Diagnose My Wife, Please!

Hi Hills1:

Thank you for writing with such an interesting question about a not so unusual phenomena.  I hope you will excuse the seemingly flippant nature of my title to this reply, but I couldn't resist giving a nod to the late comedian, Henny Youngman.

I appreciate the frustration and exhaustion you have been experiencing in response to your wife's many concerns about safety, health and all manner of environmental threats.  You are correct in that Hypochondriasis would not be the proper description of her condition.  This is primarily because her concerns do not simply involve her own potential risk, but that of your entire family, because it does not sound as if this cluster of symptoms has markedly impaired her functioning, and finally, because the condition does appear to be better explained by other syndromes.  In particular, Generalized Anxiety and Obsessive-Compulsive Disorders. 

Individuals who are excessively vigilant regarding a wide variety of environmental threats to their health and well-being and that of family members do often clearly exhibit an anxiety process.  They scan their worlds in search of any threats to safety, find the threats (we tend to find what we are looking for), worry about them, and then take precautions to protect against them.  As in GAD, this worry can focus upon a wide variety of problems, is very difficult for the individual to control, and can cause disruption of sleep and other areas of behavioral functioning.  Such individuals also tend to be FAR too good at "worst case scenario" thinking, and frequently look into cracked crystal balls to divine the future..

Where this condition also begins to overlap with Obsessive-Compulsive Disorder is in the cyclical and repetitive behavioral, cognitive and emotional responses to the concerns.  This aspect also helps us understand why the condition persists and worsens over time, and provides some guidelines for treatment.  For example, as soon as your wife begins to deveop some concern about a new threat (and the media and digital news providers are only TOO happy to provide grist for this mill!), this is experienced aversively.  Naturally, rather than sit helplessly with worry, she will then seek reassurance or information from others, and/or hit the internet to learn more in the hope that this will ease her discomfort. 

In most cases, the act of trying to quantify, assess or avoid the risk WILL bring some small degree of intial reduction in the worry, as the person now feels actively engaged in trying to protect themselves versus just experiencing helplessness.  They may also believe they have just dodged a bullet.  Thus, "behavior that allows us to avoid or terminate an aversive stimulus" IS often at least temporarily successful.  This behavior has now been "negatively reinforced," and is more likely to recur the next time a new concern surfaces.  Sadly, however, we get better at whatever we practice, and your wife is practicing hypervigilance, worry, intense research into what might go wrong, and doing all she can to prevent danger from occurring.  Each time the sequence is repeated, it gets stronger, and, especially if these potential dangers don't turn into actual problems, the process of "worry, investigate, feel relief" provides confirmation to her that her system is working and that she is in control of her environment.

Obvious problems caused by this hybrid condition include worsening worry and anxiety, potential transmission of such thoughts, feelings and behavior to children via role modelling, relationship strains caused by the preoccupation, and conflict between partners if the anxious one views the less anxious one as somehow "asleep at the wheel" or "negligent" or even "abusive" for not taking the concerns more seriously.  In addition, across time, the affected individual gets more and more into the habit of craving certainty and predictability and control, and less adept at actually dealing with the real challenges and priorities of life (which is by nature ambiguous, unpredictable and uncontrollable). 

So the presence of internet checking is an example of an OCD "ritual" or "safety behavior," as would be excessive hand washing, as is the avoidance of the garage after sawing has been done in it.  The behavior temporarily brings relief, yet another concern pops up the next day.  A former teacher of mine once said "you can never get enough of what you don't need."  So, if problems coping with ambiguity and loss of control are at the core, then all of the internet research in the world won't be curative.

A typical characteristic of individuals presenting with such a condition, however, is that they "don't present with a condition."  Their symptoms are often experienced as "ego syntonic" and these individuals may believe that they are viewed as "simply being responsible" versus "having an anxiety disorder."  On the other hand, third parties  who do not take a similar level of precaution can be seen as irresponsible and undependable.  I mention this because such patients are not typically motivated to engage in tratment for the condition unless it becomes debilitating, obviously detrimental to their families, or it starts to cause more distress.

Once the patient is motivated, however, psychological treatment is fairly straightforward, and the symptoms are most effectively resolved using cognitive-behavioral therapy.  The patient is first educated about the process of worry, and the role of negative reinforcement in perpetuating it.  The patient then learns to re-evaluate their tendencies to distort or catastrophize objects of their fear and is helped to begin eliminating all safety and avoidance behaviors from their repertoire.  Finally, the patient is guided to seek out exposure to some of the very things they fear, and is at the same time required to refrain from "scratching the itch" by ritualizing, avoiding or distracting.  In this way, the patient "habituates" to the notion of uncertainty, and begins also to "practice" and get better at lowering their hypervigilance and allowing life to flow imperfectly by.  Some developmental work may also be useful in helping the patient to understand how they learned to worry so well, and this can motivate them to live differently.  Training in various relaxation skills tends also to be quite helpful as a part of treatment.    

As you posed your question to me as a mostly diagnostic one, I am wholly unsure as to your wife's level of motivation for treatment or change.  If either of you would like to begin with some reading, David Burns' excellent book, "When Panic Attacks," is sure to be of some value.  If you are wanting to identify a psychologist or other qualified mental health professional, you may consult your primary care doctor, your state's psychological association, or go to apa.org or adaa.org.  Again, CBT is particularly effective with anxiety disorders and I would suggest a specialist in this area.

I thank you for writing and hope that my comments have been of some use to you.  If you have any further questions, need more information about treatment resources or book references, or simply need additional advice on how to speak with your wife and cope together with the challenges you described, please don't hesitate to get back in touch.

Sincerely,

Richard E. Schultz, Ph.D.