By Molly Schiffer, LGPC

Currently you may only know the suffering associated with Health Anxiety OCD, but through the right treatment, there is hope of learning to appreciate the way your mind works.

One of the things I find most heartbreaking about working with some of my OCD clients is that the disorder has ripped from them that which they treasure most and in turn engendered the very life they fear. In other words, it makes you become what you fear, just not in the way you’d expect. Those with Harm OCD may fear being rejected after hurting someone, but then they isolate themselves from their families. Those with Pedophile OCD may give up being a parent so there is no chance they will molest their child, but then they live a life not feeling safe around children.  Those with Health Anxiety OCD may worry that unidentified or untreated illness will rob them of a fulfilling life, but then they miss out on enjoying the life they always dreamed about having by devoting all their attention to trying to be sure they are not ill. Regardless of the form OCD takes, OCD is the dictator who declares the lengths that must be followed to obtain 100 percent certainty and just as you begin to think you’ve appeased him… the dictator changes the rules.

Understanding Health Anxiety OCD

Regardless of whether we call it Health Anxiety OCD, Hypochondriasis, Illness Anxiety Disorder or Somatic Symptom Disorder, this content area is often misunderstood both in the medical profession and the mental health field. Some of the confusion arises from failing to understand that the diagnosis refers to a person that is chronically anxious about their health, not about whether they are actually sick or not.  The fact is, one can be sick and have Health Anxiety OCD.

As with all content areas of OCD the real problem is not the content of the obsession, but the process of how you relate to and respond to it.  Specifically, the problem is believing that you have to do compulsions in the effort to obtain certainty your fear is untrue.  These failed efforts to be certain about one’s health ultimately lead to feeling less certain and more afraid. This being said, the content of all OCD sufferers’ obsessive thoughts always feels and seems important, and this sense of urgency about it distracts from recognizing the process problem.  Living with Health Anxiety OCD can feel like you are living on borrowed time, which makes it nearly impossible to enjoy anything. Instead you feel driven to escape what could be a potential death sentence or avert some other tragic misfortune.  What’s worse, it feels like you alone are responsible for carrying out this mission.

I remember as a child asking my mom what she was always so afraid of, and she said that she was afraid that she would be sick, and that it would be her fault for not being vigilant about watching for signs and symptoms. The look on her face was one of terror and bewilderment as she told me how unbearable it would be to find out she’s sick and to know that it would be all her fault for not having caught it sooner. As a child this made no sense to me but now, as an adult who has lived with OCD (and now specializes in the treatment of OCD) I understand that the terror and fear she felt was real. Her “fight or flight” system had signaled an emergency which she did not know was a false alarm. My mother was afraid of being sick, and everything that comes with being sick, but what really tormented her was the thought that she would be responsible for getting sick due to her failure to have checked enough.

Feared Consequences in Health Anxiety OCD

Feared consequences typically associated with Health Anxiety OCD include fear of dying or suffering from an illness of course, but also fear of permanent suffering, both mentally and physically, fear of abandoning your family because you didn’t take care of yourself, fear of never getting an accurate diagnosis and never finding treatment for your symptoms (real or imagined). This often includes intense pressure not only to figure out what is wrong with you, but also to be sure you are receiving the “right” treatment, for which you also take full responsibility. It is important to recognize when hyper-responsibility is playing a role in your health anxiety, so it can be targeted effectively during treatment.

What Health Anxiety OCD Makes You Feel Responsible For

Here are some ways OCD uses the fear of being irresponsible to keep you stuck in health anxiety.

Responsibility for seeking a diagnosis

  • What if I am ill but no one can figure it out because there isn’t a name for it?
  • What if this doctor read the results of the tests wrong?
  • How do I know that I am not developing an illness that has not been detected?
  • What if my failure to find an answer leads to endless suffering due to my awareness of symptoms

Responsibility for being vigilant about monitoring symptoms

  • What if this sensation or symptom is a sign of cancer or a chronic illness?
  • If I don’t check for signs of illness it could end up being my fault for not checking.

Responsibility for avoiding the potential of contracting an illness

  • What if I should not have allowed myself to be around someone who appeared ill?
  • What if I have not paid close enough attention to something that could have gotten me ill?

Responsibility for inadvertently causing harm

  • What if I have an undetected illness and get someone else sick?
  • What if I am currently sick or get sick due to my own lack of vigilance?

Responsibility for reporting symptoms and sensations

  • What if I fail to describe my symptoms accurately which results in the wrong diagnosis?
  • What if I fail to recognize changes in my symptoms?

Common Compulsions in Health Anxiety OCD

It can be easy to miss when apparent efforts to responsibly take care of your health are actually compulsions that fuel your obsessive thinking.  Here are some things to look out for:

  • Asking friends or family to examine you for signs of illness
  • Repeated visits to multiple doctors
  • Requests for unnecessary (and/or repeated) tests
  • Excessively checking your own body to look for new symptoms or changes in symptoms
  • Reassurance seeking from multiple sources (professional and non- professional)
  • Self-reassurance by reviewing behavior to make sure the right precautions were taken or repeating comforting advice already given
  • Excessive visits to the Emergency Room
  • Avoiding places where one might be exposed to germs or sick people (malls, doctor’s offices, grocery stores, etc.)
  • Avoiding objects imagined to cause illness (standing in front of the microwave, holding phone to one’s ear, anything sharp, anything with certain chemicals, etc.)
  • Neutralizing bad “sick thoughts” with good “healthy thoughts

The Google Problem

When I was a kid (yes, back then we used encyclopedias) whenever someone was anxious about a potential health concern we went to the bookshelf and consulted a very large medical book. While looking for reassurance from a medical book was still a compulsion which resulted in finding new possibilities and new questions, there was a limit to what information you would find.  Plus, it took a fair amount of effort.

Today we have Google, a limitless source of information which can all be obtained with a click. For those with Health Anxiety OCD, google is often a source of great misery and suffering. It starts with OCD selling you the lie that you could have your answer if you just looked up this one thing and then you could put it aside and carry on with the rest of your day (wouldn’t that be glorious?). However, it never works out this way because with Health Anxiety OCD googling itself is a reassurance seeking compulsion which maintains the cycle of OCD.  It does this by reinforcing the idea to your brain that not only is your health in question but that you better do something about it fast.

This is partly what makes Google so problematic because it offers health anxiety sufferers a promise of immediate answers and it never says “No, you have had enough, stop googling”. It feeds you possibility after possibility, mostly negative, which serves to keep you terrified, desperate and even more convinced than before that you are probably very ill. Unlike other addictions where there is an opportunity to pause prior to running out to make a purchase, Google is immediately and readily available at your fingertips. Googling is a common compulsion in many forms of OCD and is usually one of the first compulsions I work with my clients to reduce.

Case Examples

Debbie is a 27-year-old female who initially presented to her doctor with vaginal burning and was concerned she might have an infection! Debbie’s pap smear came back normal and she tested negative for any urinary tract bacterial infections. Debbie went home and was fine until she began to feel what seemed like the same sensation of burning she had 2 weeks prior. Debbie became fearful that maybe now she had an infection. Debbie returned to the doctor who again stated that Debbie did not have an infection and maybe she needed to drink more water. This went on for many months. Debbie began to go to different doctors due to feeling embarrassed about going back to the same doctor a second or third time. Debbie was constantly aware of the sensation of burning that seemed to get worse day by day. Debbie was plagued by the following thoughts: What if I have these symptoms forever? What if there is something wrong and nobody can figure it out? What if I have an STD that has been dormant for all these years?  Debbie started to Google STD’s and began to worry that maybe she had undiagnosed HPV which could result in cervical cancer. Debbie began to wonder whether she had used protection with every sexual encounter.  She began to Google information about how to know if you have HPV which only led her to more questions. She also examined herself daily to look for irritation or signs of an infection. Debbie knew she had OCD but this time her OCD had her focused on the (real) sensations that might indicate an illness instead of the familiar intolerance of uncertainty and discomfort.

Mark is a 52-year-old male who is preoccupied with several moles on his body. Mark has a family history of skin cancer. Mark was diligent with checking the moles on his body to make sure there weren’t any changes in shapes or sizes that could be a sign of melanoma. Every day after showering he would look over the moles before getting dressed. One day he had the thought “how will I know that it didn’t change, and I just didn’t notice” and “what if I have melanoma and it is my fault for not doing a better job of monitoring my body?” The more Mark looked at the moles the more confused he became and wondered what should a mole look like? Mark innocently looked on the internet searching “what does a healthy mole look like”? Mark was immediately bombarded with images of healthy and unhealthy moles. Mark began to frequent the doctor’s office and his dermatologist’s. Both doctors said Mark was fine, but as soon as he left the office he would be plagued by the thought “maybe he didn’t see the one I was talking about.” Mark stared at the moles to look for inconsistencies in shape and color and frequently asked his wife to examine his moles. He began to remember all those summer days in his teens where he had chosen not to wear sunscreen despite his mother’s warnings. Mark’s OCD had him focused on the belief that he was being responsible to monitor changes in his skin when in fact he was on a never-ending quest for certainty driven by an over-inflated sense of responsibility.

Inaccurate Beliefs Driving Health Anxiety

In treating any form of OCD, it is important to identify unhelpful ways of framing experiences that drive your belief system and perpetuate you engaging in compulsions. To assist with this process, I often like to talk about fun house mirrors and ask my clients what their experiences have been when looking at their reflection. Most of the time they respond by saying they looked fat and short or tall and skinny. I then discuss how if they believed what they saw, they may feel driven to start exercising, to drink daily milkshakes or maybe even to look for work in the circus. I use this to illustrate how mistaken beliefs (or cognitive distortions) drive OCD sufferers to engage in compulsions, leading to more uncertainty and misery.

Mistaken Belief: You can know the status of your health with absolute certainty: You can never know with 100 percent certainty that you are healthy. Chances are, if you suffer from health anxiety, you know the anguish of going to the doctor’s and immediately upon leaving the office thinking, “What if I didn’t explain my symptoms accurately? What if they misunderstood what I was saying? What if they missed something important?” The truth is that with being human we all run the risk of getting sick or having an illness pop up with no warning. I hate to say it, but we will all die and that may be the result of illness or of old age, but either way our choice is to enjoy our life being present for the things that matter or spend all our time trying to prevent illness and miss out on all the joy that can be found living in the moment.

Mistaken Belief: Symptoms and sensations indicate illness and always have a specific cause that can be determined:  This is a fallacy. Sensations happen all the time for many reasons, including for no specific reason. Sometimes sensations and symptoms are related to a specific health concern, sometimes they are indicators of nothing. However, once they are noticed, focused on and resisted, they tend to become more prominent simply because of the hyper-focus on them. To convey this idea with my clients I sometimes like to ask them where they are itchy. At first, they look at me blankly, but then usually identify a place that is itchy. The idea being that when you scan your body for sensations and symptoms you will likely find them. Just because you are aware of these experiences does not mean they are necessarily important or dangerous.

Mistaken Belief: Having the perfect diagnosis will always lead to effective treatment and elimination of all symptoms: While often there are effective treatments for your symptoms, this is not always the case. There are some conditions that even when diagnosed treatment options are limited. This is especially true for some chronic conditions such as Inflammatory Bowel Disease, Headache Disorders and Musculoskeletal conditions like Fibromyalgia. Your OCD is misleading you to believe that having a diagnosis (i.e. “the Answer”) will lead to relief.

Mistaken Belief: You are responsible for taking all possible precautions to avoid illness. The reality is that if you took every precaution you could possibly take to prevent illness, you would never be able to leave your home or have anyone come to your home, including the mail carrier. Even then, you couldn’t be sure that you took all precautions to prevent illness. Most enjoyable things in life inherently come with some risk.  If you get out of bed, your risk goes up.  Stay in bed too long, and your risk goes up too.  But your OCD, not restricted by reason, would have you believe that there is no amount of risk worth taking when it comes to your health.

Mindfulness and ERP for Health Anxiety OCD

Exposure and Response Prevention (ERP), simply put, is a process where you confront your fears about your health and refrain from doing compulsions. People often think of mindfulness and ERP as two separate strategies when in fact mindfulness is often a part of ERP. While doing exposure to your fear you are mindfully allowing yourself to both approach and remain in the presence of your fear and mindfully choosing not to engage in compulsions. The purpose of this exercise is to essentially retrain your brain to respond to the obsessive thoughts without doing compulsions which ultimately teaches your brain that these thoughts are irrelevant (or tolerable) and require no response.

Learning to respond differently to these thoughts ultimately results in accepting uncertainty about their meaning. This both reduces your anxiety about the thoughts and increases your willingness to feel whatever anxiety may remain.

Examples of Exposures for Health Anxiety OCD

  • Reading articles about people dying from diseases both common and uncommon
  • Watching movies or videos about someone with a terminal illness
  • Visiting hospitals, nursing homes, or places where you might fear acquiring an illness
  • Writing imaginal scripts about being chronically or terminally ill and the consequences that could arise from this
  • Writing imaginal scripts about failing to do enough to prevent an illness, failing to take enough precautions or perfectly follow medical advice

For any of the above approaches to work, they must be paired with resisting checking, comparing, reassurance-seeking or other compulsions.  Making contracts/agreements with loved ones to help you resist reassurance-seeking can also be instrumental in your progress.

Mindful Awareness

With health anxiety, practicing mindful awareness is knowing that you tend to be aware of your body’s symptoms and sensations in every possible way and understanding that simply being aware doesn’t necessarily have to be experienced as aversive. The awareness is experienced as aversive often because of the meaning and judgement subscribed to the experience. Being mindful of physical symptoms and sensations means viewing them from a different standpoint.

I don’t know about you, but I never wake up being greeted by a host of positive thoughts about my day that inspire me to feel good. Instead my brain presents potential pitfalls and disastrous outcomes that if I spend much time thinking about will land me right back into bed. With mindful awareness I can just expect to have these thoughts when I wake up, and instead of trying to make them disappear I make a choice to note them as they arise and just allow myself to get up and move forward. Accepting the presence of unwanted thoughts does not mean accepting the content of the thought as being true.

For example, I just had the thought …what if I am brewing some kind of cancer at this very moment and am irresponsibly just sitting here doing nothing about it? I could respond by taking the thought as a message or warning of some kind and immediately contact my doctor or I can thank my brain for its creativity and continue to do what I value, which at this moment is to continue to treat and support those with OCD.

Standing Up for Yourself

Sometimes living with Health Anxiety OCD can feel like you are living in your own private hell that never seems to end. On top of the despair you may feel, your OCD condemns and berates you for all the ways you imagine you may have failed, which then leads you to feel more isolated and often depressed.   From this standpoint it is difficult to feel motivated or even capable of doing what it requires to get better. This is where self-compassion can be especially helpful. At this point my clients frequently scowl because they assume I am referring to some kind of “give yourself a break type statement” which they often hate. However, self-compassion is simply about viewing yourself as a human being who has challenges like all other human beings. Self-compassion is a way of separating yourself from the nasty voice of OCD and allowing yourself to be honest about the situation without judgement and criticism. From this position you are better equipped to challenge your OCD and actively engage in treatment.

The good news is you are not alone. Currently you may only know the suffering associated with your health anxiety but through the right treatment, there is hope of learning to appreciate the way your mind works. You may even learn to laugh at the ridiculousness of some of the ideas your OCD has you focused on and you may begin to appreciate the creativity it affords you.  Above all, you may get to truly enjoy the benefits of the good health your OCD is so protective of.

Molly Schiffer, LGPC is a psychotherapist specializing in OCD and related disorders at The OCD and Anxiety Center of Greater Baltimore.