By Jonathan S. Abramowitz, Ph.D.
Donna can’t fall asleep. As she lies in bed, she can’t take her mind off the fear that she has a brain tumor. Even though her doctors reassure her that everything is fine, she can’t get past the fact that from time to time, it feels like there is something not quite right in her head. Sometimes she gets headaches for no reason. Sometimes she feels dizzy or lightheaded. What could be going on that modern medicine can’t explain? Surely, there must be something terribly wrong that the doctors can’t figure out.
Donna feels so anxious that she decides to check the World Wide Web for more information on brain cancer. Since her doctors stopped taking her calls, she had amassed quite a collection of books and articles on this topic. Some of the descriptions of brain cancer symptom seem to overlap with what she is experiencing, but then again, there are other symptoms that she doesn’t have. The urge to call the doctor grows more and more intense.
Donna has hypochondriasis, which involves a preoccupation with the belief that one has, or is in danger of developing, a serious illness. Many people with hypochondriasis are disabled because of their problem. They can’t function very well in work, school, or family settings. People with hypochondriasis usually focus on bodily functions (e.g., breathing, heartbeat), minor physical abnormalities (e.g., skin blemishes), or physical sensations (e.g., headaches, stomach aches). The person might also worry about a specific organ or disease (e.g., fear of having cancer). Unfortunately, many people with hypochondriasis are reluctant to seek mental health evaluations since they believe very strongly they have unexplained medical illnesses. Our OCD and anxiety clinic evaluates and treats many people with hypochondriasis. So, in this article I will discuss how we to think about this problem, where we observe overlaps with OCD, and how we treat people with hypochondriasis.
Hypochondriasis as Severe Health Anxiety
Anxiety serves an adaptive function: it protects us from harm by activating the “fight or flight” response, the body’s automatic danger detection mechanism. But it is important to understand that the anxiety response is activated by the perception of threat, even if true danger doesn’t really exist. Research, including our own, shows that a main problem in hypochondriasis is that people are actually misinterpreting as dangerous, their otherwise normal bodily perturbations and sensations. That’s right, humans have “noisy bodies” that create all kinds of sensations that probably have some physiologic or metabolic purpose (which we might not be aware of), but which aren’t at all dangerous.
To help, you might think of the human body as similar to other complex machines such as computers and automobiles. These machines, even when working properly, often produce strange noises such as clicking, whirring, buzzing, and screeching, among other noises. As with such machinery, even a healthy human body produces all sorts of physical symptoms that might be uncomfortable (or even painful), unexpected, and otherwise unwanted.
These normal symptoms might include changes in visual acuity, in heart rate and blood pressure, in saliva levels, depth of breathing, balance, and muscle tone, to name just a few. These are normal and harmless bodily changes. But when a person misinterprets them as symptoms of some terrible disease, it (naturally) makes them worry. This explains why medical tests come out negative: the sensations are real, but they are not symptoms of a disease.
Why do people misinterpret body sensations when there is actually no need for concern? Probably because of their basic assumptions about health and illness. For example, the idea that “hurt equals harm” or that “my father died of cancer, so it’s only a matter of time until I get it too.” People with hypochondriasis hold rigid definitions of good health, perhaps believing that any discomfort whatsoever means “bad health.”
Why does Health Anxiety Persist Despite Reassurance?
If people with hypochondriasis are incorrect about their fears, why doesn’t reassurance from doctors help them? Unfortunately, it’s not so simple. As I mentioned above, when we become anxious, we experience the fight-or-flight response which involves an increase in symptoms such as rapid heart rate, difficulty catching your breath, and sometimes dizziness, the sweats, and seeing spots. Although these sensations are not dangerous in the least, if they happen to occur right when you’re anxious about your health (as what happens in hypochondriasis) — wham! It just adds fuel to the worry fire.
Certain behaviors that people with hypochondriasis do can also prevent a person from realizing that they are not really sick; for example, seeking reassurance from a doctor or other expert source. This habit leads the person to rely upon such reassurance to obtain relief from health worries. Checking your body also makes a person preoccupied and likely to notice subtle sensations that most people simply ignore. So, a vicious cycle develops of noticing a sensation, misinterpreting it as threatening, becoming anxious, and seeking reassurance, which leads to further preoccupation and worry with the essentially harmless sensation.
Hypochondriasis and OCD
OCD, of course, involves intrusive thoughts (obsessions) and urges to perform rituals (compulsions) that reduce obsessional anxiety. As you might notice from the case description of Donna above, there are definite overlaps in the clinical picture of hypochondriasis and OCD. Specifically, persistent fears about illness in hypochondriasis HC are similar to obsessional thoughts in OCD. Similarly, attempts to seek reassurance in hypochondriasis are akin to compulsive checking rituals in OCD. That is, checking behaviors in hypochondriasis are an attempt to reduce illness fears much as compulsive rituals are an escape from obsessional anxiety (e.g., checking to make sure I did not make a mistake). However, there are also some important differences. In particular, people with hypochondriasis show more fears of bodily sensations and less awareness that their fears are senseless compared with people with OCD. In my mind, hypochondriasis is a form of OCD. In fact, as I describe below, I tend to use the same treatment techniques as I would use to help someone with OCD.
Understanding hypochondriasis as I have described above, we can see that effective treatment requires that a person (a) corrects their threatening interpretations of certain body sensations and (b) eliminate behaviors such as compulsive checking and reassurance-seeking. This treatment approach, termed cognitive-behavioral therapy (CBT), involves the following steps that require a skilled therapist’s assistance.
1) Proper Medical Evaluation
Prior to CBT, the prospect of actual medical problems must be ruled out via a thorough physical exam. Information from this exam should be reviewed (one time only) and accepted as evidence of good health.
Education about bodily symptoms is a vital component of CBT. Patients are provided with non-threatening explanations for the bodily sensations they frequently misinterpret as threatening symptoms of underlying diseases. Of course, this is not the same as providing reassurance. The patient is required to use this knowledge for him or herself, rather than asking the doctor over and over for the same information.
3) Cognitive Therapy
Cognitive therapy techniques are used to help modify unrealistic interpretations of harmless physical sensations. It is a form of guided discovery wherein the therapist helps the patient explore the evidence for and against the threatening misinterpretation.
4) Exposure Therapy and Response Prevention
Exposure therapy is a set of techniques designed to help correct mistaken beliefs. For hypochondriasis, exposure involves gradually confronting the situations and bodily sensations that that person avoids because of the fear of illness. During exposure, patients also learn to tolerate uncertainty about whether or not a sensation is really a symptom. Even though at first, people become anxious when they do exposure practice, the distress is temporary—it subsides by a process called habituation. As a result of habituation, the person learns that they do not need to fear these situations and sensations because their distress does not go on forever.
Response prevention is used in tandem with exposure. It involves resisting the urge to seek information or reassurance about health and illness. In other words, once exposed to the feared sensations, the person is taught to use healthy coping strategies (such as examining the evidence) rather than calling doctors or running to the web.
Although research is helping us to understand and treat hypochondriasis more effectively, the main obstacle to successful treatment is that many patients are reluctant to view their problems as anything other than physical. Our experience, though, is that helping patients appreciate the role that their thoughts and behaviors play in generating health anxiety allows them to engage in treatment and reduce their symptoms.
Asmundson, G. & Taylor, S. (2005). It’s not all in your head: How worrying about your health could be making you sick. New York: Guilford Press.
Jonathan S. Abramowitz, Ph.D., ABPP
Associate Professor and Associate Chair, Department of Psychology
Research Associate Professor, Department of Psychiatry
University of North Carolina at Chapel Hill
Campus Box 3270 – Davie Hall
Chapel Hill, NC 27599-3270