.
Consequences if theory A is true:

  • I’m not really in physical danger so I don’t need to check, avoid, or seek reassurance.
  • I might need to change some of what I think and do – how I approach my problem – as these will be influencing how I feel.

Some questions that you might find it helpful to reflect upon are:

  • How long have you lived your life according to Theory A?
  • What impact has that had?
  • Has living your life in accordance with Theory A got in the way of any other parts of your life? (such as work, relationships, leisure)
  • Can you think of any ways to test if Theory B could be true?

Examining costs and benefits of change

One message of CBT treatment for health anxiety is that your attempts to control your fears may be having unintended effects. Overcoming your health anxiety with CBT could involve acting in line with Theory B: acting in ways that make you feel more anxious, at least to begin with. You might need to think about things that make you feel uncomfortable, do more things that make you anxious (e.g. face your fears, approach situations that you currently avoid), and do less of things that you currently do to feel safe (seek less reassurance, stop using your safety behaviors). The aim of all of the treatment approaches is to help you live more of the life that you want to lead, but it will take time and effort. Some people find the prospect anxiety provoking. You might find it helpful to consider the costs and benefits of making changes.

Understand more about body sensations

The human body is amazing, as is the range of physical feelings that we can feel. We all feel an enormous range of physical symptoms every day: going from feeling awake to feeling tired, feeling hungry to full of food, calm and relaxed to heart racing if we are surprised – and we all ignore many of these. CBT says that it is the way that we interpret our experiences that leads to distress – and this is especially true in health anxiety. Body sensations which are benign can become attached to threatening meanings. Once this has happened we are more likely to pay attention to those sensations. Many people are surprised by how anxiety can lead to strong but harmless physical sensations. One good way of understanding more about your body sensations is to learn about your nervous system.

Working with your thoughts and images

Thoughts and images are a key part of health anxiety. People with health anxiety often engage in worry & rumination, experience intrusive thoughts and images, and think in other unhelpful ways about their symptoms. People with health anxiety often interpret situations in particularly threatening ways, resulting in strong feelings of anxiety. CBT says that it is not situations (or body sensations) that determine how you feel, but the thoughts and interpretations you have about that situation (or body sensation). Some of the unhelpful thinking styles (or cognitive biases) that people with health anxiety have can include:

  • Catastrophizing: jumping to the worst possible conclusion, overestimating the probability of something awful happening, underestimating your ability to cope
  • Intolerance of uncertainty: not feeling comfortable unless you have a definitive explanation for what you are experiencing
  • Selective attention: only paying attention to signs of illness, or ignoring information that does not support your view
  • Thought-action fusion: believing that thinking certain things can make them happen (e.g. believing that thinking about an illness will lead to developing that illness)

Important steps in CBT treatment for anxiety include learning to recognize and then challenge your negative thinking. Psychology Tools has a number of resources that are helpful for this:

Testing your beliefs with behavioral experiments

The CBT model of health anxiety says that the anxiety can be prolonged by some of the things that you might do to manage. The best way to find out if this is the case is for you is to gather some evidence. Helpful behavioral experiments for health anxiety can include:

  • Testing your predictions (e.g. if I don’t use my hand sanitizer then I will get seriously ill)
  • Testing the effects of frequent checking & rubbing – does the checking itself produce noticeable effects on your skin (e.g. redness, swelling)
  • Testing the effects of researching about a disease that you do not currently fear. Record what happens to your anxiety.
  • Test the relationship between frequency of checking and how anxious you feel. E.g. check one day and not the next, then on and off for a week.
  • See how many benign explanations you can come up with for a body symptom that worries you. 

Working with checking and reassurance seeking

People with health anxiety often check their bodies for symptoms, and seek reassurance from doctors / friends / family / the internet. Their motivation for doing this is to decrease their anxiety – to feel more certain that they are healthy, that they are not in danger, and to decrease their worrying. CBT models of health anxiety propose that while checking and reassurance-seeking can provide short-term relief, they do not provide the long-term sense of certainty that you are seeking. The reason they don’t provide long-term relief Is because you are seeking certainty that you are healthy, and even a little bit of uncertainty (“but what if … ?”) can make you feel anxious. So we can reframe the checking and reassurance-seeking as attempts to be certain.The problem is that absolute certainty is never possible. Even with mechanical machines like cars it is not possible to be certain that they are working 100% effectively, or will never break down. With human beings even more so. One goal of CBT treatment for health anxiety is to increase your tolerance of uncertainty. You can build up this tolerance of uncertainty by:

  • Reducing your checking, or noticing your urge to check, and refraining from it – notice how this uncertainty feels.
  • Refraining from seeking reassurance, and sitting with the uncertainty.

Other ways to work with your checking and reassurance-seeking can include:

  • Monitoring your checking and reassurance seeking and looking to see whether it is doing what you want it to (reducing your anxiety) or whether it makes it worse overall.
  • Try an ABA experiment. On day A do as much checking as you normally would. On day B do none at all. Then repeat day A. Notice what happens.

Reducing avoidance and safety behaviors

Avoidance is normal: from time to time everybody avoids things that make them afraid or uncomfortable. In health anxiety avoidance can become more severe. Some people with health anxiety avoid doctors, hospitals, sources of contamination, or things that could remind them of illness such as newspapers or TV. We use avoidance because it makes us feel better in the short term – you might avoid an uncomfortable feeling, or even feel relief at having avoided something frightening. The problem of avoidance is that in the long-term it keeps your anxiety going: you never get to learn the truth about how dangerous the thing is that you’re avoiding, or about how well you would be able to cope with it.

Similar to avoidance are safety behaviours. Safety behaviours are the things you do when you cannot avoid which are intended to prevent something catastrophic or bad from happening. For example, you might use hand sanitizer if you think you have been exposed to germs, or you might be especially vigilant to watch out for people who might be sick and who could pass it to you. Safety behaviours are similar to avoidance in that they make you feel better in the short term but prolong your anxiety in the long term. CBT for health anxiety will help you to overcome your fears by confronting them. This means that you will be guided to identify your avoidance and safety behaviours, and will be helped to face your fears using a technique called exposure therapy. There are different types of exposure, you can face feared situations in person (‘in vivo’ exposure), you can face feared body sensations (interoceptive exposure), or you can face fears in your imagination (imaginal exposure – see the section on ‘exposure to worries’).

Exposure to your worries

Exposure is the most effective psychological treatment for fear and anxiety. When people are afraid of an object or situation, such as a phobia of spiders, then exposure consists of exposure to that thing. For a spider phobia treatment might start with exposure to pictures of spiders, then to a spider in a jar, then allowing a small spider to walk on your hand. There are different reasons why exposure is helpful, but one of them is habituation – with enough exposure we simply ‘get used’ to the feared situation until it no longer bothers us or causes a fear response. With health anxiety the fear is often about a possible or uncertain future event. This makes direct exposure difficult! A helpful technique for working with worries like this is called ‘worry exposure’ and it has been proven to help treat worry about future events. When you practice worry exposure your task is to write a narrative describing your worst fears happening in great detail. You can make a recording of yourself reading this ‘worry script’ aloud and expose yourself to the worry by listening to the recording for 30 minutes every day until it no longer causes an anxiety response.

References

[1] American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.

[2] Cooper, K., Gregory, J. D., Walker, I., Lambe, S., & Salkovskis, P. M. (2017). Cognitive behaviour therapy for health anxiety: a systematic review and meta-analysis. Behavioural and Cognitive Psychotherapy, 45(2), 110-123.

[3] Eilenberg, T., Fink, P., Jensen, J. S., Rief, W., & Frostholm, L. (2016). Acceptance and commitment group therapy (ACT-G) for health anxiety: a randomized controlled trial. Psychological Medicine, 46(1), 103-115.

[4] Scarella, T. M., Boland, R. J., & Barsky, A. J. (2019). Illness Anxiety Disorder: Psychopathology, Epidemiology, Clinical Characteristics, and Treatment. Psychosomatic Medicine81(5), 398-407.

[5] Taylor, S., & Asmundson, G. J. (2004). Treating health anxiety: A cognitive-behavioral approach. Guilford Press.

[6] Taylor, S., Asmundson, G. J., & Coons, M. J. (2005). Current directions in the treatment of hypochondriasis. Journal of Cognitive Psychotherapy19(3), 285.About this article

This article was written by Dr Matthew Whalley (clinical psychologist). It was reviewed by Dr Hardeep Kaur (clinical psychologist) on 2020-02-03.