CBT for Health Anxiety: Facing Your Fears with Exposure and Response Prevention

1. Reduce the fear of physiological sensations or symptoms; and
2. Reduce the use of “safety behaviors,” or the things one does when they are anxious about their health. 

How your fear of bodily sensations makes you more anxious about your health 

With health anxiety, we tend to assume that bodily sensations or symptoms are automatically dangerous. However, bodily sensations and symptoms do not automatically indicate a disease or medical crisis. Our bodies are “noisy.” We can have lots of symptoms and sensations simply because of normal health self-regulatory processes, anxiety (the “fight or flight” phenomenon), or benign medical conditions. If you think every sensation or symptom is indicative of a disease or medical emergency, this will cause you to be hypervigilant and on the lookout for symptoms. This process further increases health anxiety.

How safety behaviors and avoidance make you more anxious about your health

Your fear of bodily sensations and symptoms makes you do certain things to reduce the anxiety when a symptom pops up. These are called safety behaviors. These behaviors may reduce anxiety in the short term but definitely increase anxiety over the long term. Why? We grow dependent on them and begin to believe they are what saves us from illness and death. We never give ourselves the opportunity to test out our belief that we need these behaviors to be safe. Below are several examples of safety behaviors associated with health anxiety.

• Reassurance-seeking behaviors:
  • Asking friends and family members what they think (e.g., Do you think this twitch is something neurological? Do I look flushed to you?).
  • Frequenting primary care offices, urgent cares, hospitals, or other medical facilities and consulting with doctors and other medical professionals.
  • Googling symptoms.
• Excessive checking behaviors:
  • Repeatedly push, pull, poke, or pinch a part of one's body or new symptom; comparing two sides of one's body to identify any differences; or inspecting one's feces or urine.
  • Checking one's heart rate, blood pressure, breathing patterns, weight, or lung capacity.
  • Giving oneself examinations of some kind, such as visual tests, neurological or cognitive tests, or physical exertion tests.
  • Giving oneself recommended body examinations that beyond clinical recommendations (e.g., giving oneself a breast exam for lumps every single day or a body scan for moles every single day).
• Preventive behaviors:
  • Reading up on health websites to find recommendations on how to prevent illness or improve one's health.
  • Carrying personal medical equipment (e.g., stethoscope, heart rate monitor, blood pressure monitor) to regularly be able to check one's vitals).
  • Carrying around personal information "just in case" one needs it in a medical emergency.
  • Carrying around personal info or keeping “safe people” around in case of a medical emergency.
  • When traveling, checking where the nearest urgent care or hospital is just in case of a medical crisis.

Avoidance, as one might expect, is when a person avoids anything that makes them feel anxious about their health. For example, some people with health anxiety avoid getting physicals or regular checkups at the doctor because they fear being told there is something wrong with their health. Or if they have a concerning symptom, they might avoid or put off getting it examined by a doctor, again, because they fear being told that something is wrong. In another example, one might avoid anything that reminds them of a certain disease, such as watching a movie about cancer.

Understanding the rationale behind exposure therapy and why it works

It is only natural to want to stay away from the things that seem threatening. In fact, it is quite logical. If a man with a knife started trailing you on the street, you should most definitely run away. However, sometimes we inadvertently label something as dangerous when it is not.

With health anxiety, there is a fear of bodily sensations and symptoms, which can lead to a couple of things: (1) avoidance of any activity that leads to feared symptoms (e.g., exercise); and/or (2) engaging in “safety behaviors” anytime a symptom or sensations emerges. All of this worsens our fear of bodily sensations.

With exposure therapy, we intervene to help make one less afraid of things that are not dangerous. Exposure therapy involves the systematic confrontation of one’s fears, in which one learns to face physical symptoms without relying on safety behaviors or avoidance to feel safe. Over time, this intervention both (1) reduces fear of the symptoms; as well as (2) reduces one’s inclination to rely on safety behaviors.

Types of exposure tasks:

• Imaginal exposures: imagining feared scenarios over and over until they lose their power and seem less scary. This can be done by the therapist in sessions or by the client, using voice recordings or written narratives.
• Interoceptive exposures: engaging in physical activities that intentionally bring on feared bodily sensations (e.g., spinning in a chair, running, breathing through a straw).
• In-vivo or situational exposures: engaging in feared activities or facing feared situations without using safety behaviors or avoidance.

Preparing for and engaging in exposure tasks for health anxiety

I’ll walk you through a simplified overview of what I do with my clients to (1) prepare them for exposure exercises, and (2) complete the exposure exercises.

• I provide education on the role of hypervigilance about bodily sensations in maintaining health anxiety.
• I provide education on the role of safety behaviors and avoidance in maintaining health anxiety.
• I engage in cognitive restructuring to help my clients see their fears more logically. This is important to do prior to exposures because they will use these cognitive skills when facing difficult exposure tasks.
• I help my client identify and make a list of all their feared bodily sensations and symptoms. This is important because health anxiety involves hypervigilance around physiological symptoms due to the fear that they indicate a medical emergency or underlying disease.
• I help my client to identify their “go-to” habits when they feel anxious about their health. We collaboratively “brain dump” all of their behaviors into a list. This is an important step in the process because we want the exposure hierarchy to fit well with the person’s unique problematic behaviors and feared sensations. This will make the exposure tasks more effective.

Below are the two “brain dump” lists I created with Kendra, a former client of mine.

Kendra’s list of feared physiological sensations

• Heart palpitations.
• Elevated body temperature.
• Sweating.
• Dizziness.
• Chest pain.
• Numbness.

Kendra’s list of common safety behaviors/avoidance:

• She checked her pulse a couple of times a day. Usually, she would do this when she would exercise or when she felt “off” or it seemed like something was wrong.
• She would avoid working out so as to not increase her heart rate.
• She would go to the doctor or urgent care frequently, especially if she thought it was some type of cardiovascular symptom.
• She spent lots of time on the internet searching for symptom causes or reading about diseases.
• She would ask her husband regularly if he thought she seemed OK or if she should be worried about a certain symptom.
• The rare times she did allow herself to exercise, she would stay close to home in case she had a medical emergency.
• When she went on longer drives, she would make sure there were urgent cares and/or hospitals along the way.

After my client and I created our two lists (i.e., feared bodily sensations and safety or avoidance behaviors), we drew from these lists to create a variety of exposure items. Below are some examples of different exposure tasks Kendra completed.

Examples of Kendra’s interoceptive exposures tasks:

• Run in place for five minutes.
• Spin around in her chair.
• Run up and down the staircase 10 times.

Examples of Kendra’s imaginal exposure tasks:

• Experiencing intense heart palpitations.
• Getting dizzy and passing out.

Examples of Kendra’s in-vivo or situational exposure tasks:

• Take a walk to the park (about a mile walk) without taking her phone.
• Take an hourlong drive by herself without looking up urgent care or hospital locations beforehand.
• Refrain from going to the doctor for a new symptom for three days.
• Refrain from checking pulse if I feel “off” or notice my heart rate increase.
• Run a 45-minute run by myself, away from home and with no phone.

The results

Exposure therapy can be scary and challenging at times but it can have incredible results. After several months of working together, Kendra’s health anxiety improved immensely. She began to view health and illness much more logically and stopped using her safety behaviors because she no longer believed they were necessary. We were able to transition her out of treatment.

If you want to take the next step to improve your health anxiety, get my free guide on how to improve health anxiety with CBT.