Fighting Fear

Confronting phobias and other fears

The Worry Wheel

The start of health anxiety, and the way it progresses.

When I first developed a program for the treatment of health anxiety, I sent out a letter to the physicians affiliated with White Plains Hospital informing them that we were offering a behavioral treatment program for those patients who worried too much about their health. One doctor responded by telling me that if he referred to us all such patients in his practice, there would be no one left. Indeed, there are very many people who worry excessively about health. We call them “health worriers.”  They fall into different formal diagnostic categories:  Some have somatization disorder. These are individuals who express emotional distress by developing physical symptoms such as headache, stomachache, dizziness and so on. A second group, hypochondriacs, are individuals who, given a certain set of symptoms, tend to imagine the worst possible explanation, such as cancer, or a heart attack or AIDS. Individuals who have obsessive compulsive disorder are a third group. They tend to worry about germs or other poisons. And there are depressed individuals who tend as part of their illness to focus on bodily symptoms. All of them have in common an exaggerated concern about their health, and possibly the health of members of their family. As a rule, they recognize clearly that they worry too much.

Health worriers tend to report similar experiences growing up. Some had to deal with an unusual illness in themselves or in their families—a crippling or a prolonged illness, for instance. More typically, they report parents who were themselves overly concerned about matters of health. They learned from them that health was precarious. Such parents were likely to emphasize the importance of eating right, sleeping right, and going to the bathroom with proper regularity. They might also have warned against the dangers of catching illnesses from others.

These learned attitudes about health and illness lie dormant in the health worriers’ minds until an incident sets in motion the Worry Wheel, which brings the concerns about ill health to the fore. The precipitating event can be a stubborn or an obscure illness, or even the sudden illness of someone they know—or even an illness that is reported to affect a celebrity with whom they identify because of a similarity in age. In other words, any untoward event can set in motion the Worry Wheel.

Once health worriers begin to wonder if they are sick—or might just possibly be sick—they start to check their body, or bodily functions.  Just checking produces panicky feelings, which are then taken to be signs of illness, since they include elevated pulse or, possibly, stomach discomfort, or any of a wide variety of commonplace physical symptoms, such as headache or light-headedness. Or they discover in, or on, their bodies some previously unnoticed variation, such as a freckle or a bony protuberance. These are taken to be, possibly, signs of an illness.

Two other consequences of these behaviors appear soon after:

  1. Visits to the doctor’s office in search of reassurance. Instead, the doctor’s remarks seem to be ambiguous. Laboratory results, if they are extensive enough, include results slightly out of the normal range. Instead of feeling calmer, these troubled individuals feel more worried.
  2. Further checking, which focuses still greater attention on physical symptoms, thereby worsening some of them. (An enlarged lymph node will grow larger with repeated examination.)

Then, the health worriers start reading about the imagined illness (not enough to realize they do not have that condition, but just enough to worry more.)

They enter into a state of catastrophizing.  Imagining they have a terrible illness, they become depressed. They avoid physical exercise. And they worry more—sending them around the Worry Wheel once again.

The treatment of health anxiety—like the treatment of the other anxiety disorders—is simple in principle, but complicated in practice. In principle, phobias and compulsions and other anxiety states respond to exposure. That is, they respond to confronting the underlying fears in ways which show those fears to be unrealistic. In practice, it is difficult getting patients to do those things that they need to do, because confrontation leads  initially to heightened anxiety. 

The Worry Wheel presents a number of points where intervention can stop this process.  They differ, depending on the particular concerns of the health worrier. © Fredric Neuman Follow Dr. Neuman's blog at fredricneumanmd.com/blog

(This blog is drawn in part from “Worried Sick?” which is an account of this condition and its treatment.)

Fredric Neuman, M.D. is the Director of the Anxiety and Phobia Center at White Plains Hospital.

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