‘Health anxiety’ in the time of COVID

With COVID-19 infections continuing to rise in the U.S., and debates remaining on how and when to open schools, and if mask-wearing should be mandatory, many of us are understandably uneasy. Most of these circumstances are beyond our personal control, but our individual characteristics can influence responses to the pandemic. Undeniably, personal attributes play a role in the success of public health strategies used to mitigate COVID-19 and determine how well we handle the threat of infection. Health anxiety, excessive concern about one’s health, is one important psychological factor that is affecting people’s reactions to the stress that comes along with COVID.

Thinking, and even worrying, about one’s health is normal. Most of us have experienced finding a lump and wondered if we might have cancer or felt a skip of our heart and questioned if we might be having an attack. Studies indicate that between 10 and 20 percent of the population worries frequently about having a physical illness. And, during this pandemic, some anxiety about one’s health can be adaptive. Pushing us to engage in recommended protective strategies, such as mask-wearing and social distancing.

But true health anxiety is something different. It involves over-diligent monitoring of our symptoms and health and is associated with the misinterpretation of benign bodily signs as proof of disease. This includes an unhealthy rumination with the belief that one has COVID or is in dire danger of developing it. Those with high health anxiety strongly believe in the likelihood and awfulness of illness, that they would have great difficulty coping with an illness, and that medical services would be inadequate if they were to become ill.

Health anxiety exists along a continuum, ranging from mild and circumscribed worry to severe and all-encompassing preoccupation. When health anxiety is on the extreme end of the range, persistent and distress-inducing, that’s a problem. Folks with health anxiety often have an emotional reactivity, a heightened sensitivity to feeling states. They have difficulties tolerating emotional distress and intolerance of uncertainty. They catastrophize bodily sensations in a cyclical, self-perpetuating pattern. It’s like a wind-up toy with an automatic rewind mechanism that keeps on going and going.

People with extreme health anxiety not only have a tendency to over-estimate health threats but they often seek reassurance from friends, family members and health care professionals. This can involve making health care appointments or going to the emergency room for symptoms that are minor or have already been evaluated or leaving multiple phone messages for providers in a panicked manner. 

Laboratory experiments indicate the power and perspective of health anxiety. In one study, people with varying levels of health anxiety were shown health-threatening and neutral pictures. Those with high levels of anxiety sensitivity paid significantly more time and attention to the threat pictures and had faster response times when making evaluations of health compared to non-health words. In another study, individuals were shown close-up photos of random people and asked their perceptions of how sick the person in the photo appears. Generally, those with severe health anxiety rated people in the photos as less healthy. That means, people with high health anxiety are in a sense primed and ready to pounce on health information in themselves and others. And their high vigilance toward health threat is difficult to disengage from.

There isn’t one cause of health anxiety. It likely occurs for several intersecting reasons. Health anxiety is thought to run in families because of genetics and parental modeling. Early experiences with some kind of illness can also lead people to develop an exaggerated internal alarm system of inaccurate health beliefs. People with high health anxiety often have an anxious or disrupted attachment with a primary caregiver or have experienced the death of an ill parent. Some of the intrusive imagery experienced by those with health anxiety centers around abandonment and isolation. Those with higher exposure to adverse childhood experiences, such as childhood abuse and household dysfunction, also have higher levels of health anxiety in adulthood. Contrary to what some may think, folks who are high in neuroticism do not report more health anxiety.

Dr. Andrew Gerber, President and Medical Director of Silver Hill Hospital in Connecticut, had this to say, “As a behavioral health hospital, we’re seeing that more than a third of our patients are presenting with primary distress about COVID. While many of these are individuals with a long history of anxiety-related disorders, some have never identified anxiety as a significant problem in the past and are being overwhelmed by it for the first time in the setting of the current pandemic.

What they tell us is that it’s not just the anxiety around COVID that is so disorienting, but the fact that this is happening when they are isolated, worried about economic insecurity, and afraid that our democracy is on the brink of disintegration. Importantly, the individuals who need help the most are those who try to cope with frightening levels of anxiety by engaging in maladaptive behaviors, like substance misuse, self-harm, and pulling away from relationships. We intervene by helping to reduce levels of anxiety through psychotherapy and medication, but also by teaching our patients ways to cope with their anxiety in positive ways including personal connections, exercise, meditation, and self-care.” 

He’s right. Psychological interventions can help people with health anxiety. In fact, certain psychotherapies are significantly more effective than waitlist, treatment-as-usual, placebo or medication. Cognitive-behavioral therapy (CBT) is the most frequently studied psychological treatment for health anxiety. Essentially this intervention works by guiding a person to identify and modify their thinking patterns. This is often done by using logical reasoning or behavioral experiments to expose folks to the thoughts that trigger and maintain their anxiety. There are also several CBT self-help books and internet-based CBT, that uses self-help text, video clips, and audio files, to help individuals with health anxiety.

Those with elevated health anxiety can also benefit from learning mindfulness skills such as acting with greater awareness, non-judgment, and non-reactivity. People can learn that stress associated with living and managing in the time of a pandemic, can exacerbate feared bodily sensations. They can also come to recognize that most of these sensations are relatively non-threatening and can be effectively regulated. They can also learn to accept or at least tolerate some level of health uncertainty.

The role of health anxiety and pandemics is not new to COVID. Health anxiety was also a significant predictor of people’s responses to the 2009–2010 H1N1 influenza or swine flu as well as to the Ebola outbreak in 2014. But, as the number of people with COVID infections surge, and our country struggles with how best to mitigate risk, we need to take what we’ve learned and helped people mitigate risk and cope more effectively with uncertainty. Now more than ever, it’s important to help people manage realistic and pathological health anxiety. 

Joan M. Cook, Ph.D. is a psychologist and associate professor at Yale University who researches traumatic stress and has clinically worked with a range of trauma survivors including combat veterans, interpersonal violence survivors and people who escaped the former World Trade Center towers on 9/11.