My name's Josh, I'm the co-host of The Imperfects and I'd like to acknowledge the Wurundjeri people of the Kulin Nation as the traditional owners of the land on which this podcast is recorded.
The Imperfects is not a licensed mental health service and is not a substitute for professional mental health advice, treatment or assessment.
The advice given in this episode is general in nature, but if you're struggling, please see a healthcare professional or call Lifeline on 13 11, 14.
In the DSM, it's called Illness Anxiety Disorder.
That really refers to having an excessive preoccupation with developing an illness that is serious.
We become very preoccupied with a vigilance to changes in the body and to any symptoms that might arise.
In doing this work, I don't ever want people not to go and get things checked out.
But what we want to declutter in some ways is what is anxiety, what is excessive worry, and when is it reasonable to What this condition kind of thrives on is seeking certainty in an uncertain world.
And in fact, if we look at our health, our health is and always will be uncertain.
So we're developing skills to be accepting of uncertainty, that I can have these worries and I can still be okay.
Quick, is anyone here a doctor?
Yes, her name is Dr Emily and she's a psychologist.
Please welcome to The Imperfects our very own psychologist, Dr M.
Oh, Dr M, It's very comforting having you in here.
That's so nice.
Yeah.
Thanks.
It was meant to be nice.
I was about to say it's like seeing an old friend, but that's exactly what it is for me.
It's the perfect analogy.
It's like, It's like seeing someone who's a psychologist but isn't my psychologist.
That's what it feels like.
Who you used to work with at a cinema making ice creams together.
Yeah, from your point of view, that's a good analogy.
It's like catching up with someone who I met through my friend Hugh van Kylenburg.
Do you know what's amazing about cinemas, which I don't know if I've said this before, but with the popcorn.
Oh God, get your notebooks out.
Yeah.
You know, so you decide you get to get popcorn.
You're very excited to get your popcorn.
It comes in a huge big thing where the popcorn's made and it spills out.
End of the day, Em and I and I'm guessing they'll still do it would get this gigantic.
I mean, that's the biggest plastic bag I've seen in my entire life.
Probably the largest.
And you put all the popcorn into this huge garbage bag, really.
Yeah, yeah.
Next day, just get in there, put it back into the machine, put it back in, yeah.
And so there is a chance.
Hang on, sorry.
The-
Popcorn you're picking up off the floor goes back in the machine.
Oh, no, no, no, no.
Out of the machine.
So at the end of the day you look at the machine and there's still popcorn left there that hasn't sold.
Put it in a big, it's actually a big garbage bag.
Seal it up?
Seal it, just tie a knot on it.
What sort of knot?
The twisty one, the only one I know.
Yeah, great.
And then you put it back in the popcorn machine the next day.
And you keep doing that.
So there is a chance at the bottom of that popcorn, it's been there for years.
Maybe some popcorn M&I, mate.
It's kind of like the master stock in a kitchen.
You know, like there's like a master stock.
Oh, yeah, yeah, yeah.
Or a sourdough starter.
Or a sourdough starter.
It's like there's a part of apparently I mean, I haven't worked in a kitchen for years, but there's like apparently, like a part of a stock.
That's like they keep adding to it over years and years and years.
Yeah, so it's like that.
I guess it's a good ad for Bourne Cinema in that if you go now you might be able to get popcorn made by Dr M and Hugh 20-something years ago.
Yeah.
Anyway, is this what you want to talk about today?
Absolutely.
Yeah, great.
If we haven't covered anything, please feel free to chip in.
No, so Dr. M, every month you drop by and for people who don't know, you –
Look back at one of our previous episodes of The Imperfects.
You find a moment or a story or something that someone talks about and you expand on it in a clinical way.
Yeah.
And which episode are you looking back on?
I wanted to look back on a part of Brian Brown's episode.
The Australian icon, Brian Brown.
Yes.
Yes.
Laconic and iconic.
Yeah.
Brian Brown from...
Along came Polly, Fame and... Oh, Break My Rant.
Break My Rant, Two Hands, everything.
So many films.
Over 100 productions.
Yeah.
There you go.
But there was a particular part of his episode that highlighted something that I see really frequently in my practice, and I will also acknowledge that a little while ago I put out a call on Instagram to see if there were topics that people might like me to address, and one of them was this particular topic.
And what was that?
And it's health anxiety...
Health anxiety.
Health anxiety.
And I'll explain it more clinically, but that's kind of probably the term we would use colloquially.
Oh my God.
We got it.
Yep.
Colloquially.
That word.
Yes.
I will explain the clinical criteria and diagnosis around that.
But generally speaking, we would refer to it as health anxiety.
Yeah.
Never heard of that before in my life.
Health anxiety.
Okay.
Really?
No.
I mean other than the fact that I knew you were talking about it today, but before you brought it up, I'd never heard of health anxiety.
Never.
Really?
No.
Yeah.
Okay.
Well.
Is it a common thing that you deal with a lot with your clients?
Yeah, it can be.
Absolutely.
You know, I certainly work with this kind of presentation and I think also, as you know, sometimes as we age we get more exposed to this distress and this discomfort about our health and the possibility that there might be something serious here.
So there's a whole heap of research that sits behind this, and it is a clinical diagnosis that we can absolutely identify based upon a particular criteria.
So in this clip, prior to the clip that we will show, Brian Brown is talking about an experience he had when he developed a urinary tract infection and the symptoms that he experienced.
That were quite distressing to him.
Yes, after that.
Yeah.
But I thought perhaps we can play Brian's excerpt just as one example of how it could look.
This is not certainly the only manifestation of that.
But what I didn't realise every time I'd start to travel or go somewhere, what would happen to me is I'd go somewhere and I'd start to want to pee more.
What was happening was that subconsciously I'm thinking, oh, I'm going to such and such a place.
Well...
I hope they've got a really good hospital there if I get sick.
Well, maybe they haven't got a good hospital there.
So that was building up the anxiety.
But what it was showing was that I was wanting to pee.
The first time this happened, I went to the doctors and it was like okay, you've got a urinary infection.
Again, we'll give you these antibiotics.
I didn't have a urinary infection at all.
I had anxiety and that was bringing it on.
But it took like and that would happen to me.
That happened to me for during the next 12 months quite a few times right.
And it was, you know, like, oh, not this again, not this infection again.
I knew how important it was I had to get rid of the infection.
Well, I didn't have an infection.
I actually had anxiety.
Right.
And so it was only when I was with Matilda, my daughter, and we were coming from Sydney down to the Melbourne Film Festival or something, and as we went to get on the plane, I went oh God Tilly, I've got that.
I must have the infection again.
I want to go to the toilet.
And she said, Dad- you're like me when I go for an audition.
I want to pee.
And I went, is that what it is?
Is that, I haven't got, something's making me want to pee?
So I said all right, I want to talk to a.
When I went home I said to my doctor I want to see a psychologist.
And that's with all the changes coming in the world with AI and things they're going to change up.
I reckon one of the things that will change is that we will no longer be using the word pee.
I feel like that is a word that older men use and when they are gone, they're told the word pee.
Did you think of our grandpa?
I did.
Yeah, I thought of our grandpa when I was listening to that again.
I can just imagine him saying that.
I need to take a pee.
Yeah, but I don't reckon our parents use that word.
Yeah, pee.
It's a word that's disappearing.
That could be the last time people ever hear it.
Well, it's been great.
Thank you.
Useful.
For the last time.
Yeah.
Good to hear you again, P. So, Em.
Yeah.
Unless you've stolen your thunder.
Is there anything else to say?
I guess you know it was just a really poignant example of how anxiety can show up and how our fears for our health can be held so tightly that we actually it begins to cause us some problems.
Yeah.
You might go on to this, but I think the interesting thing for me about that was that he did have a UTI originally.
That caused him quite some distress and quite an episode.
But then, as he said, then he didn't have it for the next year, but the physical symptoms remained, so he was still needing to pee.
Yeah.
And so we'll look at that, like physiologically what's happening, because...
There are genuine symptoms that can be occurring, but we need to declutter what is anxiety and what's a genuine health concern.
So if we would look at, you know, in the DSM-5, which is the Diagnostic and Statistical Manual of Psychiatric Disorders, this is what we use to make clinical diagnoses.
Psychologist's Bible.
Correct.
Is it international or is there like an Australian one?
Well, that's a controversial question.
There is also the ICD-10, which is the World Health Organization's classification system for psychiatric illness, which is separate from the DSM.
The DSM is based out of America, as far as I'm aware.
So there are these two classification systems.
They generally tend to be fairly similar, but there is some controversy, which I won't go into, around that.
But where are you planting your flag?
What's the best one?
So we're trained in the DSM, but it's also helpful to have an awareness of the ICD as well.
To know what's wrong.
Yes.
So in the DSM.
Well, first of all, historically speaking, what we might be talking about here is what has otherwise been known as in the DSM earlier versions hypochondriasis, or being a hypochondriac.
Yeah, that's the first one.
Hypochondriasis, that was the condition or the disorder.
Yeah.
The one you use at primary school is the word is hypochondriac.
Hypochondriac.
You're a hypochondriac.
So in I think it was 2013 that the DSM classification people decided to drop the term hypochondriasis.
Because if you think about, if I tell you you're a hypochondriac, what does that do to your experience?
It's sort of invalidating.
Yeah.
A littles.
Yes.
Yeah.
And so there were, you know historically, some almost like derogatory terms minimizing um associations with the term being a hypochondriac.
Yeah, that in some ways it really does say like you're just being ridiculous, stop worrying and get on with it.
Yeah, so i think that change really embodied the fact that for people that are struggling with this, it's deeply distressing and can be really impairing upon your functioning in life.
Well as, as brian talks about in that episode, he was so worried about it it was almost like getting in the way of him traveling.
Yes.
And if we look at diagnostic criteria, one of them for almost all disorders is a question about the impact that it has on your daily functioning.
So if daily functioning is impaired, then we can say in addition to the other criteria of course that this is something really worthy of consideration.
Gotcha.
So this is different from this is someone who is potentially irrationally concerned about getting sick, as opposed to someone who is putting a lot of thought into being healthy all the time.
Yes.
Is it different?
Yes, it is.
So if we look at the definition that in the DSM it's called illness anxiety disorder.
Right, okay.
There are a number of other types that come under a general heading, but the one that we're looking at today is illness anxiety disorder.
Okay.
And that really refers to having an excessive preoccupation with developing an illness that is serious.
So it's not a preoccupation with developing like a cold, for example.
It would be usually that there is excessive preoccupation and worry about developing a serious illness.
This might come up, but it seems like the first thing I thought of is this must be so serious. common and difficult for people with OCD?
Yeah, there is.
So if we look at technically, if we look at diagnostic criteria, we can see that they are two distinct disorders.
But there is considerable overlap.
And there's considerable overlap because, let's just say that I have, I notice, a trembling in my hand.
Okay.
So this trembling then makes me feel worried.
And that this worry is telling me this could be Parkinson's, for example.
And so in order to obtain a certainty that this is not it, I reassurance seek.
And so the reassurance seeking is in some ways like a compulsion that we would see manifest in OCD, for example.
So the trembling in the hand prompts me to do things like Google search chat GPT, WebMD.
You might do that quite frequently, right?
You might go to the doctor and seek multiple tests.
And that, if we look at what's happening there is that that reassurance seeking brings about a temporary relief.
So we can see in there how it does mimic OCD.
So we get an intrusive thought or a worry and then the behaviour comes on board or the compulsion comes on board to in some ways distinguish the intrusive thought or the worry.
Mm-hmm.
So you go to the doctor and the doctor says, you know, what are your other symptoms?
It doesn't medical.
And the doctor says, I'm not that concerned.
Okay.
And so you might go away and say, okay, that's good.
And then not that long after the mind goes, the doctor said, I'm not that concerned.
That sounds very, that's very OCD.
Yeah.
And what it's what this condition kind of thrives on is is seeking certainty in an uncertain world.
Yeah.
And which is like maybe near impossible in many situations.
And, in fact, if we look at our health, our health is and always will be uncertain, because we will die.
And so this is what is so, so challenging.
This sits at the heart of this struggle is that we're searching for safety and we're searching for certainty that I am okay.
Hmm.
So when you said it mimics OCD, they are distinctly different things.
They're not.
That's probably a poor phrasing by me, actually.
You can have in OCD, for example, your obsession could be around health.
Yeah.
And so then yes, like then we could say that this is occurring within an OCD diagnosis, but it doesn't have to be.
So there is a distinct diagnosis that is separate from OCD.
And there, I mean, there are, In the end, it doesn't really matter.
Like in some ways.
Yes, finding the diagnosis being clear about that is very, very useful for treatment.
But in some ways the treatment is very similar because at the heart of both of those is this yearning for certainty that I'm safe, or that people around me are safe, and that there's a fear of losing, a fear of loss in here in some way.
Yeah.
So I want to give you an example though, of what happens and what kind of exacerbates this struggle, and If you imagine that you've got an alarm in your house.
If you have a house alarm, you can determine its sensitivity to pick up movement inside the house.
And I always remember my parents were away at one point and they got a call from the alarm people to say the alarm had gone off.
And, in essence, they determined that it was a moth that had flown through the house and Was anything missing.
No, there was no break-in.
The moth was not stealing stuff.
Yeah, and if it was just one moth, I wouldn't be worried.
But if it was multiple moths, then you've got to be worried.
Yeah, yeah.
Check the locks, obviously.
Moths are sneaky.
So we think about there that the sensitivity of the alarm system was very high.
So it detected threat very easily.
So what they had to do obviously, was turn down the sensitivity so that it was only going to be larger threats.
Exactly.
That was going to set off the alarm.
Yeah.
We can think about this in terms of our internal threat alarm system.
Is that for people that are anxious about their health?
It's like the sensitivity on the internal alarm is turned up.
That's a killer analogy.
Thank you.
So what that means is that we become very preoccupied with things.
A vigilance to changes in the body and to any symptoms that might arise.
And the paradox of this is that the more vigilant you are, the more you will notice changes, the more that you will interpret those changes as dangerous and the more that that will trip you into a threat fight-flight response situation.
The problem with the fight-flight response when it's being misfired is that it will also bring on physiological changes that make this whole situation so much worse.
A great example of this is that, if you have concerns about your heart right, you might have some sort of – and this might be based on, maybe there's a family history of heart disease, for example –
Maybe at some point in your life you've been told there's something around your heart that you should pay attention to.
So now we get a vigilance to my heartbeat and a vigilance to changes in my heart.
And if we look at the function of anxiety, it increases our heart rate.
Oh, that's cruel.
Yes, it is.
And so that means that we kind of sit in this perpetual state of worry and And then reassurance seeking.
And I'm assuming that then, like anything in your body that feels off you, probably the first thought that pops into your head is like well, my heart, I've got a problem with my heart.
I've got to watch my heart.
Maybe that's connected.
And it doesn't take many like Reddit searches to find something that kind of confirms that.
What a disruptive like if you're very hard to live a happy, fulfilling life, if that is, with your alarm system like that, finally attuned to things that might be going wrong.
It is very distressing.
It's very distressing and the irony of this is that, like when you kind of dig under what this is all about, so we think about basically it would be really good to have a lisp in that moment.
I didn't know you spoke Spanish.
That what sits at the heart of this is death.
And that if we fear so, I get an illness, a serious illness, and it is going to bring about a threat to my life and I die.
Me being so preoccupied with this fear of this illness is actually stopping me living.
Yeah.
So here's the irony is that I'm so fearful of dying that, But my fear is actually stopping me from being alive.
Yeah.
Yeah.
Well, you mean like living to your full.
Yes.
Yeah.
And so for some people it can be, like you know, there's this excessive worry here all the time, like totally preoccupied.
Like when this mind is so busy and there's vigilance in the body, like how hard is it to have a conversation?
Or you know, you might be sitting at your desk and you notice a change, so you quickly do a Google search like temporary relief, and then it's back again.
Or you might seek reassurance from your family like do you think this has changed?
Can you feel this for me?
And so that, again, provides a temporary relief, but inevitably the loop begins again.
I'm not sure if they would know how to check it, or maybe they haven't viewed it properly.
What if?
What if?
It's thriving on this what if, even like the 0.01% chance that this could be something.
Like CHAT-GBT, would just be a landing ground, for so many people would be using that as a assurance seeking device.
Yeah.
And that's even an interesting turn that you said then too, because there is this difference between assurance and reassurance.
So something like AI or chat JPT can move us into reassurance seeking.
So that kind of repetitive cycle of seeking some kind of certainty.
And that's really different from assurance seeking.
So assurance might be something that is experienced when we have sought medical attention and they have provided us with some kind of result or information.
So I want to just begin by like even acknowledging that in doing this work, I don't ever want people not to go and get things checked out for a start, right.
And so if I have someone that's coming in to see me and they tell me that they're really, really worried that they have um a kind of cancer,
And so always the first point of call is, have you had this check down?
We need to know, you know, really that you've taken reasonable steps and this is important.
What are reasonable steps, that you've sought consultation, that you've got test results, for example?
And now it's only at that point that we would be like okay.
So it feels to me like it's anxiety here that's keeping you stuck.
Yeah.
So I'd Always want to put in this kind of disclaimer that you know, please do your appropriate testing and consultation with your medical professionals.
How many times you do this, of course, is your choice.
But can we also have a look at what else is happening here at the same time?
Hey, Hugh and Ryan.
Yeah, Josh.
I am so excited about our brand new live show Together Again.
That's going to be around the country in so many cities which we'll tell you about in a second.
It's all new.
It's kind of like it'd be like if you've watched the first season of Game of Thrones and you're like oh, that was good.
I like that.
And then the second season comes out and you go, I don't need to see the second season.
I've seen the first.
I mean, that doesn't make much sense.
Not really.
Hang on, which bit?
Yeah.
What we're trying to say is it's a whole new season of our live show.
Brand new episodes, brand new bits.
You've never seen it before.
You would never even dream of missing.
If you're into Game of Thrones, you'd never dream of missing season two.
So please don't dream of missing our season two.
And if you're desperate like I am, I cannot wait to see Hugh flying on a dragon across the stage.
Just like Game of Thrones.
That's what we're saying.
It's season two of Game of Thrones, live on stage across the country.
Without orgies or anything like that.
No.
Let's not give too much away, Josh.
Well, if you want to find out what's happening on stage, you can get your tickets at livenationcomau.
It's a difficult... I feel sorry for... I don't know if feeling sorry for is the right word, but...
It's a difficult position for GPs.
I think of how to handle this, because how do you play that game correctly to not – because, like I, don't have health anxiety.
I definitely don't.
But I'm prone to mild overthinking about stuff.
For a few years I've had a sort of uncomfortable feeling in my chest.
I went to the doctor a few times about it.
And I felt like he thinks it's nothing.
In fact, he's told me a few times, I don't think anything's... We've done these tests.
And then on like the third time, he's like, maybe we should... It's clearly causing you concern.
I don't think these tests are going to show anything, but maybe we should go get them done anyway.
But I...
And ironically, when he said that to me, I've got the paperwork to do it.
I haven't gone and done the tests.
It was this weird thing of like the way he explained it.
But it almost felt like he was, I think he knows nothing's wrong.
Yeah.
But he's managing my anxiety and my process with it as much as anything.
Yeah.
And I feel like that's a difficult position for him to be in, because the more he says no, we'll just get the test done.
That might make me go.
Oh, hang on, maybe there is something wrong if you think we should get tests done straight away.
Yeah.
I think it's a tremendously difficult position for GPs in particular to manage because yes, we can see that there can be an interplay of anxiety here.
And so how they walk the line of being validating and compassionate, and yet also not at times, like not buying into the excessive need for reassurance.
And I think...
It sounds like your GP managed that in such a kind way and I think I like that part where I don't think there's anything wrong.
But I can see you're worried.
Even that phrase is very validating.
It's kind of really stepping into how you might be feeling there.
Yeah, and he was like if it's causing you worry, then that is a problem in itself, so let's try and stop that.
So that's chat GP.
LAUGHTER
As opposed to, yeah.
It was like the opposite of the experience.
I called him last week to talk about the experience I had with my GP.
No, not my GP.
My GP was busy and I wanted to get a referral to see a psychiatrist.
I was hoping to get medication for my ADHD, which I need to see a psychiatrist for.
And I spoke to this lady on the phone and explained.
I said I think I might have ADHD and would like to.
I just would like to see a psychiatrist and a referral.
And she goes, okay, tell me about your life a bit.
It was over the phone.
And then she said, you know, I don't think it's ADHD.
I think you just need to get a good night's sleep and you could really try to use your calendar better so you're not late to things.
And maybe you could work on communication styles with people so that it's a bit clearer, and So I don't think that's ADHD.
You just need a good night's sleep and just use your calendar better.
With all due respect, we've already put out a fair bit of ADHD content in regards to Hughes, so we can't wind up.
Yeah.
So this is, and I think that kind of highlights also how painful it feels to be dismissed, and But also we can see the function there of the reassurance seeking.
So let's just say, Josh, that you got that referral for that test, for example.
Your GP says, I don't think it's anything.
So you go and get the test and then the test comes back all clear and the mind says well, what if the radiologist didn't read the results properly?
Yeah, yeah.
I've heard about this before.
You know, I've heard about so-and-so's neighbour.
Their doctor missed that.
Yeah.
What if mine's missed it?
So this anxiety is feeding on this possibility of what if.
Absolutely.
Yeah, and again it becomes so immensely preoccupying.
There also feels like a terrible irony there that not only that it can increase the anxiety, but I would assume that if you're stressed, stress can cause illness.
Yeah.
So like you could actually cause physical illness.
That's such a tricky thing, yeah.
Because it's then stressed, I'm stressed about being stressed.
Yeah.
Yes.
Yeah.
And so yes, that is absolutely something that I would work with, you know, with clients is really acknowledging that.
Yes, we know that stress in the long term can have a cumulative effect on our physiological health.
So, yeah, we do want to pay attention to what that cost is for you.
But we also want to have a look at understanding what, Understanding why this might be occurring.
I think that feels really important for people to get a sense as to why am I having this experience.
Why am I so preoccupied with this?
And there are a number of different like if we look at the origins or the etiology of something like this kind of struggle is that there are a number of different pathways that might lead us down to being more vulnerable, to feeling very anxious about our health.
And a very obvious one is that it would be through exposure, loss and illness, often earlier in your life.
So if you as a kid have been exposed, for example, to the loss of a parent or a caregiver, to an illness, you know that sometimes for some kids that elicits a belief that the body is unsafe, that I am unsafe.
I therefore need to pay attention more so that that doesn't happen to me.
So it's this notion of a vulnerability to harm.
Okay.
And it's very understandable that, as a kid, you might, you know you, witness and experience this loss or this threat.
And, as a result, to cope with that, you then develop like greater attention to my body and to what's happening in it.
We also will notice that just exposure in general, even in adulthood, to people that are close to us that may die or or that do develop a really serious illness, that sometimes exposure to that can also then increase our fear.
And again, so understandable that this would happen.
And, you know, so many of us work with, live with, spend time with people who have health anxiety.
Maybe we don't call it that or they don't know it's that, but it's the constant fear and anxiety about something wrong.
Obviously, like...
We're not doctors and so we can't say for sure.
We can't give any certainty and you want to be supportive.
But there comes a certain time where you kind of – you don't want to not take what their claims are seriously.
You want to take everything seriously and believe them.
But if you have a fairly good feeling, it's like I don't think that's – like how do you approach that?
How do you –
And I think actually there is actually a very similar, a similar protocol when it comes to supporting someone with OCD.
And, you know, Hugh, I don't know if this feels appropriate.
Please tell me.
That like how we best support someone who might be engaging in compulsions, for example in that reassurance seeking mode, that you know that there is of course this invitation here and encouragement to be kind and compassionate but to not engage in the reassurance seeking with them.
Which is so hard when they say the worst possible thing about themselves and you have to go.
Yeah like, maybe that's true.
Yeah.
Yes.
Even when you know it's not.
Anyway.
Yeah.
So it's the maybe that's true.
Yeah.
Possible.
Yeah.
But to provide that reassurance that even like you know it might even be, you've done the tests.
You know that you're okay.
That even is reassurance.
That is like reassurance provision, right?
Yeah.
Yeah.
So it may be and we'll kind of come to working with this a little bit more in a minute, but it may even be something like it sounds like you're having a really hard time with that today.
So we're actually just really validating and compassionately acknowledging that here is the fear.
Yeah.
Rather than engaging in the, stop worrying about it.
You're okay.
You've done the tests.
We know that this is the case.
That... actually just feeds the loop.
Yeah.
That's so helpful.
I mean, that's just, that's probably really helpful.
Just generally living or working with someone with just anxiety in any situation.
I mean, we can see that in so many different experiences of anxiety.
So even something like social anxiety, maybe you know.
You say to your partner did I say that wrong?
Like, do you think that like Sally didn't like what I was saying there?
And you go, no, Sally was fine.
She was fine.
The person that's seeking that reassurance for a little while will feel like, oh phew, that's good.
And then you're lying in bed at night and you're like no, there was something about Sally's face that really I just don't think.
And is that because your anxious thoughts is just like searching for any threat?
Yeah, we are searching for certainty.
Right.
So sorry, with that example.
Mm-hmm.
So searching for some sort of certainty and there's no certainty in like me saying, no, don't worry.
It was fine because- It's not enough.
You'd be like, what do you know?
How would you know?
It's good for a moment.
Yes.
Yeah.
Yeah.
It might feel, it's kind of like, it's a little bit like addiction in some ways.
It's like this cycle of reinforcement that I get a hit and I feel better.
I feel relief and now the urge is increasing again.
And so then I just get stuck in this repetitive loop of seeking reassurance, feeling slightly better, feeling anxious again, intrusive thoughts checking Googling, seeking reassurance, feeling slightly better.
It's so exhausting.
It feels like a good time to mention Penny's podcast.
She has her psychologist Andrea, who's just an expert and has done a lot of exposure therapy with Penny, but then also talks about Assurance and offering reassurance.
There's a great episode on how that actually looks, how you're meant to give or how you're meant to respond when someone is seeking assurance from you.
Yeah, that's great.
Yeah, her podcast is called It's Not What You Think.
Yeah, and look, I have referred lots of clients to that podcast and the feedback has been absolutely phenomenal.
Oh, really?
Yeah.
Oh, my gosh, yes.
Really?
Yeah, and I think it really speaks to how much I mean how much it's needed, because we don't talk about it.
Mm-hmm, because it can feel very shameful.
When we think about health anxiety, it's often very internal.
So we spend so much time focused inward.
And we may feel embarrassed or ashamed to acknowledge that I'm sitting here so anxious that I have cancer.
We actually may not disclose that to other people.
And our reassurance seeking is actually more private.
And particularly if there's a health condition that is of a more embarrassing nature, you know, in a more embarrassing area.
Like if it's something that you don't feel comfortable talking to someone about, and so then you're in it on your own.
And it's very lonely.
Yeah.
Like it's really lonely being so caught up in your mind and in your body.
And in that way it also then becomes very disconnecting.
So it's like, all the things that allow us to thrive and to find joy and pleasure and to live the life you want is really getting compromised.
What I also just want to mention, because this feels important, is that there are lots of different ways in which we would engage in checking or reassurance seeking.
So one of them does tend to be body checking.
And I want to just give you some examples of what that could look like.
So for example, if skin cancer, you're obsessively checking moles.
So it might be every day.
You might even draw, like some people will draw outlines around their moles to see if they've grown to be able to check.
Some people will use like rulers to measure distance.
Some people will be obsessively checking their breasts, for example.
And the trouble with those sorts of behaviours like, for example, with the checking of the breasts, is that the more you do that, the more you actually create tenderness in the breast and the more that it actually starts to feel painful and, And so now we have physical symptoms that have resulted from the checking that are now telling me I should be worried, right.
Yeah.
So that, I mean, there are some examples.
There are other examples like examining bodily fluids.
So, for example, like checking your poo frequently.
It can be something like even like fingernails, like these changes in my fingernails.
And I've read somewhere that that could be a sign of liver cancer sometimes.
So there are just so many incarnations of this body checking that it's actually unrelenting.
I don't think I've ever had health anxiety for a period of time, but that the moment where this is a bit graphic, but the moment where, after you've gone to the bathroom and done poo and you see it's red, the two seconds until you remember you had beetroot.
I was going to say the same thing about asparagus.
Oh, yeah.
Yeah.
But those two seconds, that's an anxiety that goes quickly and you're like, oh, yeah, that's right.
But then it's almost like that's the certainty that you luckily get from that.
Yeah.
But I imagine that feeling before that realisation is that, like the health anxiety that people are living with,
Yes, it absolutely is.
It's kind of a crippling dread.
That is horrific.
That's horrible.
Can you have health anxiety for someone else?
So you can be on behalf of your child or your partner.
Yes, absolutely.
I'd like that to be a common one.
Yeah, it certainly can be.
We're really looking at this notion of a preoccupation with, and worry about my health, but it also can be other people's health.
I also want to acknowledge that health anxiety or illness anxiety can also be present when you've had a diagnosis as well.
So, for example, maybe you have had a cancer diagnosis and maybe you've gone through treatment and all your tests are clear, but the experience of that diagnosis has made you understandably much more vigilant.
Yeah.
Yeah.
Yeah.
But there is then this question.
So in this case, And I would say, and this is certainly my lived experience is that having had breast cancer before, is that that experience in some ways has undermined your sense of safety in the body?
Yeah.
That I can now no longer trust that it is well.
So then, it can absolutely lead you down a pathway of becoming extremely vigilant to any changes or any signs in the body that something is off here.
And the deep challenge in that place is to be able to acknowledge that, yes, this has happened.
But when I get so hooked into that worry, once again I'm taken off track to all the things that I want to live my life by.
Yeah.
So that's a more, I guess, more nuanced place in this particular disorder.
But so understandable.
So understandable, yeah.
But it can still be very debilitating even though you actually might be healthy.
Yeah.
This might be a pretty dark idea but you sort of went there a little bit before.
At what part of this is, if we're seeking certainty...
At what part of this is accepting the certainty of death an important step?
Yeah.
No, it's not a dark place, and I think actually it's so interesting you say that because that's in some ways, exposure work.
Yeah.
It's that we will actively and I've spoken about this in terms of when I did an episode on grief is that we have such a discomfort in talking about death and that actually the more that we can lean into being able to have these conversations to speak it to lean into.
So if death is the end game, how do I want to live my life?
These conversations actually expose us to the anxiety.
And what we know about anxiety is that the best way to manage it is through exposure.
The worst way or the way that keeps it going is through avoidance.
Yeah.
And even if you look at the gold standard treatment of OCD, for example, is exposure and response prevention.
So it's exposure to the anxiety and then preventing the response, the behavioral response, for example.
But in all anxiety work, really the heart of it is we need to expose ourselves to the anxiety, to be okay with it.
And so in doing this work like if people come in to see me really kind of what we're looking at here is developing the skills to tolerate the discomfort of uncertainty.
So we're developing skills to be accepting of uncertainty, that I can have these worries and I can still be okay.
How does that make sense?
It does.
Yeah, really well.
Yeah.
Okay, good.
It's just a hard, it's such a big jump for probably most people.
I mean anyone who is predispositioned to experience health anxiety or something like OCD.
That's the whole battle for them is to try and move towards.
Yeah, I'm going to live with that uncertainty, be comfortable with.
Yes.
And, you know, to be fair, that it's not a cognitive decision.
So what I mean by that is that I can't just tell you just be okay with uncertainty.
Or you can't tell yourself I'm going to be okay with uncertainty.
This is actually – it's much deeper work than that.
Because, to be honest, you could go and get that from ChatGPT or you could just tell yourself that and you'd be like off sailing.
I'm living my life now.
It's much, much harder than that.
How helpful is it to – because, as we know, like anxiety gets you to – spend too much time thinking about the past or the future and you're not like you say, you're not living your life now.
But how helpful is it to think positively about the future, you know, to try and imagine a time where you could be.
The anxiety could be less or gone.
You know I often think about.
I think I read this in The Courage to be Disliked or one of those books where it's to imagine the spotlight on you and to be present, to think like what can I do now?
And how can I?
How can I feel better right now, as opposed to the overwhelming and impossible feeling of like I'll one day be better?
Yeah.
No, you're spot on.
And that is absolutely what we would target in a big way.
And so that really is this practice of being able to feel safe right now.
And that would be in conjunction then, with things like what's called urge surfing, or delaying the urge.
So I'll explain that in a minute.
But yes, any practice that allows us to come to this present moment and to change the lens through which we're viewing our body.
So with health anxiety, it's a very strong, like very, very strong vigilance to internal sensations.
And we want to be careful with how we work with that.
So We might want to look at things like being able to actively use the body to change the stress response, for example.
So you might want to do engaging breath work where we're actively eliciting the relaxation response, to give the body a break, to know what it feels like to let go of holding on so tightly.
We might do something like a progressive muscle relaxation exercise, which is where we progressively tighten and then release our muscles, and So you can easily Google that one.
So we might want to practice some skills there that are really about tolerating distress and that we would use the body to help us calm down in those moments.
We can also then look at the practice of mindful meditation and mindfulness.
Meditation might involve bringing awareness to a part of the body that feels safe enough.
So it could be the breath.
It could be just mindful walking, for example.
You can just notice what it feels like to lift the leg up and put the leg down.
Lift the leg up, put the leg down.
So we're really kind of practicing training attention to be here in this present moment, not off in the life where I'm going to die.
So any practice that allows you to remain grounded and connected to this present moment will be very, very helpful.
There's that part.
We also do want to have a look at... at delaying the urge.
So what this means is that we delay the urge to engage in the compulsion or the reassurance seeking or the checking.
So that might be, it might be an hour at a time.
It could be half an hour at a time.
It could be longer than that.
So it might be something like that.
You have a bit of a rule that let's just say you notice a sensation in the So it's not that you genuinely think you're having a heart attack or that there's a fever or an infection.
Discarding those medical issues.
But let's just say you notice that you have something on your hand and the mind jumps to this is skin cancer.
There can be and again I say this really lightly and gently a rule of thumb that you might want to just sit with that for a week or two.
So give yourself a week.
Well, that sounds like a lot.
But that's you saying leaning into exposing yourself to anxiety.
So we are leaning willfully into uncertainty, so that we're kind of starving that compulsive response.
So what are you saying to yourself in that moment?
So then we really need to bring on board a whole lot of – this is actually really complex, I realise, as I'm saying this.
And perhaps I will say here that, if there's this – please, if this is something that you are struggling with, I absolutely encourage you, if it's possible, to engage with a health professional about this, because it's quite complex and you really need to pay good attention to how it feels, for example, when you're listening to this.
But we need to bring on board a lot of self-compassion when that is happening.
So it might be like I'll tell you for myself, and that is that if I notice a symptom in my body, my natural symptoms, currently my natural urge would be to book a doctor's appointment pretty immediately.
And these symptoms that I might notice may have absolutely nothing to do with breast cancer.
They sometimes can be a completely different part of my body.
And so my response to that would be just like I'm noticing I'm feeling really anxious.
So we can kind of bring on board this really compassionate language that allows me to step back from getting really hooked into the thoughts.
So I'm using this kind of noticing language.
I'm noticing I'm feeling really anxious.
And then it might be something like, Emily, that's very understandable.
This feels really hard.
And so we're kind of offering this compassion here.
And then it might be, I'm also noticing the urge to Google that.
Okay, so I'm not just noticing it.
I don't have to act on it.
I'm also noticing that I want to book a doctor's appointment, but I'm just going to sit with that for a second.
And then we can kind of what we tend to notice when we call it urge surfing is that an urge will.
If you imagine a wave, the wave reaches a peak.
But often we will jump off the wave before it's reached the peak.
And what we want to be kind of practicing is that this urge or the anxiety will reach a peak and then it will start to subside.
Now, if this symptom is still here in a few days or in a week, I'd be like okay, so it's probably reasonable for me to go and see the doctor.
Mm-hmm.
But what we want to declutter in some ways is what is anxiety?
What is excessive worry?
And when is it reasonable?
Now, sometimes we may find that that urge is now just kind of coming and going and we can be okay with them.
The reason why this is so tricky is because we never want to dismiss a medical concern.
This is why it's really hard to navigate and why it requires a lot of curiosity when you're struggling with that to notice what is reasonable.
What can I be okay tolerating?
And when do I seek medical attention?
Yeah.
So, you know, the practice of self-compassion is really, really helpful.
Being able to notice and name what's here.
I've noticed I'm really struggling with this feeling today.
And then it might be, okay, what do I need now?
And maybe it's self-soothing stuff.
So maybe you want to go and do something that feels calming or relaxing to you.
Maybe it's that you want to I don't know go and do something silly with your kids, or you want to go out and go for a run.
What is that next thing that you're going to do?
That's going to help you sit with this discomfort.
That's here to help you not engage in that checking again.
Because this is, I think, really helpful obviously, but for a lot of people who will, if something feels a bit off, the person who will immediately book a doctor's appointment and be like well, I'm checking it.
Even if someone tells them or they think that's overkill, like I don't need to like, it's just the same little thing, but why not?
And I think the mentality of doing that is like, what's the harm?
Like, why not?
I'll just go and get it checked out and then at least I know.
But I think what you're saying in this episode is like well, the harm is living with this anxiety all the time.
Yes, exactly.
And that the anxiety is pushing you around so much that you're not living your life anymore.
Yeah, and you're living with a life of worry.
Yes, yes.
And gosh, how exhausting and how distressing that is.
And, you know, it is such a tricky thing because the fear of death is very understandable.
And it highlights how much we value and love this life.
It's this fear of losing something that is deeply important to us.
And so when that fear is here, it's very natural that that is going to push us around.
Like it's a big thing for new parents.
I think that's when you really start to think about your own mortality, when you have kids for a lot of people.
Yes.
And then anything, any threat to the fact that you may not be here for them is just you pay.
You're so hyper fixated on.
I don't have health anxiety at all, but I feel like the first few months maybe –
Maybe for the first six months of like our first child's life, I was – absolutely did.
Yeah.
But, yes, I'm just acknowledging it's probably a lot of parents who all of a sudden have this.
Yeah, and it's actually – it's very common in the postnatal period to have a lot of intrusive, anxious thoughts about their child's health.
Very, very common.
And also very, again, very distressing.
Their child or their own?
Well, sometimes both.
Yeah well, that's true, because I was thinking like my health and – Yes, people would have it for their own health now that they realize they've got to keep someone alive.
Yes.
Yeah, exactly.
So it's, it's tends to be, well, it can be both, not necessarily at the same time.
I know some people that, uh, have never had any concerns about their health.
And then, as soon as they had a child, became absolutely terrified of becoming sick, because now we have this tiny little baby that is relying upon me.
Um, So yeah, and so again.
It's just really holding this very compassionate stance here that we know why this would be occurring.
But can we step back from it so that it's not pushing us around like it's not sitting in the driver's seat all day, every day, and I'm just this passive passenger that's coming along for the ride like the anxiety ride?
It requires so much real attunement to what you're doing.
So it's a little bit like, Instead of if you imagine that you're sitting on a train and you're watching the scenery go by.
That's the kind of stance that we're looking for, rather than being in the scenery.
So that we're able to notice and name what's happening here with a bit of space.
So if I can notice it, I am not the anxiety.
Yeah.
I don't want to put you on the spot here.
So we can cut it out if you don't have an answer.
But I'm wearing a band that, gives you health insights.
I've never done it before.
An activity tracker.
Yeah, yeah.
And I haven't really done it until the last few months and I thought I'd give it a go.
And I find myself checking my sleep scores and all that kind of stuff, getting a little bit fixated on it.
But it's certainly not an unhealthy place for me yet.
But is there an increase in presentations of health anxiety or correlated to more of these tools and devices out there that people can wear?
Does it feed the beast, so to speak?
Look, being transparent, I don't know the data on this.
My hunch is that it would.
It's almost like how do we – can we use it for good or evil?
Yeah, yeah.
And that may not feel like an intentional kind of choice in there.
But how are we relating to this information?
Am I using it just as – data point, or am I using it as an alarm, like an alarm that something is wrong?
And you know, that kind of really opens the door to a different kind of anxiety more around, like a longevity and sometimes a preoccupation and obsession with health, rather than an obsession with being unwell, an obsession with being well.
Oh, yeah.
And that's a hard.
I mean that's being fed anxiety us a lot on social media algorithms, for example.
Is this big, burgeoning preoccupation with the wellness industry really?
If we look at any diagnosis, for example again, one of the key criteria in almost all of them is impaired daily functioning.
So maybe you're not really anxious about becoming ill or unwell, but you're really preoccupied with your health.
That will often mean that that you and I think Dyson Heppel actually talked about in his episode, where he was so preoccupied, for example, with what he was going to be able to eat when he was going out.
So it's the preoccupation that actually impairs our life.
So anything that moves into preoccupation is for me kind of an alarm bell that we've moved into basically more rigid and inflexible responses.
Oh, yeah.
So of course it's okay for us to dip in and out of feeling worried.
Nothing wrong with that.
This is very normal.
It's very normal to at times be worried like quite a lot about something.
But it's when it turns into it being rigid and inflexible or black and white that we really are encountering more problems.
And I think that tends to show up or at least in my observation that tends to show up a lot around the health and wellness industry.
Yeah.
Yeah.
Well, it's interesting, Josh, that you said, because I think that's such a good point.
And obviously, as that technology gets better in, like the watches and the bands and the rings and everything it's almost like what we're seeking is this certainty
We're trying to get like more certainty on like our sleep, and God, my sleep score was 75, but God if I can get to 77 tonight.
They're like what does that even mean?
But like the certainty of of success or health but you're saying m that there is no certainty and so it feels like what this tech is giving us is the illusion of certainty yes that's a great point but it probably never can actually give us the certainty we're looking for yeah it's a tricky thing i think for me because i i think i've been thinking a lot about this and i think potentially kind of genetically i think because i think the least health anxious person i've ever met is our dad And I think potentially I just don't have that thing.
So for me, wearing this has been kind of just a positive, because I've looked at it and gone oh, maybe I haven't strained enough today.
Maybe I should walk home instead of catch it.
Like little things like that or like sleep score is bad, I should make sure I get sleep.
So for me it's been good.
But I feel like for someone who has health anxiety, it would be like giving someone with an eating disorder are wearable scales that they can't.
Yeah, I think that that's a wonderful analogy.
Yeah.
And so this is the thing is that it's There's individual differences here and that it depends how we're using.
Yeah,
How we're using it.
So how are we using the information?
Same thing can be said with chat GPT.
Are we using chat GPT for reassurance or are we using it for strategies?
So, for example... the reassurance seeking would be like, I've got this here.
What could it be?
And then you get involved in all the prompts and it becomes pretty intense.
Or you can say, I'm really struggling with health anxiety today.
Can you give me some tools?
So, you know, we can use it.
It's like, again, like we use it for good or we use it for evil.
And so the big invitation there is to be really discerning.
What am I actually engaging in here?
Yeah.
And how is this helping me?
Yeah.
That's so good, Em.
I feel like, especially, I'm sure it absolutely boomed during COVID, that whole experience.
And I feel like off the back of that, people are probably a lot more aware of it.
I think it's such a great topic.
Yeah.
Well, I hope that, you know, it is a really complex thing to understand.
But I think you know, for me the reason that it felt really important to mention is, you know, like in so many other circumstances, the more that we name this, the less shame there is attached to it and the more that we can readily work with it.
So, you know, if there's something that people have heard in the episode today that really resonates, you know, I would absolutely encourage you to seek some assistance with it.
It is absolutely workable.
So this is the thing.
It's not that it needs to be, like ironically, like a death sentence.
You know that this is something that we can really actively work with so that you get back to living the life that you actually so dearly hold.
It's so relieving when there are these things that we talk about in this podcast and there actually is something you can do.
Like a lot of the things, it's really really hard or there is nothing you can do and it's just dealing with it.
But this, you can do something.
There are evidence-based interventions and strategies that we know work really well with this.
Yeah, that's great.
Amazing.
Thank you.
Pleasure.
So good to see you.
Thanks for having me.
Maybe, as a fun game to finish, we could all try and say the word that Em couldn't say earlier and see who's best at it.
So let's all take it in turns and see who.
Josh, do you want to go first?
Yeah.
Colloquial.
Colloquially.
Oh, no problem.
Yeah.
No, I can't do it.
Colloquially.
Colloquially.
Yeah, close.
What a hard word.
It's a tough word.
It's a bit.
Poor choice on my part to choose that one.
Shame on you, Em.
Yeah.
I think the person who invented the word probably needs to think about that person.
Yeah.
Let's find their Instagram and let's absolutely troll them.
Yeah, sounds good.
Yeah.
Anyway, Em, thank you so much for another incredibly helpful episode.
Thank you very much.
Thank you, Em.
Thanks, Em.
Thank you.
The Imperfects is hosted and produced by Hugh van Kylenburg, Ryan Shelton and Josh van Kylenburg.
Our executive producer is Bridget North East, producer Bella North East.
This episode was filmed by George Martin and edited by Jamison Moore.
