Knowing What You Should Really Worry About

What should you really worry about?

Posted Jun 06, 2008

Not Seeing What You Don't Want to See

•You evaluate risk by relying on your emotion-If you don't feel anxious, it's not risky
•You estimate risk by relying on unusual dramatic events-if you are not reading about it in the news, it's not risky
•You ignore "baseline" information-the real "averages" and "odds"
•You assume that because nothing bad has happened so far that you are safe
•You focus on what you think will happen the next time-"The next cigarette won't kill me"
•You ignore "cumulative risk"-how risks build up over time
•You want to avoid thinking about things that are upsetting-so you avoid thinking of real problems-"I'd rather have a drink"
•You do not want to experience the discomfort of making a change-"Its too hard"
•You prefer to procrastinate about things that are not affecting you right now-"I'll wait until I'm ready"

In fact, the same processes that make you worry about things that are unlikely will lead you to avoid thinking about or doing anything about things that are actually risky. I have observed that many of my patients over the years who are chronic worriers (about things that seem rather trivial or unlikely) are likely to avoid thinking about or doing anything about the following preventable risks:

1. Obesity
2. Smoking
3. Alcohol abuse
4. Unsafe driving
5. Unprotected sex
6. Inattention to medical care
7. Financial irresponsibility

You Use both Worry and Avoidance to Handle Your Anxiety

Worry is a tool that you use to "manage" your anxiety by trying to "think through" things. You worry in order to "protect, prepare and solve problems". Let me repeat-when you are worrying you are less physically aroused and less anxious. Worry is your technique for managing your anxiety. You may also avoid thinking about preventable risk---because not thinking and avoiding are also ways in which you manage your anxiety.

You worry and you avoid in order to eliminate your anxiety----for right now.

Sometimes Risky Behavior Reduces Your Anxiety
Let's consider Rachel. She was in a car accident and barely escaped with her life. Over the next five months she had flashbacks about the accident and thought, "I'm going to end up getting killed in a car accident". Even though she wasn't driving a car, while she lived in New York, she worried about this daily. She began drinking heavily-hanging out in bars until three in the morning and smoking excessively. Rachel would get drunk at the bar and invite strange men to her apartment where she would have unprotected sex. Although she was worried and anxious since the car accident, she was now engaging in very high-risk behavior.

Think about the preventable risks that Rachel was taking---- drinking, smoking, and unsafe sex. Why would someone who worried about safety engage in such unsafe behavior? But consider that Rachel is trying to eliminate her anxiety--- so drinking reduces her anxiety temporarily, smoking makes her feel less anxious right now, and unsafe sex feels good for the moment. Rachel was focusing on eliminating her anxiety for today---and not thinking about the longer-term risks that she was incurring by her behavior.

Let's consider the seven examples of risk that I have identified above---risks that are epidemic in our country-and risks that you can avoid.

Preventable Risks

How risky are these behaviors?
People who are anxious and worry ironically expose themselves to preventable risks on a daily basis-and hardly ever think about these things. Someone may worry about a blemish on her face, but not worry about the fact that she is smoking or is facing possible eventual financial ruin. If we look at many of these preventable risks---such as smoking, drinking, overeating, and avoiding medical treatment-we will find that many of the people who engage in these preventable risks are worriers---who worry about something else.

How serious and widespread are these seven preventable risks? Let's take a look.

•55% of adults are overweight and 33% of adults are obese
•325,000 people die each year from obesity
•Obesity has been increasing over the past 20 years (due to increased sedentary activities (e.g., television, computers), labor-saving devices, fast foods, high-fat food, larger portions)1
•Obesity among children and teens is three times higher than in 1980
•50% of restaurant purchases are for fast-food
•The health consequences are severe for obesity: diabetes, cardiovascular disease (stroke, heart attack), cancer (breast, endometrial, colon), high blood pressure, high cholesterol, higher mortality
•There are $99 billion in direct medical costs per year due to being overweight (1995)2


Alcohol Abuse

Unsafe Driving

Unprotected Sex
•Fewer than half of unmarried adults used condoms the last time they engaged in sexual intercourse.7
•Only one-fourth of drug abusers used condoms the last time they had sex
•15 million new STDs are acquired annually by Americans. Of the top 10 most frequently reported infections, five are STDs.8
•By age 25 more than 33% of the population will have a sexually transmitted disease. 15 million new cases of STDs are diagnosed each year.9
•More than 65 million people are currently living with an incurable STD
•Two-thirds of all STDs occur in people 25 years of age or younger
•One in four new STD infections occurs in teenagers
•One in five Americans has genital herpes, yet at least 80 percent of those are unaware they have it.10
•In 1994, the direct and indirect costs of the major STDs and their complications were estimated to total almost $17 billion annually.11
•How Americans became infected with HIV, through 1999? For 407,169 people it was through unprotected sex.12

Inattention to Medical Care
•The cost of medication non-compliance is $50 billion annually
•Compliance rates for colonoscopy are as low as 10%
•50% of patients do not take their medication for high-blood pressure.13
•There is a 76 % discrepancy between what medications are prescribed to patients and which medications they actually take
•50% of patients with high blood pressure (hypertension) did not take their medication
•50% of heart patients discontinue cardiac rehabilitation in the first year
•Non-adherence is just as high in patients with symptomatic diseases (e.g., epilepsy and diabetes) as it is with diseases without symptoms (e.g., hypertension).

Financial Irresponsibility
•In 2002 there were 1.5 million filings for bankruptcy
•This was the highest in history
•Home foreclosures are the highest in history
•20% of credit cards are maxed out
•The average household has $8400 in credit card debt
•60% of households carry credit-card balances
•The average household receives an offer of one new credit card per week14

Some of these risks can kill you, others can drive you into financial ruin---and all of them are preventable. You can do something about each one of these risks. However, as widespread as these risks are I have never had a patient come in to me for the first time and tell me that they are "worried" about their tendency to engage in these preventable risks. People may want to lose weight, stop smoking or decrease their drinking, but they do not say that they are worried about these behaviors. Perhaps they are worried---but that is not what they say. They think it's a "good idea" to make some changes. Perhaps their husband or wife may have told them to make a change or perhaps their doctor thinks it's a good idea --but these are not the things people worry about.

What could account for the apparent blindness to real risk in people who are anxious? Why would people not worry about daily behaviors that are so substantially risky-and avoidable?

Estimating Risk

•How often has this event happened in the past?
•How many times have I (or others) been exposed to this in the past?
•What is the magnitude of the outcome? How bad would it be?
•How much do I enjoy the behavior?

These questions are difficult to answer-which is one of the reasons that most of us don't estimate risk logically. Much of this information is abstract or even unavailable to you when you are estimating the risk of any given behavior. For example, smokers ignore information about lung cancer and nicotine-that is, they ignore the "baseline" information of the percent of people who smoke who get lung cancer. Moreover, they will often use evidence that they have been exposed to the risk---of smoking for years-as evidence that they have less risk: "I've been smoking for years and I'm fine". Smokers also will justify their smoking by selective sampling of examples of non-smokers who die from cancer---"He never smoked and he died at fifty from cancer".

We tend to reduce our estimate of risk if we enjoy the behavior. For example, few people enjoy being near electrical power lines or nuclear power plants, but many people enjoy smoking, drinking and unprotected sex. Consequently, we tend to overestimate the risk of "deadly", but highly improbable events (like nuclear power-plant accidents or electrical leakage), and we underestimate the risk of behaviors that we enjoy (like smoking, drinking, and unsafe sex).

What are the Chances?
Let's consider the following: "Flip a coin-heads you win, tails you lose". What is the likelihood that this will be tails? What is the risk?
When you are facing preventable risks---you are usually using the famous gambler's fallacy--- superstitious beliefs about luck turning, string of luck or luck running out. In daily life we do not estimate risk in any consistently logical manner. We tend to rely on "patterns" that we see---we see tails ten times---we assume the next time it will be tails. We seem to think that the coin remembers what it has just been doing.

"If it hasn't happened yet, it will never happen"
This is what happens when you do not wear your seatbelt for five years in a row. You assume that you are safe because nothing has happened. You believe that there is a pattern. You do not conclude that your luck may be running out.

"I saw it on the news"
If I were to ask you, "What is the likelihood that you will be a victim of a terrorist attack", you might consider what the recent news stories have been-especially if you live in New York City. One of my patients concluded two months after the September 11th terrorist attacks in New York that the chances that she would be killed by a terrorist were 100%. How does someone come up with this estimate?

Like many other people who are frightened by terrorism she will rely on what she sees on the daily news, the presence of armed soldiers in Manhattan, pictures of terrorist attacks on television, and the fact that she lives in a city where there was a terrorist attack. One woman who feared a terrorist attack increased her alcohol abuse and increased smoking cigarettes. She was estimating that the risk of dying from terrorism far outweighed the risk of dying from the effects of lung cancer or alcoholism.

But what are the real risks?

Overestimating Risk
Let's imagine that you have just seen a news story on television of a shark attack in Florida and you are now planning on swimming at a beach in New Jersey. How afraid of a shark attack are you? You might be very frightened and decide to stay on shore.

How risky are these behaviors? In a fascinating compilation edited by David Ropeik and George Gray of the Harvard Center for Risk Analysis, scientists and experts from different disciplines calculated the real-world risks for a variety of behaviors or hazards.16 These scientists calculated risk by considering the following: Hazard---the substance, agent, or behavior (e.g., smoking); Range of exposures-how we are exposed and over what period of time; Range of consequences---how much harm is done and to how many people? All of the risk estimates are calculated for the United States.

Consider the one-year odds of the risk of being killed by a shark---280 million to one. Now consider the life-time risk of dying from the effects of smoking---about one in two---half of the people who are currently smoking who continue to smoke will die from smoking. Or consider the relative odds of being killed in a car accident vs. flying in a commercial airplane. However, many more people have a fear of flying than a fear of driving-indeed, many people with a fear of flying will drive 1000 miles to avoid flying.

Factors Affecting Overestimation of Risk
Psychologists have been interested in the degree to which people over-estimate certain risks-and underestimate others. I have listed below several of the dimensions that psychologists have identified that are associated with overestimating risks.17

1. It's uncontrollable
2. You don't like the activity
3. It's involuntary

What do these dimensions of risk represent? We often believe that hazards that are uncontrollable---for example, sharks, radiation, and terrorism---are more risky. So, if we believe that we have control over an activity-like we might convince ourselves that we are in control of our eating, drinking, smoking and sexual behavior-then we will underestimate these risks. We also believe that if we like an activity, then it is less risky. Thus, we may believe that smoking and drinking-behaviors that we may enjoy-are less risky. Finally, we also tend to believe that behaviors that are voluntary-and also within our control---are less risky.

How can we apply these dimensions to evaluating how we underestimate risk? First, there certainly are horrible consequences of smoking or dying from cirrhosis from alcoholism. But we should keep in mind that in assessing the risk of the next behavior-the risk of smoking a cigarette in the next five minutes while having a drink-will not lead to a horrible consequence. Second, our intuition is that the next cigarette or drink will not kill us-and that overeating at the buffet will not make us obese. Again, we tend to be near-sighted---focusing on this next behavior and its consequences. Third, how "newsworthy" the behavior is and how much are people talking about it affects risk assessment. It's doubtful that we are hearing about how dangerous our smoking and drinking and overeating are--- these are not newsworthy stories. Ironically, the reason that these are not newsworthy stories is that they are so common. Thus, we are not reading on the front page of the risk of our own behavior because these problems are so common throughout the country that they are no longer newsworthy. This is why it seems so ludicrous to almost everyone that an obese person would sue McDonald's because he ate so many cheeseburgers and fries that he got fat. "Everyone knows that eating high-fat foods will make you fat". It is not newsworthy-because everyone knows it. And, ironically, because everyone knows it, he was not thinking about the risks he was taking.

How uncontrollable the hazard might be also makes us reduce our estimate of risk. We do "control" whether we drive our car-but we do not control the airplane. Thus, we consider the plane more dangerous than the car. We control whether we have a cigarette, a drink or a cheeseburger-so we may think it is less risky. We may also be kidding ourselves in thinking that we will be able to choose or control stopping these somewhat addictive behaviors. Also, we underestimate risk because we like these behaviors. "How bad can it be if it feels so good?" Thus, we enjoy smoking, drinking, overeating, and spending money---so it feels less risky. And, finally, we have voluntarily engaged in this behavior---we have freely chosen to smoke, drink or spend---so we want to justify our own choices by convincing ourselves that our behavior is not risky.

Consistently Underestimating Risk
Certainly none of us wants to be obese, die from lung cancer, or get killed in a head-on-collision. No one wants to have an undetected cancer continue to grow or to slowly go bankrupt. The reason for many of these preventable risks cannot be due to lack of information. Is there anyone today who doubts that smoking causes cancer? Or that eating high-calorie foods without exercise will result in weight-gain? Or that early detection of cancer can save your life? Is it out of ignorance that people incur debt at 21% --and never get out of debt? Almost everyone knows that herpes is epidemic and that not using birth control can make you a parent.

So, why do people seem to ignore the dangers that might result from their own choices? I will argue here that-just as distortions in thinking lead us to overestimate risks for some things--there are distortions in thinking that lead us to ignore risks that can kill us. Let's look at some of the ways in which we keep our blinders on.

Familiarity Breeds Risk
We often think that the things that we are doing on a regular basis have become safer. For example, if you smoke, you think that "smoking hasn't killed me yet", or if you are overweight, you think, "I haven't had a heart attack yet". The same thing is true for daily bad habits---if you drink too much, overeat or spend too much-you will think that the fact that nothing terrible has happened (yet) is evidence that you are safe. Familiarity with risky behavior lulls you into thinking that things are not so bad. Some people say, "I never use a seatbelt" or "I never wear a prophylactic" and then conclude that the absence of a bad outcome is evidence that they are somehow immune.

But, unfortunately, the day comes when your luck runs out. You die from cirrhosis or collapse from a heart attack. You look back and ask yourself, "What was I thinking?"

We underestimate the danger of behaviors or conditions that continue on a regular basis. Smokers, drivers not wearing seat-belts, people who don't take their medication, people who are in debt, obese individuals and people who drive unsafely all underestimate their future risk because they assume that nothing bad has happened and therefore the future is safe. This is like playing Russian roulette with successive spins of the barrel--eventually, your number is up. However, as you have been spinning the barrel-and each time it is empty-you have become more complacent, incorrectly believing that your good luck so far is a predictor of better luck in the future.

Ironically, then, exposure to risk over the long-term produces cumulative risk.18 Cumulative risk is risk that increases over the long term. The more you repeat the behavior, the greater the chance that something bad will happen. The longer you drink, the greater the risk of cirrhosis. The longer you are obese, the greater the risk of a heart attack. The longer your exposure to risk, the greater the risk. But risk-takers act as if each time they engage in a "risky" behavior-and nothing bad happens---they feel safer.
Increased exposure to risk paradoxically reduces the perception of risk. Thus, smokers will underestimate risk. They think, "I haven't died yet, so it must be safe".

The Next One Won't Kill Me
Young cigarette smokers say to researchers, "The next cigarette won't kill me".19 When we think about taking another smoke or overeating or drinking another drink or not wearing a seat-belt, we often think, "There's very little chance that the next time will kill me". Of course, this is true. The next cigarette or drink may not kill you. But what if this is your continual belief for the next 350,000 cigarettes during your lifetime? It may not be that the next cigarette will kill you, but it may be true that holding onto this belief will kill you.

All of these risks involve "near-sightedness"-or what we call "myopia". We focus on the next one-not on the long string of behaviors. We tend to think that the "next time I go out driving without my seat-belt, there is a very low probability that I will get killed". This is true---but each time increases the probability. It's like playing Russian roulette. There is a bullet in the barrel, but you don't know how many barrels there are.

You Don't Recognize Addiction
A common problem for these deadly bad habits is that we seldom recognize the addictive quality of our behavior. Although there is clear evidence now that nicotine addiction is a true addiction (just as heroin addiction is real), we tend to discount the addictive nature of overeating, drinking, and over-spending. These are behaviors that bring immediate gratification---we feel good instantaneously---and this immediate gratification strengthens the bad habit. When young smokers were asked if they worried about the addictive nature of smoking, they often said, "I'll stop before it gets too bad."20 Thus, we tend to underestimate how addictive these behaviors are. By the time the addiction is established, it has become extremely difficult to reverse the bad habit. We are hooked.

You Use Anecdotes Rather Than Probabilities
When I asked a 55 year-old smoker if he was concerned about getting lung cancer, he told me about his uncle who smoked until he died at 83. Another man justified his heavy drinking by claiming that his grandfather drank every day---although he failed to point out that his grandfather only had two glasses of wine each day. We tend to rely on concrete examples---or anecdotes-to support our belief that things are safe. Worriers also rely on anecdotes or concrete examples---rather than relying on abstract baseline information. For example, the worrier who has a headache refers to an anecdote or concrete example of someone he heard about who had a headache that was due to a brain tumor. These concrete, emotionally evocative anecdotes are more "convincing" to a worrier that the abstract, baseline information that refers to the percent of people with headaches who do not have brain tumors. And if you are trying to justify your risky behavior you will turn to anecdotes that "show" you how safe it is.

Anecdotes are quite memorable for us---we can get a picture of someone who does not wear a seat belt or who smokes every day. When we form the picture, we then use this as evidence that things are safe. Now trying to think about probabilities is very hard. It's almost impossible. Our primitive brains are not built to think about abstract probabilities. It wasn't useful in the primitive environment of our ancestors to try to calculate the percent of people who ate something who died.

The problem, though, in relying on anecdotes, rather than probabilities, is that you can always come up with an anecdote to justify your behavior. For example, even though we know that smoking causes cancer, that alcohol abuse results in early death for many, or that unsafe sex can lead to contracting herpes or AIDS, we can readily come up with concrete examples of people who smoke who do not have cancer, people who drink excessively who go to work every day, and people who do not use condoms who are healthy. We need to keep in mind that safety is about probabilities-and anecdotes do not tell us anything about probabilities.

You Try To Feel Better Too Quickly
Worriers are often trying to avoid negative emotions---they do not want to allow themselves to feel anxious right now-so they worry to engage in "problem-solving" or "hypervigilant" thinking that actually temporarily reduces their anxiety. This emotional avoidance ironically also underlies the tendency to avoid thinking about actual risky behavior. For example, Frank worried about his girlfriend's opinions of him-whether she saw him as a successful man---but he did not worry about his taxes that had not been filed in two years. Whenever he thought about his taxes he became anxious-and, therefore, he avoided thinking about them. This emotional avoidance-and the attempt to feel better right now---is a key element in both worry and in avoiding thinking about preventable risk.

A key element in your risky behavior is that you are trying to feel better immediately. Research on drug addiction and alcohol abuse shows that people with these addictions seldom get to the "withdrawal" experience---they are continually experiencing the "positive" feelings associated with drugs and alcohol.22 The reason people do these things is that they are immediately reinforcing--they work immediately. The same thing is true for overeating, unsafe sex, and over-spending. The rewards are up-front.

Psychologists have referred to this kind of addictive process as a "contingency-trap".22 This means that you continue to choose a habit-forming behavior because the consequence (contingency) is immediate gratification. This immediate gratification not only strengthens the habit, but blinds you to consider the longer-term consequences of the habit that could be devastating.

Ellen had been upset about a breakup with her boyfriend-so she began to drink more. This made her feel better immediately. It worked. When I asked her what she predicted would happen if she didn't drink for three months she predicted that she would feel worse. Ellen believed that drinking made her feel better immediately and terminating drinking would make her feel worse. My argument is that there is some truth in Ellen's "myopic" or "near-sighted" emphasis on feeling better immediately-but it is only part of the truth.

A Contingency Trap

The question-it seems-is, "When would you feel worse"? People who are alcohol abusers are often depressed. They think that they need to drink in order to deal with their depression. But within two months of abstaining from drinking, 90% are feeling less depressed. This is because alcohol serves as a central nervous system depressant---it will depress you. But it initially reinforces you, because alcohol can calm you down immediately. So when you stop drinking completely you might feel more anxious for the first week-but later, after a week or two, you begin feeling better.

Familiarity Breeds Hopelessness
When we are following these bad habits for a long period of time, we begin to label ourselves as "having a weight problem" or "a smoker" or "someone who does this". We treat our familiarity and long-established habits as evidence that this is the kind of person that we are and this "label" becomes "proof" that we can't change. "I'm an overeater" becomes evidence that "I can't lose weight".

However, this labeling does not stand up to critical evaluation of the evidence. At one time you were not a smoker, not overweight, not overspending and not engaging in risky behavior. You might have said at that earlier time, "I'm someone who doesn't do risky things". But, of course, that label was only true for a particular period of time. Then things changed-you began taking more risks. So, if it changed once, then maybe it can change again. All ex-smokers were once "smokers" and all recovered alcoholics were once active alcoholics. People who are no longer obese were once obese.

The consequence of labeling yourself is that you feel hopeless and helpless about changing yourself -and you stop thinking about ways by which you can change. With prolonged familiarity of your habit you may begin to believe that there are no choices involved. You begin to think that this behavior-for example, smoking or drinking-has nothing to do with the situations that trigger the behavior, your conscious thinking and your ability to make a choice.

I once treated a 75 year-old man who had been an alcoholic for 45 years---he could not recall a period as an adult when he did not drink to excess. As we examined the costs and benefits of drinking, he commented, "I have been a drinker all my life-so it's hopeless-I can't change". I asked him if he knew any other elderly people who have stopped drinking in recent years and he commented that he did. The question, then, was, "How was it possible that they were able to stop doing something that they did for fifty years?" Much to everyone's surprise, he stopped drinking completely and remained sober for another ten years.

You Normalize Your Mistakes
We often believe that behaviors that are frequently engaged in by other people are safer than they really are. If so many other people are drinking, driving beyond the speed limit, or smoking-then we think it must be fairly safe. This "popularity" of risky behavior helps us "normalize" our own behavior, providing a justification for us to continue to do what we are doing.

Almost every alcoholic that I have treated would normalize his behavior by pointing out that all his friends drink as much if not more than he does. Ironically, this is because many of his friends are alcoholics in the bar. People who overspend often justify their behavior by saying that all their friends are maxed-out on their credit cards. We tend to socialize with people with similar habits. If you are abusing alcohol or drugs, you are very likely socializing with other people who engage in the same behavior. Alcoholics and drug abusers tell me that they do not like socializing with people who do not engage in these behaviors because they will feel "judged". This is probably true-since non-alcoholics are judgmental of people who are drunk.

Although it's doubtful that everyone is just like you, pointing to others as examples of your own problematic behavior does not solve your problem or reduce your risk. It may make you feel better to think that you are just like your friends, but it also may be true that your friends will face some dire consequences at some point.

Vincent was an alcoholic who justified his drinking by pointing out how many of his friends-at the bar---drank to excess. He also believed that if he stopped drinking he would lose some of his friends. (This turned out to be partly true.) However, as he pointed to his friends who drank as the "norm", I asked him if he knew any people who had developed a problem from drinking. He indicated that one of his friends had developed a liver problem and was in the hospital-his friend was 41. The problem with normalizing your behavior this way is that you may be selectively sampling people similar to you, you may underestimate the longer-term effects on your "friends", and you may ignore the benefits of not having the problem that you have.

You Avoid Doing What Is Unpleasant
Underlying changing all of the risk behaviors is the fear of facing the negative emotions of making these changes. If you are an alcohol abuser-and you stop drinking-you will experience some anxiety. If you stop smoking, you will become irritated and upset for a short period of time. If you are an over-spender, you will feel anxious or resentful if you keep a budget. Similar to many people who worry or who are anxious, you are using avoidance to handle problems that may occur.

When I asked Wendy to consider keeping a budget to find out how she was spending her money, she initially resisted doing this. Even though she was increasing her debt on her credit cards-and even though her job was not secure-Wendy said, "If I start writing down how I am spending my money, I'm going to realize how poor I really am. I will feel deprived not getting what I want to get". In fact, Wendy felt that buying new shoes-that she did not need-would give her immediate pleasure. Similarly, when Dan considered trying to abstain from drinking, he was flooded with thoughts about how negative this experience would be for him: "I'll feel tense all the time, I won't be able to sleep, I won't have any fun with my friends".

In fact, deciding to do some of these things-like not smoking, eliminating or reducing drinking, or living within your means---will initially cost you some discomfort. I have found it helpful to ask people the costs and benefits "immediately" after changing and the costs and benefits "of having changed this one year after you have changed". Wendy was able to realize that the benefits of living within her budget for one year would far out-weigh the discomforts of keeping a budget. However, she also realized that the initial experience of keeping a budget would be frustrating.

The same trade-offs hold for the other problematic habits-overeating, smoking, avoiding seeing a doctor, etc. For example, Paul was a sixty year-old man who never had a colonoscopy - a rather simple (but unpleasant-sounding) evaluation. When he thought of having this done, he felt anxious-and then avoided thinking about it. I asked him to identify the specific things that he thought were unpleasant. He indicated that having to experience the procedure might be painful, the preparation (using laxatives) would be very distasteful and-most importantly-he was afraid that he would find out that he had cancer. This factor in procrastination and avoidance is very common for medical non-compliance---the fear of finding out that you have gone too long without an exam and now you have a dreaded disease. Paul did have the procedure and he was surprised that everything was not only fine-but that the procedure was relatively non-eventful.

Underestimating risk often reflects the same kinds of biases and processes underlying worry-where you overestimate risk. In both cases, you want to avoid anxiety or discomfort and you selectively focus on information consistent with your bias. Worry won't kill you, but failing to worry-and do something about it-can kill you if you are avoiding preventable risk.

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