S2E22 Health Anxiety

As the medical world advances, so too do the labels that help guide providers with treatment. In this episode, Dr. Pete and Dr. Rubin chat about illness anxiety, OCD with a health focus, and other behavioral presentations related to health concerns. The east and west coast psychologists flush out the difference between the fear of having a disease versus contracting one, worry, obsessions, and much more that plays into how people respond to health anxiety.




Pete: So as we come out of a pandemic, certainly a lot of us are thinking about our health, whether we've put on the quarantine 15, or if we're just a little bit more anxious around our health and our mortality. Nikki, what do you know about some health anxiety?

Nikki: Oh, well, I've had it myself. I'll say I'm familiar with it personally. And it's obviously it's a pretty common concern, and obviously, during the pandemic, even those people that I think, haven't tended to have health anxiety, obviously, COVID has certainly, understandably and appropriately activated that. So as the pandemic wanes, it is a useful time, I think, for us to start talking about, like how to navigate some of those scary thoughts that could show up about our health.

Pete: Well, as we did in season one, I mean, everything is behaviorism. And so I think that there's so many topics that we can cover, but sometimes I still remain surprised for the topics that we have yet to cover. And this was one of them.

Nikki: Yes. I mean, I think it's just like we always say, humans are very complex. So I just think there's so many things. There's just so many things that we experience.

Pete: I'm just rushing to it.

Nikki: You're like, “how are we going to cover all the things?”

Pete: I don't know,

Nikki: I don't know, I don't think we're going to get to them all. But I think we can make a depth here.

Pete: I felt that way during dissertation, I’d go to library, and I'd look around and see all these books. And there's no way, you could never read every book.

Nikki: No, you can. No,

Pete: Never,

Nikki: Never.

Pete: But that was like a nice thing to embrace during the practice of writing a dissertation.

Nikki: Well, yes and just like a practice of like, we can't, it's impossible to know everything, which honestly, I do think is a helpful segue into talking about health anxiety, because part of it is we can't always have the answers. That is, of course, the other side of that is learning to tolerate uncertainty, which we have a whole episode on uncertainty, but comes up in everything.

Pete: Everything, everything. So health anxiety is obsessive and irrational worry about having a serious medical condition. So it's like a basic way that we can think about it. It can also be called illness anxiety. It was formerly hypochondriasis. But we'll get to that in a moment. I'm going to ask you to break that down. But how often do you say you see this in clinical practice?

Nikki: That's a good question. I think, I mean, I see it with consistency, I would say. It's not something that I'm like, “Oh, I haven't seen this in forever”, it definitely comes up because I would say even somebody that doesn't maybe reach a level like a diagnostic level,

Pete: Well, hold on, break that down.

Nikki: Yeah. So what I mean by that is someone that doesn't meet a criteria for a diagnosis of illness, anxiety disorder, or we'll talk in a moment there's a differential between OCD can also have this flavor. There's a difference in how those present. Even if somebody doesn't have OCD, or illness, anxiety disorder, it's just people worry about their health. I mean, it's just a natural, normal thing. And…

Pete: Well, hold on, I'm going to stop there for a second, I'm going to challenge you, you always me,

Nikki: Yeah, please.

Pete: I'm going to challenge you. Because you just use worry.

Nikki: Yes.

Pete: So what I'm going to say is, we focus on or we prioritize, or we have a value of health. But that's probably part of the differential is that when the worry comes in, is when it might become a little bit more diagnostic.

Nikki: I appreciate the challenge. You're going to laugh at what I’m going to say. What I was going to say is on a spectrum. So I agree, I think you're absolutely correct that when it becomes, there could also be obsessions, by the way. So there could be intensive worry, or obsessions where it starts to become diagnostic. However, even  people that don't reach that level of like, needing a diagnosis, it's not impacting their functioning. Everybody engages in worry behavior. And when there's something like you're saying, many if not most people, probably value health in and we, most humans,

Pete: I don't like that assumption.

Nikki: Well, I'm saying, it's kind of like saying many people. Let's say many people value, if not, like if we were going to do a survey of like, again, just think from an evolutionary perspective, valuing health, paying attention to one's health is a survival mechanism, could be aware of that. So yes, 100%

Pete: Well, but survival will be different than health. Because I guess what I'm thinking when I think of how they give well being, and maybe,

Nikki: Oh, okay. So I'm saying it like, think about, I'm saying it is the most broad, like, It encompasses everything. So it's both well, I mean it can…

Pete:  What do you think about like weight, heart rate? Like, what do you think about as you’re thinking about health?

Nikki: Everything, everything related to functioning, like functioning well as in our bodies and our brains. So that includes everything. So it's like, there's every little different nook and cranny of how you could behaviorally act in alignment with that. And so, again, if I'm sort of maybe thinking about it from starting from an evolutionary standpoint of being a lot like wanting to maintain being alive. And so is a foundational function of most living beings, or of all living beings, maybe, dare I say. So worry behavior when, and this is what's different about humans compared to other animals, because we have language we can start to want to problem solve, if something is wrong in our brains. Like, if you feel something uncomfortable in your body we're like, “oh, no, is this something wrong”, like that's not diagnostic, that's just like what human brains do. So that's what I mean about like, I would say, in terms of who comes into my office with health anxiety, I see a version of that both just like diagnostic all the way down to just like, most people have those types of thoughts at some point, does that make sense?

Pete: No, it does. And I think we're probably saying the same thing. And I just want to create space that like, I don't know that everyone values health, because also health requires time and money. So there's a ton of literature around really higher socio economic status folk can really focus on health more easily.

Nikki: Well, and so now, I'm going to challenge you. So this is one thing, and this, for those of you who haven't listened to our values episode, that'd be helpful episode to listen to. So one thing we say in acceptance and Commitment Therapy, and is true, that everyone gets to choose their values, so if you don't value something, you don't have to value it, you really might not value your health. However, oftentimes people misinterpret because they're not acting in alignment with something that it's not important to them. So, again, health is just about like what I'm saying, that it's just about being alive, so the term well, or wellness in this current era has a certain connotation to it. And I think that's what you're getting at, Pete. It's like, “yeah, people don't have access to all the things and all the healthy food”.

Pete: I was actually only thinking about, like food deserts, I was really just thinking, like I was thinking about access to healthy food, or even just the affordability of healthy food.

Nikki: But that person might say, “but it is important to me to be alive”, to be alive, and so that would be a value of health, and how could that person act in alignment with their value, given the limitations?

Pete: Exactly, right. And so I guess what we're trying to focus on is the health anxiety. So there are people who worry excessively or obsess around. I want to give us one stat before we link in and then I'll asked you maybe to break down some of these diagnosis.

Nikki: Sure, yeah, sure.

Pete: There was a study from Rally Health that found, and this is post COVID. Because I do think that really post COVID there's going to be an emphasis on health more.

Nikki: 100%, totally, how could it not be.

Pete: And what I'm thinking is, especially because we found that the virus didn't impact healthy people more than those that had pre existing or were less healthy. So I think that that's going to change people's brains to be like, “well, if I'm less healthy, let me commit to that”.

Nikki: That's a good point. That's a very good point, yeah.

Pete: So right now this study found that 43% of the respondents had said that they're focusing more on their health following COVID.

Nikki: Interesting.

Pete: Yep. So it said, and 49% said it made them more aware of their physical health and 44% reported that it had made them more aware of their mental health. So I think our field in the mental health is starting to wait for this kind of transition back and to see what people think. So let's just break down some of these diagnoses that the DSM5 has highlighted for health anxiety.

Nikki: Absolutely. Okay, so Pete mentioned a few minutes ago that this term health anxiety, it was previously known as hypochondriasis. So kind of out in the world, people will say, like, I mean, it's,

Pete: Hypochondriac,

Nikki: Hypochondriac, I was going to say, it's not like the most common word, I wouldn't say like, every person is walking around saying that, but I would say maybe some of our listeners have heard that term, like, ‘I'm a hypochondriac'. And that's really what that refers to, is like worrying about one's health, and it was a formal term in the DSM. However, in the DSM5, which is the current version that we use, it was changed to illness anxiety disorder. So illness anxiety disorder, it's really focused on basically like when somebody is worrying about their health. And what can get a little bit confusing is that sometimes people kind of don't know that… or people, I should say clinicians have difficulty distinguishing between illness anxiety disorder, and OCD. And so we sort of like…

Pete:  OCD, Obsessive Compulsive Disorder.

Nikki: Thank you. So both of them focus on health, and so sometimes you'll just like hear people talk about like, “I have health anxiety”, and then they're not really sure what that means. But basically, the easiest way to distinguish is that those people that have illness anxiety disorder, fear that they have a disease, and that people with OCD, that have like a focus on health concerns, fear that they're going to get a disease. So that's the difference. So that might sound a little bit like splitting hairs to our non clinician listeners. But that's really the biggest difference.

Pete: That’s a huge difference, though.

Nikki: Okay, so it does sound like a huge difference to you.

Pete: I mean, well I'm a clinician,

Nikki: You're like, “that is a stark difference when I hear you describe it”.

Pete: Well, and because I think some listeners are going to think about this of like, because it's not about death, necessarily, because that would be a whole other type of fear. I do want to say that the ICD does include hypochondriasis still. So we've talked a little bit about this, and the DSM5 will use here in the US only, but the rest of the International Classification System, the ICD, they're still [inaudible 11:53] hypochondriasis. So go ahead and keep calling each other hypochondriacs if you want.

Nikki: Yeah, wherever you are in the world, it's going to depend on what you want to call it.

Pete: People will know who that is.

Nikki: Yes. Well, so then, it's interesting that you're saying about death? Because I think it is related to that, though, because even like the fear of having a disease versus getting one. It's like, well look, part of that can be the fear of what would happen if you, and then obviously, there's many different types of illness, so that not all illnesses result in death. So there can be the fear of like, having or getting an illness where you're going to be suffering in some way. It's like a fear of the suffering.

Pete: The suffering, exactly.

Nikki: But I would say that more common ones I hear is like a fear of like, for example, getting or having cancer,

Pete: Of course,

Nikki: Which is like, that's what I hear a lot. So it's like the that type of illness, obviously, people fear death, so,

Pete: I think what's important here also for listeners is that, I don't know, maybe there's a human… No one has ever said, like, I hope I get cancer. So like, I'm imagining that a listener is thinking like, “well fear, well, then I must have this”, because I don't want to get cancer, I don't want to get something that's there. Where it becomes clinical is when there's the obsessions or the worry, so that they, right?

Nikki: Yes, yes. Well, it's so funny, what was going through my mind, and this is another, we'll do a depression episode. It's like he said, I don't think anyone's ever thought I hope I get cancer. Unfortunately, there are people that think that sometimes, people that are struggling when they're really, people that are…

Pete: Suicidal,

Nikki: Yes, experiencing suicidality,

Pete: But I'm saying like in the general population,

Nikki: Sure, yes.

Pete: Like if someone's healthy and stable, no one's like, I want to get sick, because when I heard you, what was coming to mind when you were describing differential diagnosis was like, I have a really good colleague, and she's open about her experiences with cancer. And so, I think it's like, I respect them so much, because then I say now, because now her husband's going through it. So she's been through it three times, now her husband's going through it. And so when I reflect on their experience, I'm just like, wow, what would I do? The selfish me is like, how would I manage this? Because you just don't know until you're there.

Nikki: I think what you're getting at, and this is where, when it starts to become like, diagnostic, or another way of saying it's, like impacting someone's functioning, is look, what Pete's describing is, anybody can have a worry. It's like, what would happen or will I be okay? Which is the brains way of trying to problem solve something that's not solvable, which is uncertainty, which is the future. ‘How would I tolerate this, would I suffer?’ Like, ‘what would the outcome be?’ And every human being engages in that behavior. Where it starts to impact one's functioning is when that worry behavior becomes so like, consistent that some anxiety is reaching levels where they're not functioning well. Or if it's OCD, we've talked a little bit about this for too. They're having obsessions, which basically means you have an intrusive thought that that thought alone reaches on a scale of like one to 10, your anxiety shoots to like a nine, as soon as that comes in. So I'm guessing when you have that thought, Pete, your anxiety is probably not a nine, like maybe that's an uncomfortable thought, maybe it's like three or something. And if you kept worrying, you'd get more anxious.

Pete: Well that's where the behavioral science comes in. Because it's such a vicious cycle. That's why we have all this research with chronic illness where what you need to do is break the cycle, because the more you think about and obsess around your body, I guess that's also the differentiation of somatic symptom disorder, where people psychosomatically, and people I have found, I don't know if you've seen this, but clients or patients, they respond to that in such a defensive way. And so the way that I always explain that is, somaticism doesn't mean it, means it exists, it just means that the origin of the epidemiology of it is unsure. We're uncertain.

Nikki: Right. Absolutely.

Pete: So people feel what they feel, and the brain can create it. I'll ask clients, and maybe for listeners, like, just think about your foot for this moment, and if you think about a pain in your foot, you might be able to have just felt the pain in your foot, you may have just felt something.

Nikki: Well, and actually, I think that's important to, I'm glad you're bringing that up.

Because I think that's also important to say, when talking about this umbrella term of health anxiety, either illness anxiety disorder, or OCD with a health focus, or just general worries is that, we feel sensations in our bodies all the time, like odd sensations. Those can be caused by, again, I don't know, like there's a weird itch on your body somewhere, your stomach's upset, it could also be any emotions, we experience emotions, also all have hardwired, physiological sensations attached to them. So we're feeling sensation all the time. And then when we start to focus on them, and like over focus I should say, over focus, and then begin to try to problem solve them, ‘what its that, what does that mean, am I sick, do I have an illness, am I going to get sick…’

Pete: Am I going to die?

Nikki: Yeah, well what's interesting is then anxiety starts to grow. And guess what shows up with anxiety, more physical sensation. This is actually how, we need to do an episode on panic, actually. That's actually how panic attacks happen. So the misinterpretation of bodily sensation. So yeah, it's messy in there, our brain is messy in there.

Pete: It is messy. And before we end, I just wanted to bring it a little bit of the Eastern tradition,

Nikki: Please, yes.

Pete: Because I don't know that, you and I can get so stuck at the behavioral science, and I think I could do it quickly, because, most of our listeners are familiar with the Eightfold Path and the five precepts. So this idea of just no killing, and refraining from misuse of sexual misconduct, things like that. Overall, anything in the eastern practice is really around full body health and cleansing. And so one thing I'll say is like, we don't want to distort your mindfulness. And so any kind of substances, certainly like alcohol or drugs, and certainly some foods that can distort your mindfulness and your clarity, you want to refrain from that, because the ultimate goal is just to create, clearness. Also, many cultures in eastern practice, commit to like a healthy living. So there obviously, is meditation, which has a direct impact on health. There are certain cultures within China, for example, where they don't have some of the illnesses that we have, they didn't have the words for them, they don't have some of the cardiac issues we have, because they're just committing to this meditation and then to also healthy eating, or even like a vegetable-based diet, that can really help towards this health. So, I think… go ahead.

Nikki: I was going to say, I think that's really helped… I mean, obviously, I'm always learning a lot from you about this, especially with eightfold path. I think that's all really important and interesting. And the thing that I was actually thinking a few minutes ago, about, like, what I was wondering, like, what's Pete going to say about this with regards to Buddhism is, if we go back to this idea that health anxiety is about, often it's like a fear of having a disease or a fear of getting a disease, which I was saying is really about a fear of suffering some way or a fear of mortality. I think that's really interesting in terms of like, what the eastern practices would have to say, and I'm really curious what your thoughts are there?

Pete: Well, it's mostly what I hear in that as the attachment to this life. And that's what we would want to try and defuse from. So for me, it's like, if I don't like flying or if there's something that I'm afraid because it might lead to panic or discomfort, that's still attaching to my moment, like feeling in this life. And so part of the Eastern practices that, our karma or our rebirth is what allows opportunities to kind of grow and to learn. So potentially we're learning from previous life. So it's about non attachment. So what I'll end with is just to think about, and ask listeners to think about what is it that you're committing to in terms of health, recognizing that having thoughts around fears of health is normal as well, but just recognizing to diffuse from any kind of obsession of worry and see, are you willing to embrace the discomfort that is living and suffering?

Pete: This has been When East Meets West on Dr. Pete Economou.

Nikki: And I'm Dr. Nikki Rubin. Be present. Be brave.

Pete: This has been When East Meets West, all material is based on opinion and educational training of doctors Pete Economou and Nick Rubin.

Nikki: Content is for informational and educational purposes only.