The Ins and Outs of Health Anxiety OCD
OCD is a relatively rare illness found in 2.3% of the adult population and 1% of juveniles. While it’s largely believed to be a disorder marked by organization, a fear of germs, or a desire to clean the house from top to bottom, OCD is much more complicated than most people realize. It isn’t limited, either. In other words, only a portion of sufferers are concerned with things like washing their hands. The rest have obsessions limited by nothing other than their imagination.
While OCD may be painted as an illness that annoys or irks the sufferer, this minimizes its awfulness. Those with OCD aren’t simply bothered by their disease, they’re controlled by it.
The ABCs of OCD
OCD is short for Obsessive Compulsive Disorder and, as the name insinuates, is a condition marked by obsessions and compulsions. Obsessions present as intrusive, anxiety-provoking, and terrifying thoughts that scare the sufferer and cause them to question reality. These thoughts are egodystonic, which means they go against the sufferer’s true desires, values, and wishes. This is a key ingredient that leads to the thought’s terrifying nature.
Compulsions are what the sufferers engage in as ways to “cancel out” their obsessions. They’re defined as rituals or routines that are done repeatedly in an attempt to modulate anxiety. For example, someone with OCD who is afraid that they’ve left their front door unlocked will check the door over and over again to make sure it’s indeed locked.
The repetition is important as checking that a door is locked does not equate to OCD and is something performed by anyone who is safety conscious or not keen on being robbed. But those with OCD aren’t able to check the door once and then go to bed; they must check it over and over again just to be sure.
As a rule, OCD is never satisfied, which is why it requires its sufferers to engage in cycles of obsessions and compulsions. In keeping with the above example, an OCD cycle might present as follows.
- The sufferer fears that their front door is unlocked and grows concerned that a serial killer will enter in the middle of the night and murder their family.
- The sufferer checks the front door and sees that it’s locked.
- After some time (seconds to minutes to hours), the sufferer begins to question whether or not the door was truly locked. They might wonder if their eyes were playing tricks on them or if the door only looked locked. They might fear that the door was locked but not shut all the way, thus preventing the lock from holding and latching.
- The sufferer then checks the front door again and, again, sees that it’s locked.
- After some time, the sufferer starts to question again whether the front door was really locked and then repeats the above pattern over and over.
Sometimes, OCD traps the sufferer in a cycle by forcing them to concentrate on one thing repeatedly (the front door, for example). Other times, OCD changes specifics but maintains the overall theme. For example, someone who is concerned that the front door is unlocked may check the front door and see that it’s locked. But their OCD may force them to question whether other doors in the house are locked or whether the windows are locked. It may use creativity as an ally, leaving the sufferer to question whether a serial killer can shimmy down the chimney or in through the doggie door.
Dealing with OCD is very much like playing a Whack-a-Mole game: Conquering one obsession causes another to pop right up.
How Intrusive Thoughts Work
OCD would not be OCD without intrusive thoughts but intrusive thoughts are not limited to those with mental illness as they commonly occur in members of the general population as well. The intrusive thoughts between OCD sufferers and those with regular brains are similar in content but the way each group reacts to the thoughts is entirely different.
People without OCD regard their thoughts as insignificant, ignore them, and move on. People with OCD regard their thoughts as significant, apply meaning to them, and engage in compulsions to control them. This reaction assures that the intrusive thoughts grow more powerful and more present.
In essence, the OCD brain has a spam folder that’s broken; it fails to label intrusive thoughts as the “trash” that they are, landing in the sufferer’s “in box” instead. As a result, the thoughts control the sufferer, consuming their time, their energy, and all aspects of their lives.
Still, those with OCD know, deep down, that their intrusive thoughts aren’t real. But OCD demands 100% certainty and uses the question of “What if?” to keep the sufferer hooked.
It’s this pathological doubt that assures the cycle of OCD stays in perpetual motion.
The Specifics of Health Anxiety OCD
Health Anxiety OCD walks the fine line of hypochondria though they’re not exactly the same thing (more on that later). They do share a theme with the underlying fear of poor health or disease steering the ship.
Those with Health Anxiety OCD possess irrational fears around illness and then engage in compulsions that help assuage their fears. They may possess fears whether or not symptoms are present.
For examples, someone with Health Anxiety OCD who has a headache may fear that they have a brain tumor although the risk of a brain tumor is .6% and virtually everyone has headaches from time to time. But OCD sufferers don’t need a headache in order to fear a tumor. They may possess this fear in the absence of any symptoms at all.
Common Health Anxiety OCD Obsessions
Those with Health Anxiety OCD may have obsessions about any illness or disease. Some of the most common obsessions include:
- Fear that certain words (e.g., cancer or heart attack) will cause disease
- Fear that medications will cause illness
- Fear that everyday aches and pains are proof of a serious illness
- Fear that hearing about a disease means it’ll happen to them (i.e., if someone hears that their friend from high school died of an aneurysm, they may fear that that’s a sign that they’ll die of one too)
- Fear of having a disease because one thought about it
- Fear that reading about a disease will cause one to occur
- Fear that good test results are wrong or that the lab made a mistake
- Fear of communicable diseases (this is where Contamination OCD and Health Anxiety OCD intersect)
In addition to the above, those with Health Anxiety OCD tend to dramatically compound legitimate risk. For instance, women who drink wine have a higher chance of developing breast cancer than nondrinkers. However, the risk is very low and only significant in those who drink more than one glass of wine a day.
The OCD brain abandons the context and instead maintains a laser-like focus on the link between wine and breast cancer. Due to this linkage, an OCD sufferer may fear that drinking a single glass of wine (or perhaps a single sip of wine) will cause a breast tumor. The OCD brain will also ignore the benefits that wine offers. In those who are genetically predisposed to heart disease, for instance, wine protects the cardiovascular system, ultimately neutralizing the risk any small increase in cancer presents.
Common Health Anxiety OCD Compulsions
To manage the intrusive thoughts, OCD sufferers engage in compulsions aimed at relieving their anxiety. The goal of the compulsion is reassurance: The OCD sufferer wants to convince themselves that they don’t have or won’t get the disease they fear.
As such, some of the most common compulsions include:
- Excessive washing (if the health anxiety involves a communicable disease, it may overlap with Contamination OCD and sufferers will engage in similar compulsions as those afraid of germs)
- Searching their symptoms on the internet (this almost always worsens the anxiety as the internet tends to tell everyone that they’re dying)
- Seeking reassurance from friends, family members, or doctors
- Requesting medical tests that are not necessary (for instance, someone with Health Anxiety OCD may request a CT scan of their lungs in the absence of symptoms because they fear they have an embolism)
- Seeking second opinions when test results find no indication of disease (OCD sufferers my seek second opinions in person or send their scans and test results to online doctor sites)
- Avoiding things that they fear may cause illness (using the example above, someone who fears that wine causes breast cancer will avoid drinking it)
- Avoiding certain words, phrases, or numbers in fear that those may cause illness
- Doctor shopping as a way to access more imaging tests or bloodwork
- Faking an illness in order to gain access to medical tests
- Praying, counting, snapping, or engaging in other similar compulsions whenever the thought of a disease pops up
- Needing to do things “just right” in order to prevent disease
Those with Health Anxiety OCD may also adopt very rigid wellness routines and place heavy emphasis on maintaining a healthy weight, exercising regularly, avoiding fats or sugar, and eating a diet rich in fruits and vegetables. This type of wellness routine may be akin to one adopted by those with other mental illnesses, specifically anorexia.
A routine like this is different than one seen in someone who is merely dedicated to healthy living. In the latter, there is more flexibility (the person may engage in a cheat day every now and then), much less intensity, and a failure to stick to the routine does not cause unrelenting anxiety. The person doesn’t engage in the routine as a compulsion, either – they do it because they want to live healthy. Conversely, someone with OCD engages in this routine because they fear that something bad will happen if they don’t.
What Causes Health Anxiety OCD?
Like all types of OCD, there’s not one main cause; OCD is believed to result from a combination of several factors. These include the following:
- Genetics (25% of those with OCD have an immediate family member who has it as well and when OCD is seen in one twin, it’s most often seen in the other (particularly when the twins are identical))
- Compromised communication in the frontal parts of the brain and the deeper parts of the brain
- A hyperactive amygdala (the threat center of the brain)
- Low levels of serotonin and dopamine
- Mutations in the serotonin transporter gene (hSERT)
- High levels of glutamate
- Learned behavior (this won’t cause OCD out of the blue but it allows the OCD to solidify and evolve into a full-fledged disorder)
The Important Role of Dysfunctional Beliefs
Among the factors that make OCD so powerful are the dysfunctional beliefs that buoy the illness. OCD sufferers possess these as a rule, which stops them from seeing their intrusive thoughts as meaningless.
According to the Obsessive-Compulsive Cognitions Working Group, six types of dysfunctional beliefs are most common in OCD, including:
Hyper-responsibility: Hyper-responsibility makes OCD sufferers believe they’re responsible for things they can’t control or things that are well outside what would be considered reasonable.
In Health Anxiety OCD, the sufferer may feel as though they are responsible for their health to a degree past normalcy. Someone who fears heart disease, for example, may believe they need to keep their blood pressure at a very specific number (such as 120/80) or else they’ll put themselves at risk.
A Desire to Control Thoughts: The desire to control thoughts (as well as the failure to do so) is not unique to OCD; everyone would like to control their thoughts and no one can. But OCD sufferers really, really, really want control because their thoughts are so torturous.
In Health Anxiety OCD, a sufferer may experience an intrusive thought telling them that they have COVID. They might then engage in thought-stopping activities designed to erase the thought from their mind. This can involve slapping themselves in the face or pinching their arm. But the more they try to control their thoughts, the more their thoughts control them. It’s impossible to not think of something without actually thinking about it.
Magical Thinking: Magical thinking, or thought-action fusion, may be the dysfunctional thought that reigns supreme in Health Anxiety OCD. This is the idea that something can happen simply because you thought about it.
For example, someone with Health Anxiety OCD may think they have a tumor in their foot solely because they think they do. They’ll fear this outside of any real evidence – their foot doesn’t need to hurt, swell, or have a visible mass in order for this thought to grab hold. The thought alone is enough to cause anxiety.
Overestimation of Threats: As discussed above, those with OCD typically overestimate legitimate threats, believing that something bad is much more likely than it is.
In Health Anxiety OCD, a person may fear mesothelioma because they were exposed to asbestos. While asbestos is linked to this type of cancer, nearly everyone at one time or another has been exposed to asbestos and, nonetheless, mesothelioma continues to be a rare disease.
The greatest risk for it is seen in those who worked with asbestos over a significant period of time, exposing themselves to large amounts year after year. But the OCD brain, again, abandons logic and fears mesothelioma if they were exposed one time during childhood or if they lived in a house with intact asbestos in the walls (which, in itself, is not a risk as the asbestos needs to be disturbed in order to enter the body).
Getting mesothelioma without consistent commercial exposure over a long period of time is highly, highly unlikely. But none of that matters to the person with OCD. If it’s possible, OCD tells them that it’s probable.
Even with the above, no legitimate threat needs to exist in order for OCD to take hold. People may fear getting a disease when the likelihood is zero.
Perfectionism: OCD doesn’t have the market cornered when it comes to perfectionism and it’s quite common for members of the general population to identify as perfectionists. But perfectionism is a cornerstone of OCD and those who have it usually fear something bad happening if they don’t engage in specific actions exactly right.
For example, someone with Health Anxiety OCD may fear consuming red meat because of its link to colon cancer. While this link applies to those who regularly consume red meat, the OCD sufferer may fear that eating a hamburger at a summer BBQ (i.e., an imperfect diet) will put them at risk.
The Inability to Tolerate Uncertainty: At the foundation of all OCD is the inability to tolerate uncertainty. This is why the OCD mind is not persuaded by words like “unlikely” or “rare”; if something is possible or theoretical, OCD moves in.
In Health Anxiety OCD, sufferers are not comforted by the low odds of a disease and instead, need to be 100% sure. But this leaves them chasing something they’ll never catch.
If someone with OCD fears they have a brain tumor, they might request a CT scan at their doctor’s office. But when the scan comes back normal, their OCD will continue manufacturing uncertainty. It might tell the sufferer that the technician made a mistake, that the radiologist missed something, or that they didn’t have a brain tumor a week ago when the scan was performed but they could have one now.
No amount of “checking” sates OCD; it only strengthens it.
Factors that Increase the Likelihood of OCD
OCD can affect anyone, regardless of race, nationality, or socioeconomic status. It’s not particular in who it goes after with the exception of age.
There are two period of life where OCD is most likely to begin: The ages between eight and 12 and between late adolescence and early adulthood.
This doesn’t mean that OCD can’t start at other ages, but it’s not as likely. OCD onset is rare after age 50 (though there are plenty of people diagnosed later when their symptoms started much earlier).
Other factors that influence onset include:
- Genetics (having a relative with OCD or autism increases risk)
- Gender (boys are more likely to experience early onset OCD but, overall, there is no deviation among the sexes)
- Transitions (transitions, happy or sad, can trigger OCD if it’s already there)
- Brain injuries (these may act as a trigger as well in preexisting OCD)
- Trauma (this may trigger a latent disorder or influence the “flavor” of OCD that latches on)
- Strep (in kids, Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS) may cause OCD-like symptoms to appear literally overnight)
Things not believed to cause OCD include:
- Toilet training
- Parenting style
- Anal-retentiveness or personal preference
- Drugs or alcohol (though these can worsen symptoms)
- Childhood environment
What Society Gets Wrong About OCD
One of the biggest frustrations individuals with OCD face is the minimization of their disorder by society. The all too commonly heard “I’m so OCD” proclamation made by people who prefer an organized pantry or who enjoy color coordinating undermines the seriousness of the disorder while painting OCD as a condition that it’s not.
OCD does not involve preference of “liking” things a certain way; it involves fear. OCD is not something that is easily dismissed either; without treatment, it interferes with the sufferer’s life so much that many sufferers refuse to ever leave their home.
Overall, some of the most common misconceptions feeding this misinformation include:
- OCD isn’t a mental illness
- OCD is insignificant
- OCD is a neurotic quirk
- OCD is linked to personal preference
- Those with OCD enjoy performing their compulsions
- All OCD obsessions are related to germs or contamination (in reality, many of those with OCD don’t care about germs or contamination at all)
- People with OCD are uptight, rigid, or need their way
- All compulsions and rituals are physical
- The person with OCD doesn’t know they’re being irrational
- OCD sufferers can ignore their obsessions or get over them
- OCD is just a phase
- Everyone is a little OCD
- OCD causes minor annoyance (in reality, OCD causes terror and panic)
Health Anxiety OCD versus Hypochondria
Health Anxiety OCD and Hypochondria have a lot in common, but they’re not quite the same thing. Both involve a preoccupation with health and wellness and fears of disease, yet they present differently.
The Content of the Obsessions
One of the differences is that those with Health Anxiety OCD may have other worries and obsessions that are not health-related. This is because OCD sufferers often have more than one “flavor” of OCD or their OCD may rotate between flavors. For instance, someone with Health Anxiety OCD may concurrently have Relationship OCD and suffer from obsessive fears of their spouse leaving them (which has nothing to do with health). Or they may start out with Health Anxiety OCD and their OCD may eventually evolve into Harm OCD.
Hypochondria, on the other hand, always involves fears of disease. While it may ebb and flow in terms of severity, the overall theme doesn’t ever change.
An Emphasis on Physical Sensations
One of the hallmarks of OCD is that the intrusive thoughts hold power in the absence of evidence. For instance, someone with Health Anxiety OCD may fear that they’re having a heart attack even if they don’t have any symptoms of one (i.e., their heart isn’t racing, they’re not short of breath, and they’re not experiencing chest or arm pain).
In Hypochondria, physical sensations are more necessary. Hypochondriacs tend to place a strong emphasis on physical sensation, routinely studying themselves to look for them. They then tend to fear terrible things based on vague symptoms. For instance, someone suffering from Hypochondria may obsess about having leukemia because they’re tired when, in reality, lethargy is the result of all sorts of things (including worrying).
Awareness of Irrationality
People with OCD usually recognize that they’re being irrational. They follow their compulsions not because they truly believe them but because, as mentioned earlier, OCD requires 100% certainty. This insight into their irrationality motivates OCD sufferers to seek psychological care. They’re usually willing to see a therapist because they want to get better.
Those with Hypochondria are generally less convinced that they have a mental condition and thus less likely to seek therapy. They’re far more likely to see a medical doctor, believing that their fears and concerns are legitimate.
The Compulsions Involved
While OCD is a disorder that, by rule, is never sated, Hypochondria might be. For instance, someone with Health Anxiety OCD who fears that they have HIV may not be relieved by a negative HIV test. Instead, they’ll wonder if the test was inaccurate, if the lab mixed up their results with someone else, or if they were recently exposed and still in the latency period. All of this requires test after test after test. Even then, no amount of testing truly convinces them (though they may be convinced for a while, OCD rears its ugly head eventually).
In Hypochondria, there isn’t as much doubt in the face of scientific evidence. While a Hypochondriac may share the same fear of being infected with HIV, a negative test result is more likely to assure them that they’re fine.
OCD (all types) is about half as common as Hypochondria (2.3% of the population compared to 5%). But because Health Anxiety OCD only affects a portion of those with OCD, it’s markedly less common.
There are similarities, of course. Both OCD and Hypochondria involve a great deal of anxiety, fear, worrying, reassurance seeking, and safety behaviors. They can both interfere dramatically with relationships, work, school, happiness, and – ironically – health.
Treatment for Health Anxiety OCD
When seeking treatment for Health Anxiety OCD, it’s important to recognize that not all trips to the doctor translate to compulsive behavior. Anyone experiencing true symptoms of illness should seek medical attention as their concerns are valid. Likewise, no one with OCD should go against medical advice; they shouldn’t refuse a blood test or imaging if their doctor thinks they need it.
But if people seek reassurance for no other reason than fear, worries, or concerns, that’s when the OCD cycle starts. And the way to break it is with proper treatment, including the following:
CBT with ERP: The front line of OCD treatment is cognitive behavioral therapy (CBT), including exposure and response prevention (ERP). In this therapy, sufferers are instructed to expose themselves to their intrusive thoughts (either intentionally or organically) and then refrain from engaging in their anxiety-reducing rituals.
In Health Anxiety OCD, for instance, the sufferer may be asked to think about having a tumor and then refrain from seeking reassurance from doctors, looking on the internet, praying, thinking good thoughts, or anything else that lowers their discomfort.
The idea is to teach the sufferer not to respond to their intrusive thought, which allows them to render it meaningless and ignore it. Once they do this successfully, the OCD begins to go away.
Not that it’s easy! ERP is extremely hard as it causes the sufferer’s anxiety to skyrocket. But it goes down eventually and, the more ERPs are successfully completed, the less powerful the anxiety feels.
Another goal of ERP is to teach the sufferer that they can handle uncertainty as OCD has convinced them that they can’t. They learn to regain their acceptance of uncertainty while acknowledging that 100% certainty is 100% impossible.
Because ERPs cause so much distress, stopping and starting over is common. But as long as the sufferer keeps at it, they’ll experience positive change. Many therapists start their patients off on lower level ERPs before moving into the harder ones. This give patients a chance to see that ERPs work, which motivates them further.
Medication: Approximately 70% of OCD sufferers respond to medication. The reason not everyone is responsive is because OCD medications, like all medications, are designed for normal pharmacological metabolism. Some individuals metabolize drugs faster than normal and some metabolize them slower than normal.
Unfortunately, drug metabolism can’t be changed as it’s dictated by genetics. People can learn what type of metabolizer they are through a saliva test. It must be ordered by a doctor but it’s generally covered by insurance.
This genetic test tells OCD sufferers the drugs they should avoid because of a lack of response or increased side effects. Having this information can reduce a lot of trial and error, wasted time, and frustration.
When drugs are effective, they don’t make OCD go away altogether. But they reduce its potency enough to make the ERPs easier. Some of the medications that do this best include:
Serotonin Specific Reuptake Inhibitor (SSRIs)
Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
The tricyclic antidepressant most commonly used for OCD is Anafranil (Clomipramine). This is believed to be one of the most effective drugs for OCD but it also comes with the peskiest side effects. Some people may be advised not to take it if they have other underlying health conditions.
When the more traditional drugs are ineffective, doctors may look for drugs outside of the OCD box. They might prescribe medications that are FDA-approved for other things than OCD. These off-label drugs are gaining a lot of attention, due in part to the anecdotal reports of sufferers attesting to their effectiveness.
Some of the drugs that might be prescribed include:
Limiting Compulsions: The end goal of OCD treatment is to eliminate compulsions altogether as they act as validation for OCD, making it worse in the long run. Understandably, going cold turkey isn’t always realistic and limiting compulsions might be a more reasonable place to start.
This idea is occasionally used for Health Anxiety OCD more often than other types of OCD and can be effective especially in terms of internet searches. Because so many people with health obsessions rely on the world wide web (or Dr. Google) as a way to seek reassurance, some therapists recommend that OCD sufferers wean themselves off this gradually. They might suggest that the OCD sufferer first limit their searches to one day a week (such as Mondays) before graduating to one day every two weeks, to one day a month, and so on.
They’ll still need to commit to ending the compulsions entirely but doing so in increments can be more tolerable to sufferers. And this make them more likely to stick to their practice.
ACT Therapy: ERP is the gold standard of OCD treatment but Acceptance and Commitment Therapy is used as well (it may be used to treat other mental illness too). ACT focuses on looking at intrusive thoughts with blanket acceptance instead of reacting to them or responding to them. The idea of ACT is to essentially view the thoughts as separate from the sufferer – thoughts that don’t mean anything or represent anything.
Sufferers may be encouraged to use gimmicks as a means to help them, imaging their thoughts on billboards, in magazines, or on television screens. They may also be encouraged to view their thoughts as thoughts that are propelled by OCD.
For example, in Health Anxiety OCD, the sufferer may fear that they’ll get cancer if they read a book about a character who has cancer. Instead of engaging in a compulsion and avoiding the novel, the sufferer is instructed to say, “I’m having an OCD thought that I’ll get cancer if I read this book” or “My OCD is telling me that I’ll get cancer if I read this book.” This is more effective, and more rooted in reality, than saying, “I’ll get cancer if I read this book.”
Ultimately, OCD thoughts are not really the thoughts of the sufferer – they’re images, ideas, concepts, and words that almost take on a life of their own. ACT intends to remind the sufferers of this, separating the truth from the lies that OCD spins.
Lifestyle: Most people with OCD need professional help in order to get their OCD under control. Nonetheless, there are everyday things sufferers can do to manage their symptoms.
- Eat well (adopt a diet rich in fruit, vegetables, whole grains, and nuts and one that is low in high-fat diary or red meat)
- Exercise regularly (routine exercise is beneficial to several aspects of mental health)
- Engage in yoga, mindfulness, meditation, and other relaxation techniques
- Limit or remove tobacco, coffee, and alcohol
- See a therapist weekly and practice ERPs
- Find support groups and speak openly about OCD
- Maintain social relationships
- Get adequate sleep
- Go to bed early (there is new evidence that links late bedtimes to less control over obsessive thoughts)
TMS: In severe cases of OCD, Transcranial Magnetic Stimulation (TMS) may be used. This is typically prescribed for depression, but it shows effectiveness around OCD as well, especially where traditional forms of treatment fail.
TMS is a non-invasive procedure that relies on the magnetic field to regulate the deep areas of the brain believed to be associated with OCD. While it’s not brain surgery, it is more intensive than other types of treatment and requires daily appointments for a period of 4-6 weeks followed by maintenance appointments.
Finding an OCD Therapist
OCD isn’t misunderstood solely by laypeople; clinicians misunderstand it as well. This requires OCD sufferers to choose their OCD therapist with a pickiness that might not otherwise be required.
Finding a therapist who treats OCD is typically not enough as many therapists treat it without proper or extensive understanding. Thus, it’s best to limit searches to clinicians who specialize in OCD and who have completed training that is specific to obsessions and compulsions.
Those with OCD or family members can use the International OCD Foundation’s directory as a good place to start. Here you can search for qualified clinicians based on city or zip code.