The Devil’s Lettuce: Cyclospora and Health Anxiety

Written by: Marie Chesaniuk, PhD

Cyclospora Outbreak

Anyone in the Midwest right now has been confronted with a bagged lettuce recall due to cyclospora contamination. Cyclospora, as we in Michigan and Illinois have learned the hard way, is a parasite that causes cyclosporiasis: a disease characterized by explosive diarrhea, abdominal cramping, bloating, nausea, and fatigue. It can be treated with an antibiotic medication and hydration. It is spread via contaminated produce or water and minimized or prevented by thoroughly washing produce and/or cooking produce to kill the parasite. Other recommendations for mitigating risk of contagion include washing hands before and after handling produce or using the bathroom or changing diapers, using separate cutting boards and utensils for fresh produce, avoiding recalled products, and avoiding drinking untreated water from lakes, streams, or springs. 

But cyclosporiasis isn’t the only illness set off by cyclospora: this outbreak has people’s health anxiety spiking alongside the outbreak.

Health Anxiety (or Illness Anxiety Disorder)

Known as health anxiety, illness anxiety disorder (IAD), or, formerly, hypochondriasis, this anxiety disorder involves excessive worry about being ill or the possibility of becoming ill. Typically, these worries occur in context of ordinary bodily sensations, no physical symptoms, or minor symptoms that do not align with a severe illness. Medical tests and exams typically do not corroborate a serious illness in the case of health anxiety or IAD. (Not to be confused with somatic symptom disorder, which involves a fixation and worry about physical symptoms, but not the worry that they indicate a severe illness.)

Just because the symptoms someone experiences are not suggestive of the illnesses that most concern health anxious clients (e.g., cancer, or, the past few weeks in Chicago, cyclosporiasis) doesn’t mean the distress isn’t real and impairing. Also, people with health anxiety get sick – sometimes severely and seriously ill – just like everyone else. 

How does excessive worry about cyclosporiasis show up?

Unsurprisingly, a real disease outbreak triggers many of these health concerns.

Over the past several weeks of outbreak and food recalls, health anxiety related to cyclosporiasis has presented itself in a number of ways: 

• preoccupation with contracting the illness or having contact with or eating contaminated food, 
• excessively avoiding food (one client reported skipping meals entirely to avoid eating anything whatsoever, rather than avoiding recalled products only), 
• pathologizing normal body sensations as symptoms of cyclosporiasis (stomach grumbling must signal impending…explosiveness), 
• compulsively checking for symptoms or doing body scans for signs of cyclosporiasis, compulsive research about the condition, 
• making either too many medical appointments or avoiding medical care due to fear of being diagnosed with the illness, 
• experiencing such high levels of distress that it impairs functioning and 
• not feeling like a clean bill of health from a medical professional or a negative test result resolves the issue. 

The worry continues despite evidence against cause for concern.

How can we support health anxious individuals during a disease outbreak?

Inference-based CBT (I-CBT)

Taking an Inference-based CBT (I-CBT) approach, our first order of business is deciphering between reasonable doubt and obsessional doubt. In order to do so, we must get the facts about a new (to us) illness. What actually are the symptoms? What is the expected level of severity and duration of the illness? How does it spread? What treatments, if any, are available? And what are reasonable steps one should take to mitigate risk?

Much of these details are documented in the first paragraph of this article. But put in I-CBT for IAD terms:

• A rash is not a good indicator of cyclosporiasis 🡪 Obsessional doubt, dismiss the thought and ride the emotional wave back to baseline
• Explosive diarrhea within 2-10 days of eating questionable produce 🡪 Reasonable doubt, seek medical attention
• Avoiding bagged lettuce while product recalls are in effect 🡪 Reasonable doubt, either thoroughly wash a head of lettuce you buy separately or avoid raw lettuce until recalls are no longer in effect 
• Fear of dying from cyclosporiasis 🡪 Obsessional doubt (despite a miserable prognosis for the next few weeks, thus far, no health agencies have reported a single death from cyclospora and an antibiotic makes it treatable), dismiss the thought, get treatment if needed, and ride the emotional wave back to baseline
• Oh god, I just had a bagged salad yesterday and didn’t think to check the package to see if it was recalled! 🡪 Maybe worth fishing the bag out of the trash to check against recalled items, but once you check, the answer is the answer. If it WAS a recalled product, seek medical treatment if you develop the symptoms characteristic of cyclosporiasis. If it was NOT a recalled product, proceed as usual unless you must seek medical treatment if you develop symptoms characteristic of cyclosporiasis. The key distinction here is how you treat the experience of checking your item against the list of recalled products. Obsessional doubt is not reassured by real world evidence. If you find yourself spiraling despite evidence that indicates lower risk, you might be obsessively doubting.

Exposure with Response Prevention (ERP)

From an exposure with response prevention (ERP) perspective, once you’ve determined you’re obsessively doubting and compulsively attempting to lessen the anxiety or discomfort that goes with it, we’ve got a new set of options. Resist the urge to body scan or check for symptoms. Barring the characteristic symptoms of cyclosporiasis, resist the urge to interpret every sensation as that specific diagnosis. Resist the urge to research symptoms online. For a new (to us) illness, this means checking a reputable source for a summary appropriate for non-medical professionals and leaving it at that. For a lot of people, it’s the ‘leaving it at that’ that’s the hardest! 

You might counter obsessional thoughts and compulsive urges with some counter statements. 

• “A stomachache and sweating in the summer heat do not equal cyclosporiasis just as flour and an egg do not equal a cake.” 
• “This could be something, or it could be nothing. I can tolerate not knowing right now." 
• "If new, persistent, or objectively worsening symptoms develop, I can address them then."
• "There is no amount of checking that will give me permanent certainty."
• "A scary thought is not the same as a medical fact."
• "Strong emotions don't make a diagnosis more likely."
• "Bodies make random sensations all day long."
• "Not every symptom has a serious cause."
• "Paying close attention makes sensations seem stronger."
• "Stress and anxiety can create real physical symptoms."
• "My body doesn't have to feel perfect for me to be safe."
• "Searching is my compulsion, not my solution."

In the bigger picture, you might consider voting for stronger oversight and food inspection legislation and funding. You don’t have to check if professionals have already checked for you!

While an outbreak might wake up a world of health anxiety for some of us, we’ve had the skills to combat it all along. To put it in terms of some good counter statements:

• "I'd rather spend my time living than monitoring."
• "Health includes how I respond to uncertainty."
• "I'm choosing my life over my anxiety."