Relapse prevention plan - how to avoid the downward spiral

On the previous article we discussed the downward spiral of anxiety. Today we'll see about one tool to avoid letting that spiral get out of hand. That tool is a relapse prevention plan. 

Anxiety tends to come and go. Sometimes we have very little issues with it, and can go months or even years feeling stable. Then, for whatever reason, it rears it's ugly head: the anxiety and it's physical manifestations comes back. 

Thinking about this wave can already be useful. Maybe you notice that you always have more problems during the dark months, for example, or during family holidays? These are important clues in getting to the root cause of your anxiety.

A relapse prevention plan can be written after a treatment trajectory, or when you are having little to no problems from the anxiety. It should be written soon after recovering from a worse period. When writing the plan during the start of "the good times" you ensure that it's logical, and that you still remember what helped you to start feeling better.

Of course, a plan can be as complex as you want. In it's most simple for a relapse prevention plan has three sections: Situations and risks that can cause you to relapse, how you can recognize a relapse, and helpful thoughts to recover. We will now look at each section.

1. Situations and risks that can cause a relapse

This is your first section. It's simply a list of things that cause you anxiety.

For someone with health anxiety (general fear of falling ill, may or may not be focused of a specific illness) the list could have things like

- news about illnesses, problems in healthcare or relating to sickness

- someone in the family or at work getting ill

- minor physical health complaints such as colds, headache, tiredness, rash

- news about epidemics or pandemics anywhere in the world

- doctor's visits where no clear reason is found for what I'm feeling

- watching medical drama series like House, E.R., Gray's Anatomy (tip: don't.)

- hearing about a person of my age or younger passing away.

For someone with somatic symptom disorder (excessive worries about a specific, existing symptom) the list could be something like

- changes in the experiences symptoms (stronger, appearing more often)

- news about illnesses, problems in healthcare or relating to sickness

- news or shows where my symptom is linked to a very serious condition

- new physical sensations I haven't had before

- deaths or sicknesses in the family.

Try to find the real, more general reasons behind day-to-day occurrences. It's more helpful to write "sickness in the family" than "that one time when uncle George coughed the whole evening, even though it was caused by a cat hair in his mouth".

Note that this is not a list of things you should avoid. It's a list of things that under specific circumstances can cause you to experience severe anxiety for a longer period of time. 

2. How to recognize a relapse

In this section you detail how you recognize that you are slipping back to the anxious circle. 

Try to be specific. for example, instead of writing that you feel stressed, write how do you know it's stress. Perhaps you get stomach aches, even though you haven't eaten anything out of the ordinary? Swollen stomach, fast heartbeat, trouble falling asleep, thinking about sickness, hair loss, dry skin from constantly washing your hands, often considering calling in sick, withdrawing from social encounters, avoiding leaving the house... 

The point of this section is to remind you that what you're feeling is caused by your anxiety. Nothing else. You don't need to call an ambulance. When you then re-read section one, it should give you a feeling of "Ohhh I see, it's this thing again! I see I've indeed been seeing more X, and now I'm experiencing Y. "

3. How to recover

This is the most important, and sometimes most difficult, section. So you know what caused your anxiety, and you know it's indeed anxiety. Well great, but your heart is still beating million  miles an hour, you're hyperventilating and you cannot sleep. So what now?

You can start by admitting that you are more prone to anxiety, and that it causes you physical symptoms. This sounds silly, but it's important: it shows that what you experience is anxiety, not a serious illness.

If you have done CBT, cognitive behavioral therapy, you have made a list of helpful thoughts. Thoughts that make you experience your anxiety in a new light. This is where you write those thoughts. For example, if my worst fear happened and I got sick with X, I would be treated and people would be there to support me. I can rely on people around me.

If you have done exposure therapy, write here all the things you have faces and survived. Remind yourself that you've been here before, and you came out stronger. I have been to hospitals, and while they smell bad (antiseptics), they otherwise have no impact on me.

If you do ACT, acceptance and commitment therapy, remind yourself that this is who you are. Despite the anxiety, you can still do (list all your favorite things here). Focus on what you still have and can do.

Save the plan and come back to it from time to time

You can tell about the plan to your friends or family. They can remind you of it when you're feeling bad, and perhaps you yourself have forgotten about it already. 

Remember that a plan is just a plan. It's a tool. You still need to do the work - and you can always ask for help doing it. You're not alone.

I hope this post can help you the  next time you're feeling down in the dumps!

Mental pee and other lessons from a wise doctor

Recently I visited a doctor, who had a totally different view to my situation than any other doctor I've previously spoken with. I had never met her before, because my usual doctor is away, but I needed to make an appointment. I was unsure what to expect... but in the end she blew my mind. 

Usually the visits start with "so what's going on with you?". She, sitting without her white jacket and dressed in a beautiful, greed blouse, started by chatting amicably about how she came to work there. I was nervous and thinking I'm severely ill, but she kept talking about how she left her previous job to make way for a new colleague. She even joked with my husband, who usually accompanies me but gets ignored 95% of the time.

(What the heck? I thought. Why are we chatting while I'm having serious symptoms here! Except .... of course I wasn't. She was putting me at ease and observing how well I was able to listen, to focus and to reason. )

Then, instead of asking how I was, she said she'd read "my story".  She had taken the time to read about my previous visits and lab results. She had read the reason I've given for my visit. 

By this time I had a suspicion this would 1) take forever, and 2) go either very well or very poorly. It turned out to be option 1 and it went very well. Here's what I learned.

Anxiety is useful

With several examples from the nature she reminded me that anxiety is useful. It's there for a reason. We'd be very much dead if we didn't fear anything and kept taking risks. Us humans are built to stay vigilant and react to our surroundings. It's not a problem. It's what we're supposed to do.

Anxiety is not "all in your head"

Anxiety as an emotion is all in our head, yes, but it's connected to our entire body. The sensations anxiety causes are very real and definitely not in our head. Her legendary comment "You cannot escape a predator with a full bladder. In a panic our bodies empty the bladder. When that happens, we really need to pee and not just mentally pee." 

Your sensations are real. You are not crazy.

Whatever you feel is real, even if an examination cannot prove it. If your leg hurts, but an x-ray doesn't show a broken bone, you're still hurting. If your heart is skipping and pounding, but tests do not show anything abnormal in the conductance or structure of your heart, your heart is still skipping and pounding. If you're tired but bloodwork is all perfect, you're still tired. 

That sensation is real and needs to be treated.

The patient must get realistic expectations.

Especially people with health anxiety and somatic symptom disorder like to expect all kinds of tests. The fact is that many times nothing useful comes out of the tests. You can get 1000 examinations and they will show nothing.

"Testing for the sake of testing is not helpful for anyone." 

The symptoms / sensations still stay. The tests available just cannot show a reason for them.

This is really important to understand, before using medical tests as a safety blanket:

• a test can come back negative ("all good"), but it will not stop the symptoms. 
• a test is never 100% certain.
• a test can reveal something that cannot be helped. It doesn't have to be anything serious, but it can be something the doctors just cannot do anything about.
• and once again, a test may show that all is well, but you will keep having the symptoms you do.
• tests only show what the doctor is asking for. An x-ray of your chest will likely come back with a comment "no broken ribs", unless the doctor had specifically asked to look for a dime you swallowed last week. Blood work can be "all good", unless you specify that you need to know the exact value of X for monitoring purposes.

The patient should be in charge of their health and treatment, not the doctor.

I had wanted a specific test for a long time. I thought it would put my mind at ease, and I was even prepared to do it on a private clinic via a commercial provider. When I mentioned this test, the doctor turned the tables. "Okay, then we'll do that! We need to plan it. Find out what your family medical history is. We need to think what our questions are, and then we'll arrange the test." 

With those words I had a plan, and I was put back on the driver's seat of my own health. No more begging, no more hoping and me vs. the doctor. I was now working together with the doctor. 

Recognize the impact on your family

Often my husband joins me at the doctor, because I tend to get nervous and not dare to speak up. This time was no different. Instead of ignoring him, the doctor involved my husband in the discussions. She listened to him, answered his questions, and provided comfort and confirmation. He is, indeed, impacted by my anxiety. The doctor verbally confirmed that he is doing great work by supporting me. She showed that it's okay for him to sometimes feel lost with me. She confirmed that his feelings are real and worthy. 

And as a by-product she reminded me to do the same. To recognize his struggles in supporting me. To recognize his concerns and his needs.

And that's it! 

By writing these down I hope I won't forget her lessons - and I hope that you, too, will find a doctor who will work with you. 

 

The downward spiral

 Last time we spoke about how to unlock your brain during an anxiety attack / panic attack / bad period in your life. That is a tool for immediate help when the anxiety has already gotten out of control.  Those tips help when we feel like we're drowning in worries and fear. But what if we could stop the anxiety from ever getting that bad?

Let's first look at the spiral of anxiety, the infamous downward spiral. There are a few alternatives, but Dr. Julie Smith has summed it up nicely:

"The more we focus on the negative, the more negatives we experience." 

We get what we focus on. If we focus on threats, we only see threats (and miss all the good things in life). If we focus only on reward and pleasure, we'll be blind to risks and consequences. We need balance. Anxiety is very, very skilled in throwing that balance off.

The spiral works on a large scale as well as a small scale. Let's look at a few examples to see the spiral in action.

Panic attack as a downward spiral: Dr. Smith's example is about a panic attack, which is essentially a small downward spiral. We experience symptoms, misinterpret them as something scary, and desperately try to change the situation. It won't work (we misinterpreted the situation, so we're fixing the wrong problem). The symptoms get stronger the more we stress. Stronger "symptoms" -> more stress -> Stronger "symptoms" etc.

Generalized anxiety as a downward spiral: The more we think of our anxiety and panic, the more we'll feel their effects. By thinking about it we simply do not think of other, more pleasant things. We learn to think only of the perceived threats. Your first panic attack is scary, but you'll forget about it eventually... until it happens again. Now you'll start to avoid the place it happened. Then, just to be sure, places reminding you of that place. Clothes you wore when the anxiety attack happened. Activities you wanted to do when the attack hit. 

You'll not avoid the original problem (physical sensation of anxiety), but random, unrelated factors that remind you of the fear it caused. Down the spiral you go, enjoy your trip! The anxiety becomes generalized. We've become afraid of fear itself.

Not kidding, I spent months avoiding wearing a pair of shoes I had on during a panic attack. Logically I knew the shoes didn't cause the attack, but ... but... what if? I'm also still mildly uncomfortable in the place that happened. And thinking of going there. And thinking of the trains taking me there. Etc etc.

Health anxiety as a downward spiral: We feel a new sensation, and label it as a "symptom". It's not really taking that much of our time, until we start looking into it. We start to browse the Internet and other sources for information. Very soon the tiny sensation becomes a possible cancer, an impending doom, and we're dying right now. 

Through the spiral the anxiety takes over our lives. 

This example from deeperconvos.com is for social anxiety, but it works for health anxiety just as well. The more we focus on our perceived health problems, the sicker we feel - simply because we neglect all other sensations. 

Okay, so now we know we can fall into a seemingly endless spiral of sickness, anxiety and hyperventilation. Great! No, really, it is very important to realize this. We need to understand the mechanic so we can avoid it and solve it.

Stay tuned for tips to solve it.

Next time we'll talk about a prevention plan - a custom-made tool that helps you to recognize when you're getting out of control. Eventually we ourselves recognize it, sure...

but wouldn't it be nice to break out of the spiral before others notice, too?

How anxiety locks the brain - and how to unlock it

Science has proven time and again that emotions can override logic. We see this in our own lives as well: people do silly things when "blinded by love", "cannot think straight" when grieving, missing to see risks when overwhelmed with joy... We even have sayings like "driven by despair". Despair is not a real person chasing us with a whip. There's no chase, no blindfolds, no real block in our brain. It's just that the logic cannot make itself heard over the screaming of emotions.

In mental health conditions such as anxiety, mania and depression this effect can be quite extreme. When in the middle of an anxiety episode (which is not the same as a panic attack) at least I lose the ability to think logically. All I can focus on are the symptoms, what they might mean, and the crushing urgency of having to fix the problem right away. I don't care how, but the source of my anxiety has to stop. I need to get away from the source.

If your anxiety is caused by an external thing, congratulations! You can just walk away. Even run, if you want to! It's not smart, no, but you can do it. And I'm incredibly jealous. 

Someone with health anxiety cannot escape the source of their fear. My anxiety is caused by something within myself. I can't escape my body and it's physical sensations - at least not without illegal substances, which are dangerous on a whole another level. I have nowhere to go. 

Not being able to flee definitely works in favor of the anxiety lock. My brain goes in full survival mode. Nothing else matters than surviving this danger, this risk, this impending doom within me. I simply cannot think those helpful thoughts like "hey, I've felt like this before and I was always okay". I won't even remember that I have exercises I can do in these situations. Basically I'm locked in a cell with a screaming anxiety monster.

How to solve it?

Simple: Make a list of calming thoughts and keep it near you. For example if you always have your mobile with you, make a note on your phone. 

The thoughts you can write down are the things that help you to ground yourself. Things that bring you back from the well, and back to reality. Things the therapist or doctor said, for example, or your favorite lyrics. 

A panic attack list can have items such as

• My body reacts to anxiety by X, Y and Z. 
• These sensations are not symptoms of sickness. They are normal sensations of a healthy body. They prove that my body is reacting to my anxiety. 
• I have felt like this before. I have been examined by many doctors, and they all say I am healthy.
• This anxiety is real, but not permanent. It will pass.
• I don't need to fight my fear. I can float through it, and come out stronger.
• In one year, and probably much sooner, this moment will be meaningless and forgotten. It has no long-term impact on me.
• If my best friend felt like this, I would tell them to X and Z.

You could also list things to do that calm you, or that help with the physical aspects of anxiety. Such as

• Sing your favorite song - or at least hum it (this'll help to regulate your breathing) 
• Shake and dance like no one's watching (gets rid of adrenaline)
• Square breathing: breathe in for 4 counts, hold for 4 counts, breathe out for 4 counts, wait for 4 counts.
• Read out loud (regulates breathing, forces your attention away from the anxiety)
• Take a cold shower 
• Get your favorite cuddly toy and just go under a blanket for a while
• Watch cat videos
• Color
• Explain to imaginary audience what anxiety is, how it feels and how it affects you 

Whatever helps, write it down. The next time anxiety grabs a chokehold and you cannot breathe, reach out for this secret weapon of yours. You deviced it, you know it works.

You got this.

Asking Dr. Google

 

Most of us have been there. We experience a new physical sensation, label it as a symptom and try to go online to find what is going on. After a few minutes we usually have tens of possible diagnoses ranging from "ignore it" to "you're basically already dead".  

That is exactly why "Dr. Google" is such a bad idea: it is not very helpful. 

For people with health anxiety googling our symptoms can greatly increase stress and anxiety. Here are a few reasons why that happens.

1) Checking just one symptom. If you search for just a headache, you'll find that almost everything can cause a headache. Without including your other mental and physical sensations, family history, medication and current health most of these "diagnoses" are just distant possibilities. It's like ordering a meal "with salt", or buying a book "with words". You could get anything, but likely not what you actually wanted.

2) Which pages can be considered reliable? The internet is free, and full of information of varying correctness. Your best bet is to talk to your medical professional about suggestions of pages you can trust. 

Be especially careful with sites from clinics you're not familiar with. Anyone can make a website and pretend to be a clinic. Also, some clinics are after your money and will sell you unnecessary tests and checks, which actually tell nothing at all. Their results might even make your anxiety worse. After all, the harder you look and the more you test, the likelier it is that you'll find something. However, that something may not be of any importance whatsoever.

Also, watch out for scientific portals. Unless you are a scientist, interpreting peer-reviewed research reports is not simple. Without extensive medical background you might miss important clues, which render the entire research completely inapplicable to your situation. If you find a research article that backs up your (anxiety-driven) own diagnosis, and you really really believe it, talk about it with your doctor. 

3) Googling for a possible diagnosis. So let's say that I have a headache. I google it, and find out that a brain tumor is a possible diagnosis. Fueled by adrenaline and fear I now go reading up on brain tumors, and find out that yes indeed, most people with a tumor do have headaches (confirmation, ensuring I'm on the right path). I see what other symptoms are often associated with a brain tumor, and the more you think about it, the more convinced you are that you have, actually, been experiencing those symptoms as well (hint: This is often your anxiety speaking.) Then you read the prognosis. Anxiety will make sure you focus only on the lowest survival rates. Congratulations: within 15 minutes you have gone from a headache to dying in the next two weeks.

Best solution is not to Google. The next best idea is to google for solutions. Instead of googling for "brain tumor", stay with neutral topics like "stretching exercised for headache". 

4) Forgetting the big picture. We'll go with the headache-example. You are now focused on having a brain tumor. Anxiety has a way of locking your brain, so you likely forget the big picture. Let's break it down:

Fact: You have a headache. 

Fact: Many people with a brain tumor have a headache... BUT millions more people have headaches for completely different reasons. 

Fact: A headache does not mean you have a brain tumor. 

5) But Google says I'm DYING omg what do I do now???

Take a step back from the brain tumor diagnosis. What else are you experiencing than a headache, and can you do something about it right now? If you have a headache, take a painkiller. If you're tense, try relaxation-exercises.  

You probably cannot "just let go" so don't even try. It'll just give you more stress, because you're "failing to let go". Just admit that you were googling (again) and driving yourself nuts (again), so now you're feeling a ton worse, good job you. Admit it and let it go. It happened. Just breathe.

And the next time... 

... for the love of all you cherish...

... DO NOT ASK DR. GOOGLE.

A case of the Mondays

Dear diary,

Did not sleep well. I woke up 3-4 times last night, feeling my heart skipping beats and my body tensing. The thought about work made me feel even worse. Eventually decided to call in sick today and that finally let me sleep.

In the morning spent a whole 5 seconds before starting to get anxious. Was able to walk with the dog, and after doubting and worrying about it, did call in sick. Thankful to have a manager who really understands - and feeling sad because she understands. She's going through something similar. We're both struggling, both keeping up appearances and breaking up inside. But we're not giving up.

A lot of physical symptoms today: heart skipping beats, heartburn, acid reflux, extremely swollen stomach (intestines), tense shoulders and arms feeling quickly tired. Probably bad blood flow due to the muscle tension... or an impending emergency.  It's hard to relax, as I keep thinking it's something serious after all. My note on the computer screen says "You're okay", but today I don't believe it. I wrote it last week when I came back from the doctors, and now something is perhaps already changed. 

Managed to eat, and almost threw up afterwards due to the acid reflux. Managed to color a bit:

Also watched tv and played computer games. Still nervous and the voice of anxiety is annoyingly loud today.  If I just could believe it's only stress and let go... but then again, stress kills too, so I'm screwed anyway.

Yay for me.

Somatic symptom disorder vs. illness anxiety disorder

 It begins with the first conscious thought. A barrage of ifs runs through my mind.

“I am awake. Is it  already morning, or did I wake up in the  middle of the night? If it is too early, I may not be able to fall back to sleep. Then I’d be awake alone in the dark, and darkness is uncomfortable and threatening. If I open my eyes to check, I will certainly wake up… but I need to see the time. I need to know. Is it worth the risk?”

Maybe 20 seconds of my day has passed. Both sides of my mind, the real me and hypochondria, are already having their lively discussion. 

Like a spaceship in a sci-fi series I automatically do a “systems check”. In what position did I wake up? How do I feel? What is my pulse? Do I feel hungry, or is the hollow feeling the result of a sudden attack of low blood sugar? If that is the case, how do I safely get down the stairs and to the kitchen to get something sweet? 

The alarm rings and starts a new barrage of doubts.

How do I roll safely over to turn off the alarm? How far can I reach with my arm without possibly generating unpleasant bodily feelings? Which arm to use? Remember to hold your breath when you bend, says the hypochondria, otherwise your heart may again skip a beat, and you know what that can mean.

The daily struggle is on. It’s not a struggle against imaginary fears, as some might think. It’s not a struggle against voices in your head.

Hypochondria is a struggle for control - and for life and death.

It’s all about control

Hypochondria or hypochondriasis is (an outdated term and), in short, the conviction that one is sick even when all results prove otherwise. The Diagnostic and Statistical Manual of Mental Disorders used to define hypochondriasis as an individual diagnosis, but with the newest version of DSM-5 it was changed. The new diagnosis is split into two based on the existence or nonexistence of somatic symptoms (somatic simply means “relating to or affecting the body”). Hypochondria with somatic symptoms is very creatively called “somatic symptom disorder”. Without symptoms it’s, very surprisingly, “Illness anxiety disorder”.

DSM-5 attributes the following symptoms to somatic symptom disorder:

1. One or more somatic symptoms which are disrupting daily life. Some or all symptoms may be caused by other medical conditions. 

2. Excessive attention given to the symptoms or associated health concerns, described at least one of the following

1. Disproportionate and persistent thoughts about the seriousness of one’s symptoms.

2. Persistently high level of anxiety about health or symptoms.

3. Excessive time and energy devoted to these symptoms or health concerns. 

It is assumed in the DSM-5 that 5-7% of people suffer from this condition. If you think you’re alone and the only crazy person around, don’t worry. There’s a bunch of others like you and me out there.

In somatic symptom disorder the patient has one or more symptoms on which they focus. It could be for example headaches, which are fairly common to everyone, but trigger excessive worry in sufferers of somatic symptom disorder. Here’s the catch: it’s normal to worry about your health and about your symptoms. However, people with somatic symptom disorder these worries and fears are way out there.

Example

Imagine Larry and Lisa, a happily married couple. Larry has a headache, takes a painkiller and goes on with his work. It’s the third time this month, so Larry decides to contact his doctor. During the consultation Larry is assured that the headaches are caused by a stiff neck. Larry tries to focus on his posture and the symptoms improve.

Sounds normal, doesn’t it? Well, let’s have a look at Lisa, a somatic symptom disorder sufferer.

Lisa feels slight tension at the back of her neck. “Oh no!”, she thinks, “not another headache!” Her focus is gone. All she can think of is the tension, which slowly turns into a mean headache. Any plans she had are immediately cancelled. She can barely hold a conversation as all her thoughts are in the pain she’s feeling and what it might mean. A brain tumor? A blood clot? Meningitis? What must she do now? If she dies, what about Larry?

Taking a painkiller is not always an easy decision for Lisa. It could help, but it could also mask the symptoms of a more serious condition and prevent her from seeking the help she needs. A simple painkiller might mean that she misses an important symptom and dies. To her this risk is very, very real. Even if she takes a painkiller and the pain subsides, she’s not out of the woods. When will it come back? What will happen then?

Calling the doctor is another trick question. What if they do find something horribly wrong, and then all she fears really becomes true? Even if they don’t find anything, how can she trust the doctor? Maybe they missed something, maybe the laboratory made a mistake? 

During the headaches Lisa is in full fight-or-flight mode. In between the headaches she’ll spend the time preparing for the next one, reading and worrying. It’s not unlikely that her worrying causes her to constantly tense her shoulders, and guess what? She’s in for even more frequent headaches! 

Queue dramatic music as the curtains open and the Hypochondriac Spiral rolls on the stage: Worry about existing symptoms makes the symptoms either feel worse and/or occur more often, increasing the worrying. 

Definition

Alright, so this version of hypochondria sucks big time. What about the other where no physical symptoms are present? 

When the somatic symptoms are mild or not present at all, the hypochondria is classified as “Illness anxiety disorder”. The DSM-5 describes this thus:

1. Extreme concern about contracting serious illness. 

2. Somatic symptoms are not present or are mild.

3. High level of anxiety about health

4. Excessive health-related checks (temperature, pulse, balance) or avoidance of  doctors altogether

5. Preoccupation with an illness has lasted at least 6 months

While the symptoms seem very similar to somatic symptom disorder, this list adds something which the other one lacked: constant checking. To an experienced hypochondriac this seems strange, since the checks are also a big part of the daily life of someone with somatic symptom disorder. 

If our test person Lisa had an illness anxiety disorder, she would not need the headache to spiral into the realm of very unlikely and dramatic possibilities. She could do it any time. For a healthy person the obvious question this raises is “but if she hasn’t got any symptoms, why is she freaking out?” Well, check the symptoms  of practically any disease. See that small print there? Yes, the part where it says “Sometimes there are no symptoms.”  

If you now rolled your eyes, congratulations. You most likely don’t suffer from illness anxiety disorder. If you were nodding knowingly, welcome to the club of hypochondriacs.

Now we have seen the official side of it. The official diagnosis can be summarized about a health-related fear which is stronger than could be expected considering the true severity of the situation. In short: people are scared shitless (quite literally, since fear-induced stress can cause constipation). 

For the sufferers, or patients if you will, hypochondria is not about fears at all. It’s not irrational, out of proportion or even related to mental health. It’s a question of life and death. It starts with the question “what is this”, when something triggers the avalanche of fearful thoughts. When that something is identified, the question turns to “what does it mean?”. Answers are found, and for a moment the mind is at rest. Soon, though, another  question creeps in: “What if?” In the end, it all ends with the question “Is this worth the risk?”. 

This is perhaps easiest to understand by a few more examples.

Event: A red lump appears on the skin.

Thought: What is this? 

Event: The lump is identified as an in-grown hair. It looks like one, it feels like one, so it probably is one. It looks like all the other gross pictures of in-grown hairs on Google.

Thought: What does it mean?

Event: If it is an in-grown hair, nothing needs to be done. It will solve itself. Perhaps take it easy with the epilator next time… If it does get infected or change, though, perhaps it’s better to have it checked out.

Thought:  What if it does change? What if it’s not an in-grown hair but follicular cancer? (here’s where it usually starts to get interesting for hypochondriacs.) 

Event: Okay, hold your horses. It’s NOT, okay? Just go on with your daily tasks and let it be.

Thought: Is it worth the risk to let it be? Can I just ignore it and not have it removed and sent to the pathology right now? 

Event: A new viral sickness starts to spread in a far away country.

Thought: What is this? 

Event: The disease is identified as a novel virus, which can cause severe respiratory problems. It does not seem to be very infectious.

Thought: What does it mean?

Event: If it stays in that country, nothing needs to be done. It might spread or mutate, though. Then the situation must be evaluated again.

Thought:  What if it does change? If it can be asymptomatic,  maybe I have it already! It’s new so what do the scientists know, when you get down to it?

Event: Information about how to avoid the virus starts to spread while the virus itself spreads as well.

Thought: Is it worth the risk to wait for the official instructions? Perhaps I need to isolate myself already, and start to prepare for a long stay indoors. They say I can go outside and have a walk, but is it worth the risk? 

You might start to see a pattern here. Once there are more alternatives and less things the person him/herself can do, the more fear. You’re right: it’s about control. Hypochondria is in a way similar to the strategy that keeps casual Poker-players from gambling their life savings or investors from buying whatever as soon as it’s a bit cheaper: I must be in control.

To a patient, hypochondria is extremely logical and extremely realistic. It’s structured, carefully built, nurtured and maintained. It’s what keeps the patient alive.

Hypochondria is not the ragged man on the street shouting “The end is nigh!”. It’s a lawyer, carefully building a case to win the court.

Hypochondria is not the elderly person offering everyone flower-oil drops to save them from cancer. It’s a PhD student writing a thesis which can withstand the fiercest opposition.

Hypochondria is not the pregnant woman afraid of Zika-mosquitoes, asking her husband to buy some mosquito repellent for the summer. It’s her friend, a mother who does everything for her family, who reads a lot and cares for everyone who has the slightest ailment.

It’s the voice in your head whispering “What if?” and poking the water glass of self-control very close to the table edge of sanity.

It’s about control of your life. It’s about surviving.

Recognizing automatic thoughts, part 2

 Last time we checked some automatic thoughts. Today I'd like to share some of mine - more specific to somatic symptom disorder / illness anxiety disorder. First, a reminder:

Every action reinforces the motivation behind the action.

Especially for a sufferer of anxiety, an action can be motivated by automatic thoughts. The anxiety tells us to do something. Each time we take that action, we give in to the anxiety, reinforcing it's hold on us.

Recognize the thought

My favorite is avoidance. Avoidance is not a thought, but an action. This action is motivated by automatic thoughts. For example I'll avoid running, as I believe it can cause harm to me. Each time I choose not to run and nothing bad happens, my brain makes a causal connection: nothing happened because I did not run. Well done! Yet another risk avoided!

Why did I think running is dangerous? Because I believe physical activity can harm my body (classic problem in somatic symptom disorder). Why do I believe that? The two reasons are:

1) Because I have experienced scary symptoms when I have been physically active. 

2) Also, because running elevates my heartbeat, which feels like a panic attack, and I hate panic attacks. 

Evidence

Next we'll look at the evidence supporting, and against, each thought.

	Previous bad experiences	Similar to a panic attack
Evidence for	1. I have had symptoms when running.  2. News articles of people who have died during a physical activity due to the strain on their bodies, proving it's dangerous.	Yes, it feels similar...
Evidence against	1. I cannot prove my symptoms were caused by running. I could have felt them even if I did not run. 2. The news articles may have left out information of other reasons these people have passed away. Also, they are a tiny, tiny minority compared to people who have actual benefits from running.	... but the reason is completely different. My body reacts to physical activity by elevating the heart rate to make sure I can move and run, that my muscles have energy and that my body gets enough oxygen. The "panic sensations" are the sensations of my body behaving correctly and helping me achieve what I want (running).

This is already making me nervous. The evidence AGAINST is mounting. My brain right now is screaming my favorite phrase: it's not worth the risk!

For now, we'll ignore it and look at the conclusion from our evidence. 

In summary, there are some cases where physical activity has caused harm. However, there is not enough data to say those people were similar to me - what happened to them is not applicable to me. Science proves that I am causing more harm to myself by being still than by being active.  

(but it's not worth the risk there are fit and healthy people in better shape than me and they died just like that I'm going to die if I run is that what you want?)

... And I really do not know what to say. This is the part I can't cross. I get stuck. The voice of anxiety is just too loud and it's logic too strong. 

Well dang it.

Recognizing the voice of anxiety

If you hear a new song on the radio, you can probably recognize your favorite artist fairly quickly. Similarly, if a family member or a close friend calls, they don't need to introduce themselves: you will recognize their voice. Even in a large crowd you can pick up and tune into a familiar voice.

Anxiety has a voice too. The catch is that anxiety's voice sounds very, very much like your own. 

Thoughts like "this is dangerous", "no one likes me", "I am failing" and "there is a six-headed monster behind the corner waiting to eat me" are classical examples of the anxiety talking.  Real psychologists call these automatic thoughts. Thoughts that pop up without our permission, and which we accept without criticism.

Example: You ask your colleague something, and get a very short reply. If you have a poor self-image, you'll likely think they are mad at you for asking dumb things. This is your automatic thought.

The consequence is that you'll feel bad and might stop asking questions. Perhaps you blush, or feel annoyed or ashamed. 

The only way to catch those thoughts is to learn to recognize them. So when you notice you are reacting (feeling something), stop. What am I feeling? Why am I feeling this? Is that true?

In our previous example it might go something like this:

1. Automatic thought: Oh no, she's mad at me now! I did something wrong, I messed up. I'm such an idiot!
2. Feeling: Embarrassed, wanting to disappear, disappointed at myself.
3. STOP! Recognize the feeling.
4. Why am I feeling this? I did something wrong.
5. Is that true? Well.. I don't know? I have no real proof of that, actually. Wait, anxiety, did you just made me think that I suck, while I'm actually pretty okay?

See how the anxiety was trying to make a huge show of a small thing? In reality, maybe your colleague just was in a hurry, or in a call/ Maybe they dropped steaming tea on their lap - and still wanted to give you a reply as fast as they could!

We'll talk more about the spiraling anxiety and challenging your thoughts later more. For now let's focus on knowing that not each thought is our own. Not each thought is important. Some of them are downright lies, and can be ignored, stomped, burned, torn apart and forgotten.

Starting the journey

Hi, 

I am DC and I worry excessively about my health. This is my first day at Hypochondriacs Anonymous.

(imaginary audience mumbles "hi DC")

I have been zero days clean - or to be specific, zero days without googling my symptoms and contacting the doctor. I have been an excessive worrier for about 30 years now, on and off. This is my latest attempt to recover: to get back control of my life, and to silence the screaming voice of  anxiety. 

(imaginary audience nods knowingly, smell of coffee starts to waft around the room. I would like to get tea, but anxiety tells me caffeine is BAD.)

Today I went to the doctor, because I had the same symptoms as always. Only I thought they were a bit different now, so I freaked out. They did a heart film (EKG), listened to my heart and lungs, and measured oxygen saturation and blood pressure. Apparently I was tense and anxious but fine. Nothing wrong.

2 minutes after leaving the clinic the first doubts surfaced. Why no bloodwork? What if she was just too busy to interpret my results well? What if I forgot to mention a key symptom?

So that's where we're today. Oh, I also increased the dosage of my antidepressants because I can't focus worth a damn anymore. I just keep worrying. So yeah... nice to be here. Thanks for listening.

(Audience claps politely and promptly forgets what I said, as they're all busy worrying about their health.)