Health Anxiety and Interoceptive Exposure
By Norman Cotterell, PhD
Beck Institute Faculty
When a client of mine, Adam, was 22, he received the following diagnosis during a routine physical: elevated liver enzymes. He thought, “Oh my God, I’m going to die.” It was later revealed that the lab results were in error, but as he reported to me ten years later: “This catapulted me into health anxiety.”
Health anxiety involves focusing on the catastrophic consequences of an unexpected physical sensation, or health circumstance, (i.e. “If my chest hurts, I have a heart problem,” “If my enzymes are elevated, it will lead to my death.”) Unlike panic, however, the feared consequences are not immediate. Panic is characterized by an imminent catastrophe. Health anxiety is characterized by an eventual catastrophe. It is often accompanied by safety behaviors such as checking, reassurance seeking, information gathering, avoidance, thought stopping, or rumination, and is also characterized by an intolerance of uncertainty.
The Three B’s
For Adam, these eventual catastrophes were legion. Over the course of 10 years, his fears accumulated as he built his career and got married. And with two children, his anxiety grew along with his responsibilities. His health anxiety symptoms were expressed in the “Three B’s” of Body, Belief, and Behavior.
Body as Expressed in Physical Sensations
Adam reported tingling in the face, hands and feet, palpitations, premature ventricular contractions (PVCs), gastrointestinal distress, headaches, having a lump in his throat, and hot flashes.
Belief as Expressed in His Thoughts
He thought, “I have spine cancer, testicular cancer, throat cancer. I’m overwhelmed; it’s too much; I can’t get over this.”
Behavior as Expressed in Urges
He was constantly distracted by urges to:
- Check: “I can touch my groin, back or neck 50 times in a day to check for signs of cancer.”
- Seek reassurance: “I have to ask my wife, sister, mom, a co-worker, my mom’s husband (a physician), family doctor, and lastly, a specialist, whether or not I have a serious illness and am going to be okay.”
- Avoid: “I don’t watch medical shows. I stay away from sick people.”
- Engage in safety behaviors: Mental rituals (such as counting), overuse of anti-bacterial hand gel.
It’s Not About Health
People who fear an illness often behave quite differently from those who have an illness. People who fear heart disease often avoid exercise, while people with heart disease often exercise as recommended by their physician. My client was well aware that his actions were not healthy, and that knowledge added to his distress. He stated that his major goals for therapy were: “To have this weight lifted off my shoulders and stop being so worried about my health,” and be able to say, “That’s a silly thought!” He regarded his actions as ridiculous, unhealthy, and a burden on his family. But he also regarded them as the only way that he could “get a minute of peace.” By his own reckoning, he could not tolerate a minute more of these fears, feelings, sensations, thoughts, and urges to check or avoid. He expected they would lead to his complete and utter collapse. But in therapy, he needed to test this expectation, learning that a minute more of these fears would not cause him to collapse.
Jon Abramowitz regards interoceptive exposure as a way to test the expectation, present in a variety of anxiety disorders, that sensations are intolerable. By triggering feared sensations, anxious clients can gain greater distress tolerance. They can disconfirm incorrect beliefs about the sensations. And they can reduce their sensitivity to the sensations. Here’s a list of ways to elicit the sensations that trigger anxious clients’ fears:
- Dizziness, headache: Shake head side to side (30 seconds, 2 turns a second, with eyes open)
- Tight throat, breathlessness, dry mouth: Swallow quickly (10 times)
- Chest tightness, breathlessness, hot flashes: Straw breathing (30 seconds, as deeply as possible)
- Derealization, dizziness, tingling appendages: Hyperventilate (60 seconds, standing up)
- Disorientation, nausea: Place head between legs (30 seconds)
- Heart racing, feelings of heat: Run in place (60 seconds)
- Lightheadedness: Hold breath (60 seconds)
- Dizziness: Spin (30 seconds).
The most clinically relevant exposures for this client involved hyperventilation (tingling), straw breathing (breathlessness), and running in place (heart racing). We started with hyperventilation. He raised his hand after 15 seconds to indicate that the sensations seemed intolerable, and we identified the fears about the sensations:
What did you worry would happen? “It wouldn’t go away.”
Was it as bad as you expected? “I handled it better than I thought.”
Did that surprise you? “A little.”
What would happen if we did it a little longer? “Probably nothing.”
What did you learn? “I’m stronger than I thought.”
In many ways, this is also an exposure to uncertainty, as he didn’t know what would happen by increasing the feared sensations through exposures. But in courageously facing such uncertainty, he was able to attain greater certainty of his strength, and in his ability to cope with the feared sensations without using any avoidance strategies or safety behaviors. We listed the benefits of being willing to experience the sensations while embracing the uncertainty: “I have more peace. I can live in the moment. I can be a normal person. I can be happy and content.” This exercise was a step in that direction.
Blakey, S.M. & Abramowitz, J.S. (2018). Interoceptive Exposure: An Overlooked Modality in the Cognitive-Behavioral Treatment of OCD. Cognitive and Behavioral Practice 25 145-155
Craske, M.G., Treanor, M., Conway, C.C., Zbozinek, T. & Vervliet, B. (2014). Maximizing Exposure Therapy: An Inhibitory Learning Approach. Behaviour Research and Therapy 58 10–23.