Josh came to me in distress. He looked at me and said, “My heart is scaring me”. He had been to the emergency room multiple times in the past year with the same symptoms: sharp chest pain, cardiac arrythmia and palpitations. Many clients are referred to my practice from cardiologists and local emergency rooms for heart related health anxiety or cardiac phobia. Josh was one of those clients.

Hi, I’m Paige Pradko, a psychotherapist that specializes in anxiety disorders, health anxiety and OCD. Josh thought about his heart symptoms every waking moment of his day and researched and monitored his heart rate compulsively. He had multiple cardiac workups including EKG’s, Holter monitors, stress tests, and echo cardiograms from not only local specialists but the best specialists and hospitals in the country. But his results were considered normal or benign. None of the tests indicated that Josh had a cardiac problem or an organ system masquerading as a cardiac problem. It was frustrating for Josh to have no answers. He began to think his physicians were missing something which led to more doctor shopping and more googling and more tests. What Josh felt in his body was real, it just wasn’t disease-based or dangerous. Josh had anxiety sensitivity. A trait typical in people with health anxiety and panic disorder. He felt things in his body that other people might experience, but he felt them more intensely and interpreted them as dangerous. And because of that, Josh developed thought patterns and compulsive behaviors that led to full blown health anxiety. Josh’s symptoms seemed to wax and wane, but they always returned. Besides the constant researching and googling, he began to avoid activities and foods and drinks and anything that he believed might set off his symptoms. He avoided physical activity and travel and made sure he always had his cell phone and was at least a few miles from a well-equipped emergency room. His quality of life had declined significantly, and he now experienced depression symptoms in addition to his cardiac health anxiety. I wanted to make this video to help you.. if you may also have cardiac symptoms and sensations and health anxiety like Josh. This is a challenging condition because not only are there physical symptoms that can be uncomfortable and even painful, but it can cause so much anxiety and stress that can exacerbate the symptoms even more. I am going to share with you how I treat patients like Josh. But first, if you have excessive worries about your health, I left you a link to a free assessment to see if you might be suffering from health anxiety in the description and comments section of this video. (Leny, please show a notice on the screen “Assessment for Health Anxiety in Description Below”.) According to the American Heart Association, patients with acute chest pain symptoms should seek medical care immediately, although most will NOT have a cardiac cause and will not have been in any danger. Chest pain is the second most common reason for adults to present to the emergency department in the US. This accounts for 6.5 million ER visits and over 4 million outpatient visits annually. Of these visits, only 5.1% have acute coronary syndrome and more than half will ultimately be found to have a non-cardiac cause such as panic disorder or somatic symptom disorder, a type of Health Anxiety. These are the people I am reaching out to today. Many that enter the emergency room are cleared of any cardiac disease and sent on their way, often without answers. And like Josh, if their symptoms continue, helplessness and worry continue to build. It is not unusual for compulsive behaviors to begin like: excessive body checking, taking their pulse, excessive googling and researching, perhaps more doctor visits, excessive testing and other attempts at gaining reassurance or answers. Avoidance behaviors like avoiding physical activity and travel are also common. There are some people with health anxiety who despite their worries and symptoms avoid seeking help altogether because the fear is too intense. The physical sensations, along with worry, anxiety and safety and avoidance behaviors likely develop into full blown health anxiety. Health anxiety acts like OCD and is currently diagnosed as somatic symptom disorder or illness anxiety disorder or sometimes panic disorder. This is where I step in. After a thorough history, we begin to search for patterns. What precedes the cardiac or physical symptoms? - Were you stressed that week? Were you tired? Were you triggered by a thought or by checking your body or monitoring devices? What do you do when you experience the sensations or symptoms? - Do you do something to calm yourself? Perhaps you lay down, or begin to walk, or do deep breathing? - Do you seek reassurance or safety in some way? Perhaps you call someone or google your symptom or call your doctor? - Do you check your body in some way like check your pulse, feel your heart, take your blood pressure, or monitor your feedback devices? - Are you avoiding activities that you used to do because you are afraid that they might set off these symptoms and sensations? Do you avoid physical activity? Do you avoid eating or drinking certain things? Do you make sure you are not far from home or the hospital? Observing your behavior is important. All those activities to calm yourself, reassure yourself or avoid triggers are likely making it worse. Those safety and avoidance behaviors are all sending messages to your brain that your bodily sensations and symptoms are dangerous even if you have been medically evaluated and told they are not. Guess what the brain does when it believes something is dangerous? It activates your amygdala in your brain and your amygdala activates your sympathetic nervous symptom, your fight or flight response. Now more hormones are flowing through your body and this automatic response can make bodily sensations, especially cardiac symptoms worse. The first thing I teach clients is how to identify the safety and avoidance behaviors that are reinforcing their health anxiety cycle. There are hundreds of behaviors and avoidances that people are just not aware that they are doing, that contributes to the problem. Even mentally checking if you are having the symptoms or mentally wishing the symptoms away are compulsions that reinforce the very symptoms you wish would go away. Health anxiety acts like OCD, and it is reinforced by physical and mental compulsions. Health Anxiety is often misunderstood and mistreated by therapists that are not OCD or anxiety specialists. Telling someone to just stop worrying or do some deep breathing is unfortunately not very helpful here. Next, I teach different strategies on how to stop these reinforcing behaviors. This is called response prevention. It is possibly the most important step in recovering from health anxiety. And for some, we may move on to adding ERP, exposure and response prevention if practicing response prevention was not enough. There are several different types of ways to practice exposures, while always practicing response prevention. You may practice an incidental exposures or exposures in the moment, you may use scripts, or situational exposures or interoceptive exposures. Before treating a client for health anxiety or panic disorder, I advise them to see their medical provider and have the appropriate workup based on their symptoms. I also want their medical providers to give them permission to do interoceptive exposures if needed in therapy. The exposures may include various physical exercises to increase heart rate like running in place or doing jumping jacks or sometimes placing weights on their chest if chest pressure is a symptom. The Interoceptive exposure exercises you’ll do depend on which bodily sensations make you feel most anxious. There are exposures for a racing heart, shortness of breath, headache, lightheadedness, etc. The purpose of interoceptive exposures is to teach your brain that you can do certain activities that bring on a rapid heart rate or whatever symptom you fear and learn that you are safe, and you can tolerate your body’s reaction. In Panic disorder and health anxiety, people tend to associate different physical symptoms and sensations with panic or high anxiety. Interoceptive exposures help to create new safety learning or neuropathways that do NOT associate the targeted body symptom with the fear response. I included a link to a video on how to do Interoceptive Exposures in the description of this video. Not every client may need to practice interoceptive exposures, but I advise clients to get permission from their medical providers, nonetheless. In Josh’s case, his cardiac symptoms dramatically reduced through response prevention strategies. He stopped his compulsive checking and avoidance behaviors. He slowly began to engage in more strenuous physical activities and challenged himself with traveling even including flying. Josh can now identify the moment he recognizes a small doubt that is triggered by sensations and even pain in his chest. He now trusts what he knows instead of allowing his what-if scenarios, rumination or his imagination to blow-up his doubt into an obsession that consumes his life. Josh shared that his favorite technique is asking himself to “Bring It On” when he feels any cardiac symptoms, and this seems to work miracles for him. His brain has learned over time to no longer associate fear or anxiety with his cardiac sensations. He now accepts them as just something his body does. Josh continues his regular schedule for medical checkups that were agreed upon by his physician, who understands Josh’s cardiac sensations along with his history of health anxiety. Based on the Journal of Medical Internet Research in January 2022, there is significant evidence that internet-based CBT psychotherapy with a focus on physical activity is effective in reducing cardiac anxiety and increasing health-related quality of life in patients with noncardiac chest pain. If you are interested in learning more or would like more help for your cardiac health anxiety, I have an evidenced-based, online course called Recovery from Health Anxiety along with a support group at PaigePradko.com. I would love to help you recover at get back to enjoying your life.