Undoubtedly, it is important to be mindful of and proactive about taking care of one’s health, such as maintaining annual check-ups or following up with a medical provider when signs of physical ailment arise. However, individuals can also reach a point of excessive concern and anxiety about their health, where being proactive may turn into frequent visits to the doctor that may not be warranted. For others, delaying a routine physical exam can turn into unhelpful avoidance. In both scenarios, significant health anxiety may be at play, better known as Illness Anxiety Disorder (IAD). IAD is a mental health condition where those affected experience significant preoccupation about having or developing a serious medical illness or illnesses, such as cancer, despite the medical risk associated with the health concern being minimal or absent altogether.
IAD, along with another mental health condition, Somatic Symptom Disorder (SSD), was previously referred to as hypochondriasis prior to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). While both disorders center around significant anxiety about health, those with IAD often have minimal or no physical symptoms and still fear illness, while those with SSD are usually moderately or significantly symptomatic and experience significant distress about the physical symptoms (American Psychiatric Association, 2013). The focus of the present article is on IAD, specifically helping those affected and practitioners answer the question, “What is considered adaptive or helpful anxiety about one’s health, versus when does anxiety start to become maladaptive or unhelpful, where mental health treatment for IAD may be warranted?”
It is important to note that if there is concern about a medical condition, an initial follow-up with a medical provider is imperative to understand if there may be any medical diagnosis or risk factors that need to be treated or monitored. However, individuals with IAD may continue to feel significantly worried even after they have either received medical clearance, treatment, or knowledge that their risk factors for disease or likelihood of a serious prognosis are low.
With IAD, it is common for anxiety to initially get triggered by one’s noticing a physical sensation or symptom in the body. For example, an increase in heart rate immediately is interpreted as a sign of a heart attack, or a headache is automatically interpreted as a sign of a brain tumor. Additionally, receiving any news about one’s health status or waiting for lab results can often be difficult for those with IAD, where they may assume that the outcome of the results is the disease they had feared developing. Also, being exposed to health- and illness-related content, such as watching a commercial about treatment for multiple sclerosis, or being in an environment where exposure to disease is possible, such as being in a hospital, can result in significant anxiety for individuals with IAD. Their minds are overestimating the risk of a perceived threat (i.e., having or developing a serious disease) and having difficulty managing the worries and tolerating any amount of uncertainty about their health, which can, in turn, result in either excessive care-seeking and action-oriented behaviors or avoidant behaviors (American Psychiatric Association, 2013).
Excessive care-seeking behaviors can include seeking frequent reassurance from medical providers that you do not have an illness or extensively seeking information about how you can prevent illness from developing. For instance, an individual may go to the same doctor multiple times and repeatedly request tests and lab work to rule out their concerns about having Lyme disease, or they may seek multiple opinions from many different doctors to obtain reassurance, despite perhaps being tested and told already by a few providers that their markers are negative for Lyme. It can certainly be helpful to seek additional opinions about one’s health status, especially as some medical illnesses can be complex in nature to diagnose, such as Lyme disease. As highlighted, it is imperative to rule out any medical conditions prior to an IAD diagnosis.
Once diagnosed with IAD, many still find themselves “doctor hopping,” where no amount of medical clearance, testing, or knowledge will relieve the anxiety, and there may only be temporary reassurance felt when it is pursued. Excessive reassurance may also be sought from friends or family members between doctors’ visits. Other behaviors that may appear to be proactive on the surface but can be signs of IAD include constantly checking oneself for signs of illness, such as frequently monitoring one’s breathing due to concern about developing a pulmonary disease or using “Dr. Google” and spending a significant amount of time researching feared illnesses (e.g., looking up the symptoms for brain cancer after experiencing signs of a headache).
On the other side of the spectrum, significant anxiety about one’s health can also result in maladaptive avoidance of facing anything health-related due to the fear that one’s worst-case scenario may be true. Therefore, some individuals with IAD may lean into avoidance to help alleviate their distress and may start to avoid being around situations or settings where exposure to health content or sick people is a possibility, such as avoiding watching, reading, or hearing anything related to illness or specific illnesses. There can also be care-avoidant behavior where one starts to avoid going to the doctor and seeking medical care, even if it is in their best interest (American Psychiatric Association, 2013).
Whether one copes with their anxiety through an action-oriented or avoidant style, a person with IAD can be caught in the anxiety cycle. Anxious thoughts about their health lead to uncontrollable worries that result in the aforementioned safety behaviors (e.g., reassurance seeking, checking, researching, avoidance, etc.) or behaviors that temporarily alleviate their distress in the short-term but actually maintain their anxiety in the long-term. In other words, engaging in safety behaviors as a way of coping with health anxiety can strengthen the mind’s perception of threat related to illness and underestimate the perception of one’s ability to cope with the feared outcome. Being caught in the IAD anxiety cycle can be incredibly distressing and time consuming, potentially costly due to all of the doctors’ visits and pursued testing, and interfere with one’s daily functioning at school, work, in one’s relationships, attending to responsibilities and living a meaningful life overall. When the anxiety has risen to this level, the anxiety has become more maladaptive, and mental health treatment may be warranted.
Fortunately, cognitive behavioral therapy (CBT) is an available, evidence-based approach and is considered the most well-researched and efficacious psychotherapy for IAD at this time (Kikas et al., 2024; Olatunji et al., 2014). While research is more limited, some promising evidence suggests that other common modalities, such as Mindfulness-Based Cognitive Therapy and Acceptance and Commitment Therapy, may also be effective psychotherapy approaches for IAD (Kikas et al., 2024). CBT can help individuals with IAD to more appropriately manage their anxious thoughts with more realistic mindsets about their body sensations and health-related triggers while taking care of their health in more adaptive ways. For example, a CBT approach can assist individuals in identifying and challenging their distorted thinking and recognizing more realistic possibilities using factual evidence rather than immediately assuming the worst-case scenario (e.g., feeling temporary light-headedness that has already been ruled out as a medical issue by a physician may be better explained by not eating or hydrating rather than by a serious medical explanation). Additionally, an element of CBT can include a form of treatment called Exposure and Response Prevention (ERP), which involves gradually facing or exposing oneself to a range of feared health-related situations that intentionally trigger one’s anxiety.
The response prevention component of ERP includes choosing to intentionally not engage in safety behaviors when exposed to anxiety-inducing situations. For instance, an individual who fears developing lung cancer may benefit in their ERP treatment from reading an article about a patient’s lung cancer story and refraining from safety behaviors, such as searching online for the symptoms of lung cancer or monitoring changes in their breathing. Throughout CBT treatment, a mental health therapist can also consult with one’s medical providers to collaborate and help inform the therapy process. Ultimately, CBT and ERP can help individuals break free from the health anxiety cycle and more effectively and confidently tolerate uncertainty about their health while still addressing it proactively in reasonable ways to live a meaningful life.
Hongmarie Martinez, PsyD, is a licensed psychologist in New Jersey and New York and a certified school psychologist in New Jersey. She works at Behavior Therapy Associates in Somerset, New Jersey. Dr. Martinez has the authority to practice interjurisdictional telepsychology (APIT) from the PSYPACT commission, allowing her to provide telepsychology to clients in many states. She can be reached at [email protected] and at BehaviorTherapyAssociates.com.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
Kikas, K., Werner-Seidler, A., Upton, E., & Newby, J. (2024). Illness anxiety disorder: A review of the current research and future directions. Current Psychiatry Reports, 26(7), 331–339. https://doi.org/10.1007/s11920-024-01507-2
Olatunji, B. O., Kauffman, B. Y., Meltzer, S., Davis, M. L., Smits, J. A. J., & Powers, M. B. (2014). Cognitive-behavioral therapy for hypochondriasis/health anxiety: A meta-analysis of treatment outcome and moderators. Behaviour Research and Therapy, 58, 65–74. https://doi.org/10.1016/j.brat.2014.05.002
