Helping Health Anxiety
Helping Health Anxiety

Helping Health Anxiety
Module 7
Challenging Avoidance
and Safety Behaviours
Introduction

2

What are Avoidance and Safety Behaviours?

2

Graded Exposure

2

My Avoidance & Safety Behaviours

3

Planning Your Goals

5

Building Your Stepladder

6

Exposure Stepladder - Example

7

Exposure Stepladder - Worksheet

9

Taking a Step

10

Climbing Your Stepladder

10

Module Summary

13

About the Modules

14

The information provided in the document is for information purposes only. Please refer tothe full disclaimer and copyright statements available at www.cci.health.gov.au regarding theinformation on this website before making use of such information.

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Introduction
In Module 6, we identified how health related behaviours exist on a continuum, where too much or too
little of a behaviour may be unhelpful for us. While Module 6 explored behaviours we might be doing too
much, this Module will explore behaviours that we may be avoiding or putting off due to feelings of anxiety.
In Module 3, we introduced the notion of avoidance and safety behaviours. In this Module, we will revisit
the common types of avoidance and safety behaviours, and introduce a way to gradually start to challenge
and overcome these behaviours.

What are Avoidance and Safety Behaviours?
When we feel anxious or expect to feel anxious, we often act in one of two ways to try tocontrol our anxiety. One way is to engage in avoidance, where we stay away from thosesituations or activities that we associate with feared illnesses or that remind us of our
mortality. This could include avoiding:• people (e.g., medical staff, ill friends or relatives),• places (e.g., hospitals, public restrooms, funeral homes), or• activities (e.g., attending medical appointments, thinking about death, writing a will)
Also, because people with health anxiety tend to worry more that usual about physical symptoms in theirbodies, we may also avoid activities that bring about changes in our physiological state (e.g., exercise, having
sex, eating spicy foods, drinking caffeinated drinks).
Alternatively, we may engage in safety behaviours, where we may not outright avoid a situation or
activity, but we will only do so if certain precautions are in place. For example, someone who is fearful ofcontracting an illness may only visit a friend with a non-infectious disease if they are taking a preventative
course of antibiotics and plan minimise touching objects within the friend’s house . Safety behaviours areoften thought of as a more subtle form of avoidance because you are not fully testing out your fears or
engaging with the situation.
Avoiding situations or activities, or using safety behaviours to cope with them, may reduce the anxiety wefeel in the short term, but is likely to have some less helpful long term effects. In the long term, our healthworries and concerns will continue, because we haven’t given ourselves the opportunity to face our fears
and see how things really play out. We will also feel the need to continue to use avoidance and/or safety
behaviours, as we haven’t learnt whether we can survive without them. Over time, using avoidance andsafety behaviours can deplete our sense of self confidence. These behaviours may also stop us from doing
things we would like to do and lead to a very restricted an unsatisfying life.
Ultimately, you will need to face and confront your fears if you want to overcome health anxiety.
Overcoming the fears that drive avoidance and safety behaviours can seem daunting at first. Some people
might encourage you to tackle your biggest fear first – to “jump in the deep end” and get it over and donewith. If, however, you try to tackle your biggest fear straight away, it can end up being too overwhelming
and may even leave you more anxious than when you started. Many people therefore prefer to take it“step-by-step, like climbing up a stepladder. We call this stepladder approach “graded exposure”.

Graded Exposure
Graded exposure consists of structured and repeated exposure to anxiety-provoking situations or
activities. These are presented in levels of difficulties, starting with the situation or activity that provokes
the least amount of anxiety, and then moving towards more challenging ones. There are a number ofbenefits to engaging in exposure.
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Exposure gives you the chance to continue to challenge your fears. People with health anxiety
often overestimate the likelihood that they have or will develop a serious health problem, andunderestimate their ability to cope with such health problems. Exposure gives you the opportunity toconfront your fears regarding potential illness, and by doing so develop more realistic appraisals of the true
likelihood of a serious illness and your true coping abilities.
Exposure gives you the chance to get used to anxiety sensations. While in the short term it canfeel uncomfortable to experience anxiety sensations, in the long term you will feel more in control of youranxiety. By continuously bringing on your anxiety sensations you will also become more tolerant and lessbothered by them.
Exposure gives you the chance to use your skills. By repeatedly confronting feared situations andactivities, you will gradually become more used to them. Feeling comfortable in these situations is notinstantaneous though. First of all you need to stay in the situation long enough so that your body adjusts
your anxiety downward. Then you can use the strategies you have learnt so far to help you copewith anxious thoughts and feelings (e.g., using thought diaries to challenge unhelpful healthrelated thoughts).
Exposure gives you the chance to improve your confidence. If you plan these steps
carefully, you will build up your confidence and this will allow you to take further steps
forward. With increased confidence, you are more likely to face your other 'fears'.

My Avoidance & Safety Behaviours
The first step towards graded exposure is to identify the situations and activities you tend to avoid, or any
safety behaviours you may be engaging in. You can list these on the next page.
You can look back to Module 3, where you may have already listed some of your avoidance and safety
behaviours. If you have been working through your thought diaries, you’ve probably mentioned a few
situations that you’ve felt anxious about and avoided, or where you have employed safety behaviours tocope, so it might be worthwhile looking at those for ideas.
To help you along, we have provided some examples of situations and activities that often cause distress forpeople with health anxiety. If you see any that seem familiar to you, you can rephrase them on your “My
Avoidance & Safety Behaviours” list, so that they are more relevant to you.
Make sure that you think about any possible safety behaviours, as these may often be quite subtle (e.g.,
carrying medications “just in case”, carrying a mobile phone so that you can call for help). Also, make sure
you include those activities that might bring on feared physical sensations, such as exercising or eating spicy
foods, if this is relevant for you.
You will also need to consider whether you are avoiding thinking about illness or death. It
is quite common that people experiencing health anxiety will try to avoid thinking about
those things that they are most fearful of, especially thoughts of death and dying. This iscalled thought suppression. Unfortunately, trying not to think about something can havethe opposite effect by making us think about it even more!
Can you remember back in Module 4, we asked you to try to not think of a pinkelephant for 60 seconds? Can you remember how well you did? If not, you may wish to try this again now
to see how well you do. Generally, most people find that the more they try not to think about something,
the more our mind tends to think about it. If this type of avoidance is familiar to you, record the things you
avoid thinking about on your list too.
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Commonly avoided people, places and activities:• medical professionals• doctors’ surgeries• using public restrooms• walking past funeral homes• writing a will
• phoning for test results• eating foods close to the used by date• medical check-ups or follow-ups• watching the news or reading the newspaper• visiting a relative who has recently been sick• leaving the house without medications or amobile phone “just in case something happens”• thinking about your funeral• watching medical dramas on TV

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reading information provided by a doctor
exercising
walking up stairs
drinking coffee
having sex
eating spicy foods
drinking fizzy drinks
visiting a friend who has a non-infectious disease
reading the obituaries
going out in public without hand-sanitiser
taking a medication prescribed by your doctor
telling your doctor about concerning symptoms
thinking about how others will cope with yourdeath

Take a moment to record your own examples below:
My Avoidance & Safety Behaviours

Now that you have identified a number of situations that you fear and avoid, how do you build a stepladder
to where you want to get to? First of all, let’s take a look at where it is that you do want to get to byplanning your goals. After that you can start thinking about the steps you'll need to take to reach those goals
by building your exposure stepladder.

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Planning Your Goals
Let’s think about how you can turn those situations that you fear and avoid into specificgoals that you would like to achieve.
To start with, you might want to just choose one or two behaviours to work on, rather than trying to do it
all at once. When you’re planning goals for exposure you should focus on those behaviours that you want
to change, rather than planning goals that are not very important to you. By setting a goal that is important
to you, you will be more likely to put in the effort, and to put up with some of the discomfort that isnatural when doing exposure exercises.
It is also important to think about setting specific goals. Think about what your behaviour looks like now,and what it would look like if you met your goal. For example, if your current behaviour is “avoiding
doctors’ surgeries” then your goal might be “attending an appointment at my doctor’s surgery”. If yourcurrent behaviour is “avoiding exercise” then your goal might be “engaging in exercise so that I can feel myheart beating and am out of breath”.
Gradually allowing yourself to have thoughts about illness and even death may also be an important part toyour recovery. While it may seem strange, if your current behaviour is “avoiding thinking about my death”
then your goal might be “to write a will” or “to plan my funeral”. Or, if your behaviour is “to not let myself
think about having Multiple Sclerosis”, then your goal may be “to read a book about
Multiple Sclerosis” or “to write a story about being diagnosed with Multiple Sclerosis”.
Working on goals such as these allows you to gradually confront your feared thoughts,
and to reduce the unhelpful thought suppression that often accompanies such thoughts.
My goals
With these ideas in mind, record one or two goals below that you would like to work on. Also, take amoment to think about and record why it is important to work on this goal. You may need to review thislater if you find your motivation is waning or you are uncertain about continuing on with your stepladder.
Specific Goal #1: ______________________________________________________
Why is it important for me to work on this goal?

____________________________________________________________________________________________________________________________________________________________________________________
Specific Goal #2: ______________________________________________________
Why is it important for me to work on this goal?

____________________________________________________________________________________________________________________________________________________________________________________
If you would like to work on more goals, it is usually best to come back and work through these steps again
rather than trying to do too much at once and feeling overwhelmed.

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Building Your Stepladders
You can now start building a stepladder of situations and activities that you can begin to climb as you work
towards your goal. Remember that by taking a step-by-step approach you can get through the smaller
challenges, which will in turn help you feel more confident.
Many people who have engaged in exposure exercises have found that breaking their overall goal down into
small, specific steps helps them feel more comfortable by knowing what's coming up. It also means thatyou'll be able to make sure the steps are small enough to take, but big enough that you believe you'reheading in the right direction.
Try to think of a set of situations and activities you can engage in, starting with the least anxiety provoking
then building up in intensity until you reach your main goal. Just like in the last module, each step on the
stepladder can be given a “Distress” rating between 0 and 100, where 0 = this step is not distressing at all,and 100 = this step is highly distressing. Your stepladder might have fewer or more “in between” steps thanthe example provided. In general, a very difficult goal may need lots of small achievable steps so that you
don’t feel overwhelmed and discouraged while working up the stepladder.
You can break your overall goal into smaller steps by changing WHO is there, WHAT you
do, WHEN you do it, WHERE you do it, and HOW long you do it for. Sometimes yourgoals will be opportunity-specific, that is, there might not always be a steady stream of
medical follow-ups where you can practise your steps. So you need to think of situations
that can act as steps that will still help you to climb the ladder to your goal.
The following case illustrates how you can set a goal and build a stepladder to work
towards it. You can then use the Exposure Stepladder Worksheet to complete the steps foryour own goal.
Phil avoids places associated with people who are unwell. He avoids medical facilities because he is fearful ofcatching something from the other people who are there for appointments or procedures. He is especially reluctant
to attend his doctor’s surgery on weekends when the clinic is at its busiest, even though he works full time and finds
it difficult to attend during the week. He also sometimes avoids the medicinal aisle at his local supermarket. He
worries that people who are unwell have been there before him and possibly touched and “contaminated” items on
the shelves. He no longer feels that he can go to larger shopping centres as he feels the risk of contamination ishigher at these. Phil is aware that he is well overdue for a check-up and is becoming frustrated with himself eachtime he has to shop.
Phil identified a goal of “attending an appointment at my doctor’s surgery”. He recognised that this wasimportant because he was well overdue for an annual check-up and putting it off was adding to the amount
he worried about his health. In developing his Exposure Stepladder, Phil was able to identify that any steps
that involved directly attending his doctors surgery would be quite challenging (Distress = 80). He
therefore developed some steps around visiting the medicinal aisle at various supermarkets, visiting apharmacy, and attending a walk-in clinic so that he could gradually build up his confidence to engage in theharder step of visiting his own doctor’s surgery for an appointment. Phil also identified that he would needto gradually reduce his safety behaviour of not touching things in these situations, so that he could truly
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Exposure Stepladder – Example
GOAL:

Attending an appointment at my doctor’s surgery

STEP

DISTRESS (0-100)

1

Attend local supermarket, stand in medicinal aisle for five minutes, nottouching anything

25

2

Attend local supermarket, stand in medicinal aisle for ten minutes,
touching a range of items (e.g., picking up different boxes of tissues,reading the information on a packet of cough lozenges)

35

3

Attend larger supermarket store, stand in medicinal aisle for ten
minutes, not touching anything

40

4

Attend larger supermarket store, stand in medicinal aisle for ten
minutes, touching a range of items

50

5Attend local pharmacy, on a weeknight, stay for ten minutes, touchinga range of items

55

6

Attend local pharmacy, on a weekend, stay for ten minutes, touching a
range of items

65

7

Attend local after hours walk-in clinic, sit in waiting room for 15
minutes, not touching anything

70

8

Attend local after hours walk-in clinic, sit in waiting room for
15minutes, touch items in waiting room (e.g., read magazines)

75

9Attend my doctor’s surgery without appointment booked, sit in waiting
room for 15 minutes, touch items in waiting room (e.g., readmagazines)

80

10Attend my doctor’s surgery with appointment booked, touch items in
waiting room (e.g., read magazines)

90

Exposure to feared thoughts
Your exposure stepladder can also include exposure to feared thoughts about illness and death. The
following activities could be built in to your stepladder to help gradually start to confront, rather than
avoid, feared thoughts about illness and death.
• Reading the obituaries to trigger thoughts about how loved ones feel when someone passes away
• Writing the word “death” repeatedly on a piece of paper to trigger thoughts of death• Preparing a will to confront the reality of death• Visiting a funeral home or cemetery to confront the processes involved with death and dying• Planning your own funeral. Discussing this plan with others.
• Reading a story written by someone else who has been diagnosed with a terminal illness• Watching a movie or reading a book where the central character has the same condition you are fearfulof• Writing your own obituary to confront the reality of death. Writing it as though you died this week, atyour current age.
It can also be helpful to confront your greatest fears head on by writing out a Worry Story. Your story
could be about being diagnosed with a terminal illness, about your own death, or about how others would
cope if you were to die. If you are going to try this, be sure to write stories about diagnosis and your own
death in the first person, and as though it is happening here and now. Focus on how you are feeling andwhat you are thinking about or doing. Here is an example:
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I am at the doctor’s surgery and he calls me in. He is normally quite happy to see me but thistime he looks grim and serious. I already know that something is wrong but try to convince myselfthat this can’t be happening to me. I sit down in the chair and he starts to say that he hasreceived my test results back. As he is saying the words I am nodding and saying “ok” but inside
my heart is beating so fast and I am feeling so sick that it is hard to focus on what he is saying.
He hands me a brochure on motor neuron disease and is talking about a referral to a specialist.
I’m not really listening because my head is full of the words “two to five years”. For the first timein my life, I truly know that I am going to die. I’m thinking about how bad it will get and whether
I’ll go quickly or suffer in pain. I then think about my kids. All I can focus on is that they are going
to see me deteriorate and that is all they will remember of me because they are too young. I feelso stuck and helpless, knowing there is no cure.
How did you feel reading through the story above? Most people will find this at least a little upsetting toread, even if you are not worried about motor neuron disease, or don’t have children. How many times
per day do you think you would need to read this story over the next week so that it no longer affects you
the way it did today?
Remember that with any exposure exercises, once is often not enough. You will need to repeat yourexposure exercises multiple times to truly confront these feared thoughts and to see a reduction in the
anxiety and distress associated with these thoughts. You may need to read your Worry Story several times
per day, over one or two weeks, before you see a noticeable change in how upsetting it is to you.

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Exposure Stepladder Worksheet
GOAL:

STEP

DISTRESS (0-100)

Remember, your stepladder might have more or fewer steps depending on how difficult your overall goal
is. You can include more ‘in-between’ steps if you think the jump between one step and the next is too big.
You can break your goal into smaller steps by changing:• WHO is there• WHERE you do it• WHAT you do• HOW long you do it for• WHEN you do itforCentrelinical
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Taking a Step
So, you’ve selected a goal that you want to work on first. Where do you go from here? First, let’s have alook at how to take a step on the stepladder. Then we will explore how to climb up your stepladder.
Plan your first step
It can be helpful to set a specific date, time and place that you will begin your first step. That way, you aremaking a firm commitment to yourself to begin the process of change. Usually, you would start at the stepon your stepladder that had the lowest ‘Distress’ rating. If your goal only has a few steps, it is still often
useful to gradually work up to this goal, even though it might seem like a “waste of time”. These steps giveyou extra situations for your body to get used to things that are uncomfortable for you. They also give you
extra opportunities to gather evidence about any unhelpful health related thoughts you might beexperiencing.
Expect some anxiety
When you enter the situation – at any step - remember that you’ll probably experience some anxiety or
discomfort. That’s why it’s important to start small, and work your way up. This gives you the chance toadapt to that level of anxiety, so that you aren’t overwhelmed by higher levels of distress.
After all, the only way to get used to those feelings is by experiencing them.
Remember your realistic health related thoughts
If you haven’t completed a thought diary to challenge any unhelpful health related thinking,you may want to complete one prior to taking your first step. If you have completed one,
remind yourself of your realistic health related thoughts if you notice any of the unhelpful
thoughts coming up.
Stay in the situation
Some anxiety is expected, and it might be tempting to leave if you feel uncomfortable, but try to stay in thesituation until the anxiety goes down. In this way you can see that, as frightening as the feelings are, they
are not dangerous, and they do subside. If you leave just as the level of anxiety experienced reaches its
highest point, it will be more difficult to accomplish the same step the next time. On each attempt, you
should try to face as much fear as you can stand and just try to “ride out” the anxiety – like surfing a wave.
Drop those safety behaviours
Some steps on your stepladder might involve recognising and dropping safety behaviours. Regardless of thesituation or activity, try to be honest with yourself about whether you are fully participating, or only doing
so if there are some precautions in place. Full participation means being fully aware of what is happening
within and around you. This also means not taking alcohol or drugs to try and “mentally escape” from theexposure exercise. Remember, if it seems too hard to drop a safety behaviour immediately, you could use
your stepladder to gradually decrease it.

Climbing the StepladderOK, so now that you have some tips on how to get through one step, how do you keep moving onwards
and upwards? Here are some guidelines for how you can continue to climb each step to reach your goal.
Take one step at a time
Climbing a stepladder is not about taking one giant leap, it’s about taking one small step at a time. You
begin with the least difficult step and gradually work your way up the step ladder. As you climb higher up
the ladder, your ‘Distress’ rating becomes higher, but you also get used to the anxiety at each of those
steps. Your primary aim at each step is to complete that step and that step alone.
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Over and over again
Do a step frequently and repeatedly, and do them in close succession to make sure you are comfortablewith the situation before you move onto the next step. This might take 3 or 4 times. If you only enter asituation once, you might be relieved it is over, convince yourself that it was luck that you got through it,
and think that if you did it again it wouldn’t go so well. If you can, it is best to repeat the step
as soon as possible so that you can get used to the situation more quickly and become more
comfortable, and so you are truly convinced that the step is no longer a problem for you.
Acknowledge the steps you’ve madeWhen you are comfortable with a particular step, admit to your successes and acknowledge
the steps that you’ve made so far. You can even build in some rewards to acknowledge yourprogress along the way.
Deal with step-backs
We all have our up and down days, and sometimes you might think might you’ve taken a ‘step-back’
because an exposure exercise didn’t go as well as you hoped. Each time we do an exposure exercise islikely to be different. That’s why it’s important to do a step over and over until you are comfortable withthat step. If you are having some trouble with a particular step, you may want to create a “bridging” or inbetween step. This would involve planning another step that is slightly less distressing and has a slightly
lower ‘Distress’ rating. Alternatively, you could try going back to the previous step and use it as anopportunity to refresh your skills before attempting to move up again. Don’t forget to set a specific date,time and place as to when you will take the next step.
Use the Exposure Diary
On the next page is an Exposure diary for you to record details about the exposure exercises that you
make. This is useful because it helps you to acknowledge the steps that you’ve made, it reminds you ofthings that helped you to get through this, and it helps you identify what you can do if the step didn’t go aswell as you hoped.

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Exposure Diary

Helping Health Anxiety

You can use this sheet to record your progress on your stepladders. You can describe what you planned
to do, and your ‘Distress’ ratings for how nervous you both expected to be and how nervous you actually
were. The last column asks you to jot down any comments about the experience – were you able to dowhat you planned? What helped you to do this? If you experienced a great deal of difficulty, you can note
down why you think this might have been the case, and how you might prepare yourself for next time.
Planned exposure exercise

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ExpectedDistress
0-100

ActualDistress
0-100

Did you do it? What helped you complete the step?
OR
Describe what made it difficult to complete the step andhow you can prepare for next time?

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Module Summary•

Avoiding situations or activities, or using safety behaviours to cope with them, may reduce the anxiety
you feel in the short term, but in the long term can keep your health anxiety going.

•

Confronting feared situations and activities, and thoughts about illness and death, is known as exposure.
Exposure gives you the chance to:• get used to previously feared situations/activities• get used to anxiety sensations• continue to challenge your fears• use your skills• improve your confidence•

Grading your exposure allows you to break your planned exposure exercises down in to moremanageable steps. These can be recorded on a Stepladder so that you know what steps you need totake to reach your overall goal.

•

When taking a step, it is important to remember to:• Plan your steps – be specific about what you will do and when
• Expect some anxiety• Remember your realistic health related thoughts from your thought diaries• Try to stay in the situation or activity until your anxiety goes down
• Drop any safety behaviours you are aware of•

When climbing your stepladder:• Take it one step at a time
• Do the step frequently and repeatedly – make sure you are comfortable with that step
before trying to move up to the next one• Acknowledge the steps you’ve made• Expect to have some step-backs. Recognise that everyone has their up and down days. If
you had difficulty completing a step, get yourself back on track by either adding an inbetween step, or going back to the previous step and refreshing your skills before trying tomove up again.

Coming up next …
In the next module, we will learn toadjust any unhelpful health rules orassumptions we may hold, and tocreate more realistic and flexible ones.

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About The Modules
CONTRIBUTORSDr Rebecca Anderson (MPsych1; PhD2)Centre for Clinical Interventions

Paula Nathan (MPsych1)
Centre for Clinical Interventions

Dr Lisa Saulsman (MPsych1; PhD2)Centre for Clinical Interventions
1

Masters of Psychology (Clinical Psychology)2

Doctor of Philosophy (Clinical Psychology)

BACKGROUND
The concepts and strategies in these modules have been developed from evidence based psychologicalpractice, primarily Cognitive-Behaviour Therapy (CBT). CBT for health anxiety is based on the approachthat health anxiety is a result of problematic cognitions (thoughts) and behaviours.

REFERENCES
These are some of the professional references used to create the modules in this information package.
Abramowitz, J., Taylor, S., & McKay, D. (2010). Hypochondriasis and severe health anxiety. In McKay, D.,
Abramowitz, J., S., & Taylor, S. (Eds.). Cognitive -behavior therapy: Turning failure into success (pp. 327-346).
Washington, DC: American Psychological Association.
Asmundson, G., & Taylor, S. (2005). It’s not all in your head: How worrying about your health could be making
you sick – and what you can do about it. New York: The Guilford Press.
Furer, P., & Walker, J. (2006). Health anxiety treatment manual. University of Manitoba: Manitoba.
Furer, P., Walker, J., & Stein, M. (2007). Treating health anxiety and fear of death. New York: Springer.
Papageorgiou, C., & Wells., A. (1998). Effects of attention training on hypochondriasis: A brief case series.
Psychological Medicine, 28, 193-200.
Salkovskis, P., Warwick, H., & Deale., A. (2003). Cognitive-behavioural treatment for severe and persistent
health anxiety (Hypochondriasis). Brief Treatment and Crisis Intervention, 3, 353-367.
Willson, R., & Veale, D. (2009). Overcoming health anxiety: A self-help guide using cognitive behavioural
techniques. London: Robinson.

“HELPING HEALTH ANXIETY”
This module forms part of:Anderson, R., Saulsman, L., & Nathan, P. (2011). Helping Health Anxiety. Perth, Western Australia: Centre
for Clinical Interventions.
ISBN: 0 9757995 6 8

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Created: August 2011

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