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It has been my observation both clinically and personally that those of us who have lived with OCD for a long time often have had the experience of OCD jumping from one theme to the next throughout our lifespan. While there are specific themes that people with OCD tend to report (kind of like OCD’s greatest hits), there are no limits to what a person’s OCD can latch onto. Recently, I was thinking about the topic of health anxiety (not surprising considering we are navigating a worldwide health crisis). Only I was thinking about mental health anxiety, a manifestation of health anxiety.
With mental health anxiety, one is excessively preoccupied with the status of their mental health, whereas in health anxiety one is preoccupied with the status of their physical health. While there are plenty of assessment tools and criteria to help determine a mental health diagnosis, there are no definitive tests that provide any measure of certainty about the overall status of one’s mental health. This fact can be scary for anyone, but if you have OCD it can be terrifying. Isn’t it hard enough to worry about getting cancer or HIV? But what about a psychiatric condition or just “losing your mind” (to use a colloquial phrase)? What is a person to do?
What’s Wrong with Me??? Just Tell Me!
People I work with often tell me they are worried they are going “crazy.” When I ask clients what that looks like, they typically describe being permanently disassociated from reality along with a complete loss of dignity. They imagine what the loss of their mental faculties would look like, which often resembles things falsely and harmfully depicted in the movies. They worry that the content of their obsessive thoughts may be evidence of something additional going on, perhaps something more sinister that could possibly lead to harming someone.
OCD may trick you into believing that any shift in mood, thought, or perception may be an indicator of their descent to “losing their mind.” Stress (like a pandemic) or significant changes (like being isolated from family and friends) exacerbate OCD symptoms, and naturally lead to increased irritability and moodiness, which in turn may reinforce one’s fear that their mental health is declining.
Hyperawareness in Mental Health Anxiety
Having anxiety about mental health is like having an OCD hall monitor in your mind. The sole purpose of the OCD hall monitor is to watch out for brain activity that might be an indicator of a potential danger which should be promptly evaluated.
In mental health anxiety, OCD manifests as hyperawareness of mental processes that keep you embroiled in anxiety about mental health. Here are some ways OCD uses hyperawareness to keep you on the lookout for signs of feared mental illnesses.
Hyperawareness of Moods
- What if my mood swings are evidence of having manic episodes during which I could lose control of myself?
- What if my feelings of sadness and frustration are a sign of clinical depression that could lead me to harm myself?
- What if I feel terrible forever?
Hyperawareness of Perception
- What if my feelings of depersonalization are indicators of losing touch with reality?
- What if my obsessive thoughts are delusions and I am psychotic?
- What if taking medication altered my brain permanently?
Hyperawareness of Thought
- What if my racing thoughts are a symptom of another disorder which might ruin my life?
- What if my false memories are delusions?
- What if my obsessive thoughts are not OCD, but rather signs of being a sociopath?
While seeking appropriate treatment for your mental health needs is important, it is equally important to distinguish self-care from compulsive certainty seeking in OCD.
Common Compulsions in Mental Health Anxiety
Once OCD has identified what it deems to be an unauthorized thought, feeling, or experience, the investigation ensues. In health anxiety one scans their body for physical symptoms while in mental health anxiety one scans their mind for irregular patterns of thoughts and feelings.
- Mental review of conversations with mental health practitioners
- Excessive mental evaluation of mood
- Reassurance seeking from mental health professionals
- Researching mental health disorders to ensure an accurate diagnosis
- Researching feared symptoms to try to be certain they do not apply to you
- Reassurance seeking from family members about family psychiatric history
- Staring at objects to check for feelings of derealization
- Checking to see if you feel real
- Mental review of experiences to assess if they were symptoms
- Avoiding media that depicts mental health issues
Mary is a 27-year-old female who was doing well after several years of CBT treatment for her OCD. Following a routine psychiatric appointment, Mary and her psychiatrist decided she might benefit more from another medication. As she began to titrate off one medication and onto another, she began to have the thought that something may be terribly wrong and that she might not be okay. As time went on the thoughts arrived more frequently and the urgent feeling increased. She became preoccupied with the notion that the new medication had altered her brain somehow and that she might end up being hospitalized and having her children taken away. What if she was not okay and did not know it? What if she was now incapable of taking care of her children properly? Mary knew she had OCD, but this time her OCD had her focused on possible catastrophic outcomes which would impact the welfare of her children.
Chris is a 42-year-old graphic designer who has been working from home since March of 2020 due to COVID-19. Chris has a history of OCD, but typically his OCD focused on his relationships and his health. Recently, he noticed feeling detached from things he cares about. At first, he chalked this up to being circumstantial and therefore normal, but in the back of his mind, he worried that his feeling of detachment might be a type of depersonalization. He began to check his feelings to see if he felt connected to his life and his family members. What if he was not connected to his family and friends, because he was not himself? What if I am not myself? he worried. Chris knew he had OCD, but this time his OCD had him focused on mental processes that he feared might indicate a different disorder.
Uncertainty and Mental Health
One thing that differentiates mental health anxiety from anxiety about one’s physical health is the subjective nature of mental health. While some health diagnoses are also subjective, often there are concrete objective ways to determine or confirm health diagnoses. Unfortunately, there are no blood tests that determine if one is depressed or psychotic. The reality is that the state of one’s mental health fluctuates, creating a lot of fodder for OCD to work with. As with all forms of OCD, the core issue is intolerance of doubt and uncertainty.
Treating mental health anxiety starts with recognizing that certainty about your mental health is not possible. In theory, most of us know that there is no such thing as having 100 percent certainty about anything, but in practice it often seems like there are some things you should just know, right? Shouldn’t I be able to say that I am not going to snap and hurt my family and friends? Though I can be confident about such things, they are still not exceptions to this one rule; I cannot know anything with 100 percent certainty. However, it is also important when working with my clients that they understand that I am not asking them to accept that it is a 50/50 chance that their fears will come true. Rather, I am trying to help them accept the same, tiny amount of uncertainty that exists for us all.
ERP for Mental Health Anxiety
The gold standard treatment for OCD is exposure and response prevention (ERP) which, simply put, means to move towards the thing that makes you anxious while refraining from compulsions. It is especially important when doing exposures to identify and interrupt ruminating which often happens during exposures yet will render the exposure useless.
- Watch films about psychiatric institutions or with themes of severe mental health conditions.
- Watch video clips of individuals who had psychotic breaks.
- Watch tv shows with characters that live with mental illness.
- Write imaginal scripts about losing your mind/having a psychotic break.
- Reading about specific mental health disorders.
- Discuss which psychiatric hospital you would rather live in if you had to (my personal favorite).
Mindful Awareness and Mental Health
It may seem counterintuitive to suggest practicing mindful awareness when you are already acutely aware of the inner workings of your mind. It is important to note the distinction between being hyperaware and being mindfully aware. Hyperawareness of one’s mind is a state of being excessively, painfully aware of mental processes through vigilantly checking in on them. The excessive awareness then leads to rumination, overestimation of threat, and misattribution of mental experiences as signs of mental illness.
On the other hand, mindful awareness allows one to be aware of one’s thought patterns and emotional responses, without the element of judgment. When one can mindfully observe mood changes, thought patterns, and emotional responses without evaluating their significance, they can be transient experiences much like a weather pattern.
Living Dangerously? (Only Not Really)
I once had a client tell me that she was one step away from total disaster; I remember thinking to myself, “aren’t we all one step away from disaster?” The idea that something bad could happen at any time has always been true, regardless of your awareness of it. We all know this, but it is not at the forefront of one’s mind, unless of course, you are living through a pandemic. Living with OCD means you have a brain that is aware of all possibilities, which makes your awareness of them feel risky. Acknowledging potentially disastrous outcomes does not make them more likely.
I sometimes describe OCD as being like a well-meaning friend who desperately wants to be helpful, but often ends up being unhelpful. Viewing OCD as trying to protect you in its weird way can help you to back away from self-judgment and allow you to view your obsessive thoughts about your mental health with a sense of humor, rather than treating the thoughts like threatening information. Remember OCD is not the arbiter of your mental health or anything else for that matter.
Our society has created an environment where we are quick to identify people suffering from mental illnesses as crazy, psychos, loonies, nutcases, etc. Using these words upholds and reinforces the stigma surrounding mental illness. This lack of understanding isolates those in need and makes them more fearful to seek treatment. The terms “crazy” and “losing your mind” are used in the following article to help illustrate a common type of anxiety - mental health anxiety - that exists at the junction of OCD and stigmatizing pop culture.
Molly Schiffer, LCPCAssociate Director, The Center for OCD and AnxietySpecialties:Anxiety Disorders, Cognitive Behavioral Therapy, Obsessive-Compulsive Disorder (OCD)