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Cognitive-Behavioral Treatment for Severe

and Persistent Health Anxiety


(Hypochondriasis)

Paul M. Salkovskis, PhD


Hilary M. C. Warwick, PhD
Alicia C. Deale, PhD

Hypochondriasis is presently classified as a somatoform disorder. However, in terms of


phenomenology and cognitive processes, it is probably best considered as a form of
severe and persistent anxiety focused on health. This reconceptualization allows the
application of Becks general cognitive theory of anxiety (1985) to the understanding
and treatment of hypochondriasis. In this paper, the classification and phenomenology
of health anxiety is explained in terms of a specific cognitive-behavioral
conceptualization. The way this conceptualization has been successfully applied to the
treatment of health anxiety and hypochodriasis is described. The all-important task of
engagement is accomplished as part of the cognitive assessment, which helps the
patient develop and evaluate an alternative understanding of their problems. This
understanding focuses on how misinterpretations of health-related information (mainly
bodily variations and medical information) leads to a pattern of responses including
anxiety, distorted patterns of attention, safety-seeking behaviors, and physiological
arousal. These responses in turn account for the patients pattern of symptoms and
functional impairment. Treatment progresses by helping the patient actively explore the
validity of the alternative account of their problems arising from the shared
understanding. This objective is accomplished through two avenues: one, discussion,
which has the purpose of making sense of the persons experience; and two, active
evaluation of the mechanisms involved, through collaboratively designed and
implemented behavioral experiments. Evidence from randomized controlled trials
strongly suggests that cognitive treatments are effective and that the effects are specific
to the treatment techniques used. Development of this work will likely branch into
medical problems, where a prominent component of health anxiety exists. [Brief
Treatment and Crisis Intervention 3:353367 (2003)]

KEY WORDS: hypochondriasis, somatoform disorders, cognitive behavioral therapy.

Until relatively recently, the treatment of hy- tients with hypochondriacal beliefs suggested
pochondriasis was not considered to be an im- that hypochondriasis is always secondary to an-
portant issue, as this condition was regarded as other primary disorder, usually depression. It
invariably being secondary to depression or was subsequently suggested that hypochondri-
anxiety. Kenyons (1964) inuential study of pa- acal beliefs occurring in the absence of aective

353
SALKOVSKIS, WARWICK, AND DEALE

symptoms were due to masked depression. sis dictates that the preoccupation has to cause
More recently, studies have convincingly identi- clinically signicant distress or impairment in
ed a primary disorder in which false concerns social, occupational, or other important areas of
about health are the central problem, to which functioning.
aective symptoms are secondary (Bianchi, Despite the considerable health care resources
1971). The paper by Barsky and Klerman (1983) utilized by people with hypochondriasis, nei-
marked the reestablishment of hypochondriasis ther physical medicine nor psychiatry has pre-
not only as a recognizable clinical condition but viously established an eective treatment.
also as an important research topic (e.g., As- Hypochondriasis has long been regarded as an
mundsen & Cox, 2001). Primary hypochondri- intractable disorder, with supportive therapy
asis is now included in both ICD 10 (World and reassurance the best that can be oered. To
Health Organization) and DSM-IV (APA, 1994). some extent it has at times also been seen as a
Although hypochondriasis is now accepted nuisance, with some considering it to be akin to
as a primary problem, its taxonomy remains factitious problems and malingering.
controversial. Debate continues as to whether Recently, well-dened cognitive-behavioral
it is best seen as a somatoform disorder (as theories of hypochondriasis have been de-
presently classied) or as an anxiety disorder scribed, and treatment strategies derived from
(Salkovskis & Warwick, 1986; Warwick & Sal- them have been empirically tested in random-
kovskis, 1990). To place this debate in con- ized controlled trials. The evidence from this re-
text, let us examine the diagnostic criteria search strongly suggests that this approach is
presently used. According to DSM-IV, hypo- eective both in engaging these patients in
chondriasis is characterized by preoccupa- treatment and ameliorating the clinical symp-
tion with fears of having, or the idea that one toms. The cognitive-behavioral theory of
has, a serious disease, based on the persons hypochondriasis provides a comprehensive ac-
misinterpretation of bodily symptoms. Thus, count of the psychological processes involved in
the problem is characterized as a cognitive one, the disorder, including etiological and main-
involving erroneous appraisals. Note that this taining factors. Modication of the important
denition bears a strong resemblance to the psychological factors involved in the mainte-
cognitive theory of panic disorder (Clark, 1986; nance of each case should lead to a resolution of
Salkovskis, 1989). The denition requires that the central problemthat is, a false belief that
the preoccupation persist despite appropriate the patient is physically ill, based on the misin-
medical evaluation and reassurance, meaning terpretation of innocuous physical symptoms or
that the failure of a psychological intervention signs, and based on health-related information
(reassurance) by a doctor is required for the di- from professionals, the media, and the Internet.
agnosis to be made. In addition, formal diagno-

Controversial Issues
From the Department of Psychology, Institute of Psychiatry,
Kings College, London (Salkovskis and Deale); from the
Some authors have suggested that health con-
Department of Psychiatry, St.Georges Hospital Medical
School, London (Warwick). cerns are not central to the problem and that it
Contact information: Paul Salkovskis, PhD, Department is not uncommon for secondary gain to be sug-
of Psychology, Institute of Psychiatry, Kings College,
London, SE5 8AF, UK. E-mail: p.salkovskis@iop.kcl.ac.uk. gested as an important motivating factor in
Tel: (+44) 020 7848 5039. Fax: (+44) 020 7848 5037. these cases (see Warwick & Salkovskis, 1990).
2003 Oxford University Press No evidence has been found to support any role

354 Brief Treatment and Crisis Intervention / 3:3 Fall 2003


CBT for Hypochondriasis

of secondary gain, and ill-judged attempts to ening the hypochondriacal concerns. Lucock,
nd hidden motives for their presentation can Morley, White, and Peake (1997) examined the
alienate patients. In fact, doing so may actually time course and prediction of eectiveness of
increase their fears because they believe that responses to reassurance in 60 patients after
they are unlikely to be taken seriously by those gastroscopy showing no serious illness. Physi-
seeking to help them. Patients feel that their cian and patient rated the extent of reassurance
health concerns are not being given proper con- at the time of the consultation. Patients then
sideration and are likely to seek other sources rated their anxiety about their health and ill-
of physical investigations and help. Patients ness belief at the time of consultation and at four
would understandably be angered by such ap- follow-up sessions: 24 hours, 1 week, 1 month,
proaches and may be hostile to future attempts and 1 year. While health anxiety and illness
to engage them in psychological treatment. Pro- belief decreased markedly after reassurance,
bably the main function of this type of con- patients with high health anxiety showed a
ceptualization is to relieve the clinician of re- signicant resurgence in their worry and ill-
sponsibility for the failure of the patient to re- ness belief at 24 hours and 1 week, which was
spond to their therapeutic eorts. Sadly, maintained at 1 month and 1 year. Those with
variations are all too common on the following low levels of health anxiety maintained low
theme: the patients didnt get better, despite health worry and illness belief throughout. The
my best eorts, because they needed their authors concluded that reduction in worry
problem and therefore couldnt let it go. This and illness belief after reassurance may be very
is not to say that motivational factors never short term and that measurable individual dif-
play a role; however, they are rare, and a good ferences in health anxiety predict response to
therapist should be able to detect these at assess- reassurance.
ment or engagement. That is, there are always
straightforward ways of establishing such func-
tional factors. Development of Cognitive-
To successfully reassure a patient is one of the Behavioral Approaches
most common aims in medicine, and indeed the
diagnosis of hypochondriasis can only be made Some uncontrolled case series have demon-
when this basic medical intervention has failed. strated behavioral treatment of hypochondria-
Some authors (e.g., Kellner, 1983) suggest that sis with promising results (e.g., Warwick &
repeated reassurance should be a component Marks, 1988). Salkovskis and Warwick (1986)
of psychological treatment for hypochondriasis. reported two cases of hypochondriasis that
On the other hand, it has been demonstrated were successfully treated with cognitive-
(Salkovskis & Warwick, 1986; Warwick & Sal- behavioral treatment using a single-case exper-
kovskis, 1985) that repeated reassurance con- imental design with alternating treatments. Not-
taining no new information may lead not only to ing the similarities between hypochondria-
short-term decrease in health anxiety but also a sis and other conditionssuch as panic and
longer term increase in that anxiety and need obsessive-compulsive disorder, in which psy-
for reassurance. They suggest that therapists chological approaches have been successful
who repeatedly carry out discussions, examin- a cognitive-behavioral formulation of the dis-
ations, and investigations in response to the order was developed (Salkovskis, 1989; Salkov-
patients anxiety, rather than clinical indica- skis, Warwick, & Clark, 1993; Warwick & Sal-
tions, may inadvertently be maintaining or wors- kovskis, 1990).

Brief Treatment and Crisis Intervention / 3:3 Fall 2003 355


SALKOVSKIS, WARWICK, AND DEALE

The cognitive-behavioral hypothesis used as Information-processing biasesfor ex-


the basis for treatment proposes the following: ample, selective attention
that people who experience severe and persist- Physiological reactionsfor example,
ent health anxiety (hypochondriasis) have a heightened experience of bodily sensations
relatively enduring tendency to misinterpret bod- Safety-seeking behaviorsfor example,
ily symptoms, bodily variations, medical in- avoidance, checking, and reassurance-
formation, and any other health-relevant infor- seeking
mation as evidence that they currently have, or Aective changesparticularly anxiety
are at risk of having, a serious physical illness. and depression
This tendency will manifest when the person
experiences an ambiguous situationsuch as The maintaining factors are shown in Figure 1.
the perception of a bodily sensation for which Successful cognitive-behavioral treatment of
they do not know the causeand it will be hypochondriasis involves helping the patient
more directly experienced by the person as develop and evaluate a personalized version of
catastrophic appraisals relevant to their (ill) this model as an alternative, less-threatening ex-
health. Thus, health anxiety is said to occur planation of their problems (Salkovskis, 1989;
as a result of catastrophic misinterpretation of 1996). For example, the patient is helped to con-
health-related information. sider the possibility that their problems are bet-
Negative or even catastrophic interpretations ter accounted for by the fear of cancer and their
of health-relevant information are common- self-sustaining reactions to this fear, rather than
place in the general population. From time to actually having cancer. The failure of previous
time, the majority of people are liable to become medical interventions to provide successful re-
briey preoccupied with unexplained bodily assurance is usually due to the lack of a cred-
variations. However, such episodes of health ible alternative explanation for their problems.
anxiety are usually transient. Symptoms fade; Whereas patients need a clear account of what is
reassuring information from a doctor is ab- the matter, the traditional approach is to tell the
sorbed with relief (if believed); and anxiety them what is not wrong with them. Many com-
about health declines and disappears. The key to petent specialists can adequately exclude ill-
understanding and helping those in whom this nesses in their own eld but cannot oer an
health anxiety does not fade (or in whom it es- more general alternative explanation. Exclusion
calates to the point of dominating their life) lies of physical illnesses alone is known to be an un-
in understanding what it is that causes their satisfactory treatment for hypochondriasis. A
anxiety to persist. The cognitive theory speci- psychological explanation, which attempts to
es that the persistence of health anxiety is a re- account for the patients concerns, must appear
sult of processes that maintain the catastrophic valid and credible. It should not diverge from
interpretations from which anxiety arises. Vi- the patients previous experience, and it should
cious circles form as each of these processes is also survive their future experiences. The cog-
motivated and driven by threat beliefs, either as nitive-behavioral treatment of hypochondriasis
an automatic reaction or as strategically de- oers a positive account of what is occurring
ployed responses to the perception of threat. Al- an alternative comprehensive explanation for
though the relative contribution of each factor the patients concerns, reactions, and, in some
and the specic details of those involved vary cases, symptoms. The patients are encouraged to
from person to person, four main types of pro- discuss aspects of their problems that do not
cess tend to be involved: t with the formulation. This new explanation

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CBT for Hypochondriasis

FIGURE 1
Cognitive-Behavioral Model of the Development and Persistence of Health Anxiety (Hypochondriasis)

should lead the patients to reinterpret their in- ect schema-based problems in people suer-
nocuous symptoms and attribute them to a less- ing from health anxiety.
threatening cause. It will also demonstrate that
behaviors such as bodily checking and other
maintaining factors serve to make their prob- Cognitive-Behavioral Treatment
lems worse and should therefore be terminated.
A further intriguing possibility consistent What follows is necessarily a brief overview
with the cognitive-behavioral view described of cognitive-behavioral treatment. The reader
here is raised by the series of studies con- is referred to other sources for more detailed
ducted by Sensky and colleagues (MacLeod, accounts of assessment and treatment (e.g.,
Haynes, & Sensky, 1998; Sensky, MacLeod, & Salkovskis, 1989; Salkovskis & Bass, 1997; Sal-
Rigby, 1996), who noted that patients high in kovskis & Warwick, 1988; Warwick, 1995).
health anxiety found it more dicult than
comparison groups to generate innocuous ac-
General Issues in Assessment
counts of somatic symptoms. This nding
could, of course, be a state eect, so that ele- The principal aim of assessment is to obtain a
vated health anxiety diminishes the accessibil- thorough description of the patients problems
ity of alternative attributions; or it may also re- and psychopathology, which can then be ex-

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SALKOVSKIS, WARWICK, AND DEALE

pressed as the patients own version of the with the extent of their reassurance-seeking be-
cognitive-behavioral formulation. This formula- haviors. Patient and therapist usually commence
tion often identies aspects of the origins and assessment with very dierent expectations and
precipitants of the persons health anxiety. More agendas. The therapist often believes that the
crucially, it incorporates an account of key fac- patient has a psychological problem and that
tors involved in the maintenance of the patients cognitive-behavioral treatment is just what they
health anxiety. In addition, the formulation of- need. Unfortunately, the patients are convinced
ten provides an account of the basis of many of that they have a physical illness and that the last
the symptoms that the patient is experiencing. thing they need is a psychological treatment.
The use of the patients account of episodes of Hence engagement in psychological treatment is
intense health anxiety leads to the development likely to be problematic.
of a comprehensive psychological formulation The therapist must be well aware of these con-
that clearly describes the psychological proces- icting agendas. The style of the therapist as
ses and conrms a positive psychological di- demonstrated in the initial interview is crucial.
agnosis. If the symptoms do not t such a for- The interview should be conducted with pa-
mulation, then the therapist should consider the tience and sympathy, and it must culminate in
genuine possibility of a physical illness. the patients conviction that all their concerns
have been properly considered. The therapist
should acknowledge that the patients physical
Goals of Assessment and
concerns are real and are to be taken seriously.
Engagement
Such patients may well have been previously
Assessment has the following aims: told that their symptoms are all in the mind;
subsequently, they will be watching for evi-
Completion of a thorough comprehensive dence of similar attitudes. Frequent use of sum-
cognitive-behavioral analysis of the pa- maries by the therapist will encourage the
tients problemsincluding symptoms, patients that their concerns are being taken
beliefs, behaviors, and consequences seriously. When discussing the diagnosis and
Identication of the psychological processes treatment, the therapist should communicate to
involved in the case; deciding if a positive the patient that the therapist has seen similar
diagnosis of hypochondriasis can be made cases in the past; doing so is helpful because pa-
Construction of psychological formulation, tients often feel extremely isolated and feel that
developed as a shared understanding with no one can help them with their problems. The
the patient assessment should be used to construct a com-
Helping the patient feel understood prehensive psychological formulation of the pa-
Enabling the patient to consider (a) a pos- tients concerns. A version using actual ex-
sible noncatastrophic (psychological) alter- amples from the patient is drawn up, explaining
native explanation for their problems, and each step to them.
(b) the suggested treatment rationale and
strategies that ow from it
Specifics of Assessment
The specic assessment usually begins once the
Engagement in Assessment
therapist is condent in rmly establishing ba-
Some patients may be too embarrassed to de- sic clinical details and that health anxiety is a
scribe the illnesses that concern them, along major problem for the patient. The therapist

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CBT for Hypochondriasis

then helps the patients identify a relatively re- gressing to specic anticipated eects, namely:
cent episode during which they were troubled What did that do? At that time, what was the
by high levels of health anxiety. Memory is eect of . . . on the belief that you had multiple
primed by having the patient describe the con- sclerosis?
text. Where were they? Who were they with? Over the period of 30 minutes to an hour, a
What were they doing? Was there an obvious preliminary maintenance formulation is thus
trigger? derived, identifying
The rst signs that an episode of increased
health anxiety are identied; these are usually triggers;
physical symptoms, although sometimes they meaningincluding perceived probability,
may be information about someone elses being cost, coping, and rescue factors; and
ill, information in the media, or it may even maintenance factorsthose directly driven
be emotional stress not directly related to the by negative meanings and those motivated
health anxiety (such as a marital argument). by them.
Once the initial trigger is identied, questioning
takes the form of guided discovery that pro- All of which form the basis of the subsequent
gresses toward an interlocking set of idiosyn- engagement eorts.
cratic vicious circles (based on the model in Fig-
ure 1); the maintenance cycles are often referred
Engagement
to as a vicious ower formulation, referring to
the structure of the basic feedback loops illus- The patients previous, illness-based view of
trated in the patient example shown in Figure 2. their problems is then elicited and discussed.
These are derived through carefully sequenced The patients usually accept that following this
questioning, namely: So the rst thing you no- approach has not resolved their problems. The
ticed was tingling ngers. When you noticed psychological formulation is then discussed as
your ngers tingling, what went through your an alternative hypothesis. If, on the basis of this
mind at that time? discussion, the patients accept the possibility
If the answer is vague, the questioning is that their problems could be explained by the
pressed, as in And at that time, did that seem to psychological formulation, then they are oered
you to be the very worst thing this tingling a brief course of treatment using psychological
could mean? A belief rating (0100) for the de- techniques. The therapists need to stress that if,
rived illness-related belief is taken. The ques- after the treatment, the patients are still con-
tioning continues by eliciting the responses vinced they are physically ill, then they will be
to the negative interpretation: When you able to seek further physical treatment.
thought this tingling meant you had Multiple
Sclerosis, how did that aect you at that mo-
From Formulation to Therapy
ment? A range of specic follow-up questions
are used to elicit the main response domains: Therapy is uid, idiosyncratic, and formulation-
How did it make you feel? What did you do? led. Initial sessions focus on testing out the
What did you pay attention to? How did you try vicious ower formulation and accumulating
to deal with it? The way in which these re- evidence for an anxiety-based, rather than a
sponses aected the interpretation and symp- disease-based, explanation. This objective takes
toms themselves are then probed, again starting place through an interweaving of discussion
with a more general open query and then pro- and behavioral experiments. As therapy pro-

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SALKOVSKIS, WARWICK, AND DEALE

FIGURE 2
Specific Application of the Cognitive-Behavioral Model to a Clinical Case

ceeds, safety behaviors are dropped, and other anxiety occur. Doing so provides information
maintaining factors reversed. In later sessions, about the particular triggers for health anxiety.
assumptions are examined, and a relapse pre- It also shows up (a) activities that may be re-
vention plan is developed. stricted or avoided as a direct result of health
anxiety (e.g., fear of having heart disease leads
to avoidance of exertion), and (b) those that are
Self-Monitoring
carried out only because of the health concern
Once a preliminary vicious ower formula- (e.g., taking pulse, going to the doctor). Pa-
tion has been drawn up in session, patients are tients may express surprise when they see how
often asked to draw out more vicious ow- much time and eort they devote to health
ers for further episodes of health anxiety that anxiety, which can provide useful evidence
occur during the week. Doing so helps to so- regarding the eects of attention and bodily
cialize them into the vicious ower model focusing.
and to nd out how well it ts with their ac- Second, patients may be asked to monitor
tual experiences. The information gathered the next few episodes of health anxiety. They
can be fed into a generic vicious ower, with are provided with a record sheet (see Table 1)
more petals. in which they record triggering symptoms or
Patients may also be asked to monitor two as- events, level of health anxiety, thoughts about
pects of their problem. First, they may keep a health, and action taken. Like all negative auto-
brief record of a complete weeks activities, matic thoughts, health-anxious thoughts can be
noting when physical symptoms and health dicult to access at rst. Patients are asked to

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CBT for Hypochondriasis

is then made into a slice of a pie chart. The cat-


Table 1. Health-Anxious Thoughts Diary
astrophic interpretation is left until last, which
Situation In a playground with the children usually means that it will account for a very
Trigger Saw a bruisy mark on my leg small slice of the pie, or even just a few crumbs.
Negative
The patient can then be asked to subdivide that
automatic thought Ive got leukaemia
Anxiety (0100) 90 very small slice of pie to account for those who
Action taken Thought back to see if Id have already had negative investigations for the
knocked myself, checked myself feared illness.
for other bruises, and constantly A related exercise is the inverted pyramid
checked this mark to see if it was technique, which is helpful for addressing over-
getting bigger.
perception of risk. The patient is asked to esti-
mate the current number of people with that
particular symptom (i.e., those who have it to-
notice when they start feeling anxious about day), the number for whom it persists, the num-
their health and to ask themselves What went ber who consult their doctors, the number who
through my mind just now? are told they need tests, the number who are
Self-monitoring homework can provide both told the problem is serious, and the number who
patient and therapist with useful information, are not successfully treated. These exercises can
which can be fed back into the vicious ower be followed up by homework in which patients
formulation. In particular, it often highlights apply the same technique to a past health con-
safety-seeking behaviors and thinking errors cern and to a health concern that they have not
that become the subject of the early stages of yet had.
treatment. Specic reattribution of health-anxious
thoughts and images, reattribution may be
used. The rst stage is to help the patients to
Questioning Belief
identify thinking errors in their interpretation
Health-anxious patients interpret bodily sensa- of bodily sensations and health-related infor-
tions and health-related information as being mation. The most frequent errors include jump-
more threatening than they really are. They of- ing to conclusions, catastrophizing and selec-
ten overlook or discount nonserious causes for tive abstraction. This stage leads to generat-
bodily signs and variation. The therapists job is ing alternative, less-threatening interpretations
to help loosen the disease-based interpretations through typical questions such as What evi-
and build an alternative understanding of the dence do I have for this belief? What alterna-
problem. tive explanations could there be? and What
One means of helping patients increase their are the advantages and disadvantages of think-
range of nonthreatening explanations for in- ing in this way? The therapist must ensure that
nocuous symptoms is through the discussion of the patient generates the alternative, rational
probabilities. If a patient is worried about par- response and that they continue to use reattri-
ticular symptom (e.g., stomach ache), the thera- bution techniques between treatment sessions.
pist and patient list all possible causes of that It is important that the rational response is
symptom, including the patients catastrophic viewed as a hypothesis, to be tested out in be-
interpretation (e.g., stomach cancer). The pa- havioral experiments.
tient estimates the percentage of stomach aches While some reattribution of specic symptoms
accounted for by each cause listed. Each cause is helpful, the danger of trying too hard to ex-

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SALKOVSKIS, WARWICK, AND DEALE

plain away every symptom is that it can become clude tensing muscles to bring on pain, or run-
a form of reassurance. Questioning beliefs about ning up and down stairs to bring on breathless-
symptoms is best used as a springboard for be- ness and chest pain. If the exact or similar sen-
havioral experiments. The results of verbal reat- sations to those involved in the patients con-
tribution and behavioral experiments can be col- cerns can be reproduced, it helps to disconrm
lected in an ongoing log, such as the dual model a catastrophic interpretation and thus build up
strategy (Wells, 1997). This log collates evi- belief in the alternative explanation.
dence that supports both a disease-based and
cognitive-behavioral explanation, and includes Dropping Safety-Seeking Behaviors. Safety be-
a reframing of each piece of evidence that sup- haviorschecking, reassurance seekingmain-
ports a disease-based explanation. tain health anxiety. Patients can test out the
eects of these behaviors for themselves by
conducting an alternating treatment experi-
Behavioral Experiments
ment. This experiment involves, rst, increasing
Behavioral experiments can help the target behavior for a daysuch as bodily
checking and information seekingand, sec-
1. establish that a feared catastrophe will not ond, monitoring anxiety, bodily symptoms, and
happen; strength of belief at regular intervals. On the
2. discover the importance of maintaining next day, the patient has to completely ban car-
factors; rying out the target behavior; but once again,
3. discover the importance of negative anxiety, symptoms, and strength of belief are
thinking; monitored at intervals. The resulting data is re-
4. nd out whether an alternative strategy viewed and graphed at the next session. Patients
will be of any value; and are often surprised at how much worse they feel
5. generate evidence for a non-disease-based on the day in which the target behavior is in-
explanation. creased, and this experiment normally leads to a
decision to drop the target behavior completely.

Selective-Attention Experiments. In selective-


Dealing with Rumination, Worry, and
attention experiments, patients are asked to fo-
Images
cus on a specic body part for several minutes
(one that is not a current cause for health anxi- Health-anxious patients may spend long peri-
ety); after which, they are asked to describe any ods ruminating on the possible consequences
bodily sensations they notice. Most patients of bodily symptoms, becoming more and more
will detect sensations that they were unaware of convinced as they do so that they do indeed
before the experimentfor example, tightness have a life-threatening illness. At an in-session
in throat, tingling in feet. This exercise is help- experiment, they can be asked to ruminate
ful as a demonstration of the eects of symptom aloud for a period, which will often produce
monitoring and bodily checking. changes in mood, symptoms awareness, and dis-
ease conviction. The exercise demonstrates the
Testing Predictions. Predictions about specic eect of rumination on health anxiety and can
symptoms indicating imminent catastrophe can be used to identify thinking errors. It can be fol-
be tested in sessions. Simple procedures can be lowed by an examination of the advantages and
used to bring on feared symptoms. Examples in- disadvantages of thinking in this way. Rumina-

362 Brief Treatment and Crisis Intervention / 3:3 Fall 2003


CBT for Hypochondriasis

tion can then be scheduled as worry time, proaches usually leads to the decision to reduce,
prior to phasing it out altogether. and then stop, reassurance seeking.
Images associated with health anxiety can be Relatives and friends of those suering hypo-
powerful and convincing. They may be seen as chondriasis are often bombarded with requests
predictive, and they may stop short before, or for reassurance, from the blatantDo you
at, a catastrophic point. The procedure just de- think this lump is cancer?to the more
scribed can be helpful in demonstrating the covertjust mentioning something (I noticed
eect of imagery on anxiety and disease convic- a lump here, but Im not worried about it) or
tion. The patients may be encouraged to either showing an area that is causing concern but
nish out the image by visualizing what hap- without saying anything. It is very helpful to in-
pens next or modify the image and note the vite relatives to a session in which reassurance is
eect on anxiety and disease conviction. discussed. The patient can be asked to describe
what they have learned about how reassurance
maintains health anxiety, and to list for the rel-
Persistent Reassurance Seeking
atives all the dierent ways in which reassur-
Managing persistent requests for reassurance ance is sought. Patients are given the responsi-
has several components. The formulation is usu- bility for withholding requests for reassurance,
ally the rst step in demonstrating the adverse but they and their relatives may need to identify
eects of reassurance. This step can be taken other topics of conversation. They may need to
forward by enquiring about what happens to rehearse ways of talking about the health anxi-
symptoms when patients receive reassurance. If ety and being supportive without asking for or
the symptoms get better, what does that suggest giving reassurance.
about the cause? Would a serious disease work
this way? Patients may believe that reassurance
Dealing with Medical Consultations
is helpful, as it makes them feel better. It is im-
portant to draw out the short-term nature of any Other professionals may unwittingly be pro-
benets and its addictiveness. One technique viding repeated inappropriate reassurance and,
for doing so is to oer the patient a session of hence, reinforcing the problem. These profes-
unlimited reassurance, provided they will guar- sionals should be contacted and asked to carry
antee that it will last for the rest of the year (see out tests and examinations only when clinically
Salkovskis & Bass, 1999, for an example). This indicated, not when prompted by the patients
technique usually results in patients identify- anxiety. Patients are asked to reduce the fre-
ing for themselves that the eect is short-lived. quency of consultation: many will worry that
It is often helpful to carry out a detailed cost- doing so may lead to something important being
benet analysis of reassurance seeking. The aim missed. This anxiety can be addressed through
is to contrast the small number of short-term programmed postponement, which intro-
benets with the immediate, longer-term costs duces a delay between noticing and acting on
to both patients and their families. Patients may symptoms. A time period is agreed, based on the
write this exercise out on a ashcard, to use length of time it normally takes for a symptom to
when they are trying to break the habit of reas- die down (e.g., 10 days). When patients become
surance seeking. It can be followed with an al- concerned about a new or more intense symp-
ternating treatment experiment involving a day tom, they are asked to make a note in their diary
of reassurance seeking followed by a day with- for 10 days ahead. At this time, if the symptom
out reassurance. A combination of these ap- is still present, they will take action (e.g., visit

Brief Treatment and Crisis Intervention / 3:3 Fall 2003 363


SALKOVSKIS, WARWICK, AND DEALE

the doctor); but until then, they are asked to put


Relapse Prevention
the worry to one side. The therapist and patient
can also draw up a blueprint for when to seek Hypochondriacal patients may well be vulner-
medical help, using the patients past experience able to relapse. The experience of physical symp-
of emergencies to identify when to take action. toms is common, and any new symptoms or triv-
Ideally, therapy should not begin if the pa- ial illnesses are potential triggers for further epi-
tient is undergoing major medical tests. How- sodes of health concern. It is unclear, as yet,
ever, such tests can be turned to advantage if exactly which patients will relapse. Those who
patients are simply ask to track their anxiety in fear they have one illness after another may
the period leading up to, during, and after the be more vulnerable to relapse than those who
test. Doing so can provide valuable informa- have only been concerned about one disorder,
tion about how tests actually increase anxiety. the one directly addressed in treatment. As sug-
gested, it is likely that the correction of dys-
functional assumptions will make relapse less
Identification and Reattribution of
likely, but further assessment of this issue is
Assumptions
needed.
To prevent future relapse, patients and thera- In the nal therapy sessions, patients are usu-
pists need to identify the dysfunctional as- ally asked to work on a relapse-prevention plan,
sumptions that could be activated by dierent which can be developed and discussed over sev-
physical symptoms, which would lead to sub- eral sessions. Constructing a relapse-prevention
sequent bouts of health anxiety centred on plan includes reviewing what has been learned
fears of a dierent illness. For example, a com- during treatment; identifying future triggers for
monly held belief in hypochondriacal patients health anxiety; being aware of warning signs;
is A physical symptom is always due to physi- and understanding strategies for dealing with
cal illness. If this belief is not identied and setbacks. The patients should also have a clear
changed, further health anxiety is likely. A pa- idea of what they need to do to maintain treat-
tient with this belief was asked to construct a ment gains and set goals for the next year. While
list of examples of symptoms where this belief the aim is to make patients independent of ther-
was not true. He returned with a very extensive apy, occasional booster sessions may be par-
list, which helped him begin to challenge this ticularly helpful for this group.
longstanding, rmly held belief. The vertical
arrow is used to identify these assumptions,
and they are challenged using reattribution and Evidence for the Effectiveness of
behavioral experiments. Some may prove di- Cognitive-Behavioral Treatment
cult to change; others are not restricted to for Hypochondriasis
health and illness but may be of a more general
negative nature. Warwick, Clark, Cobb, and Salkovskis (1996) re-
For example, the lady who feared her bruises ported a controlled trial of cognitive-behavioral
meant she had leukemia believed Im Mrs. treatment for hypochondriasis. In this study, 32
Jinx; anything bad will happen to me. Physical patients were randomly assigned to cognitive-
symptoms were not the only things that could behavioral therapy or to a no-treatment waiting-
activate this assumption; many other triggers list control. Cognitive-behavioral treatment con-
led to numerous episodes of anxiety, not all of sisted of 16 individual treatment sessions over
which were health related. a 4-month period. Prior to the end of treat-

364 Brief Treatment and Crisis Intervention / 3:3 Fall 2003


CBT for Hypochondriasis

ment, possible triggers should be identied. The play an important part in severe and persistent
waiting-list control lasted for 4 months and was health anxiety.
followed by 16 sessions of cognitive-behavioral In an uncontrolled study, Stern and Fernan-
treatment. Assessments were made before allo- dez (1991) treated a group of patients with hypo-
cation and after treatment or waiting-list con- chondriasis with cognitive-behavioral treat-
trol. Patients who had cognitive-behavioral ment. This study had promising results and
treatment were reassessed three months after demonstrated that group cognitive-behavioral
completion of treatment. Paired comparisons treatment is feasible in a general hospital set-
on posttreatment/wait scores indicated that ting. A controlled trial of group treatment has
the cognitive-behavioral group showed signi- been reported, using the cognitive-educational
cantly greater improvements than the wait list approach put forward by Barsky, Geringer, and
on all but one patient rating, on all therapist rat- Wool (1988) compared with a waiting list con-
ings, and on all assessor ratings. After 3 months, trol (Avia et al., 1996). Experimental subjects
the benets of therapy were maintained. showed signicant reduction in illness fears and
While this study suggests that cognitive- attitudes, and they reported somatic symptoms
behavioral treatment is an eective therapy for and dysfunctional beliefs. Waiting-list controls
hypochondriasis, the study has limitations. changed some illness attitudes, but they showed
First, only one therapist was used. It is neces- no change in somatic symptoms and hence in-
sary to establish that similar results can be ob- creased their visits to doctors. In a crossover de-
tained by other suitably trained therapists. Sec- sign (Visser & Bouman, 1992), 3 patients re-
ond, the waiting-list group did not control for ceived exposure and response prevention fol-
the eects of attention, although it is unlikely lowed by a block of cognitive therapy. Three
that attention alone could have brought about more patients were treated with cognitive ther-
the improvements seen in the treated group. apy followed by behavioral treatment. Four pa-
In a second controlled study (Clark et al., 1998), tients made signicant improvements, with the
a number of therapists carried out cognitive- behavior therapy as rst option tending to be
behavioral treatment that was compared with a the more successful strategy. The description of
stress-management package and a waiting-list cognitive therapy used in the study suggests
control. At the end of active treatment, both that its components diered from that used in
treatments did signicantly better than the wait- other studies, thus making the results hard to
ing-list condition, while cognitive-behavioral interpret.
treatment was signicantly better on several
key measures. At the 1-year follow-up, the di-
erences between the two treatments were Future Research
greatly diminished. The authors suggested that
this result was not surprising, as behavioral Further controlled evaluations of cognitive-
stress management provides patients with a de- behavioral treatment of hypochondriasis are re-
tailed alternative explanation for their symp- quired to clearly establish its ecacy. Follow-up
toms and a comprehensive treatment based on studies are in progress to examine the longer-
this alternative explanation. This treatment in- term ecacy of the approach. Future studies
cluded the engagement strategies developed as should attempt to discover which of the com-
part of cognitive therapy to ensure nondieren- ponents of cognitive-behavioral treatment are
tial dropout rates. This study also raises the most eective, in an eort to make the treatment
intriguing possibility that general stress may briefer and more easily accessible. Similarly,

Brief Treatment and Crisis Intervention / 3:3 Fall 2003 365


SALKOVSKIS, WARWICK, AND DEALE

further controlled trials in a group setting are Two psychological treatments for hypochondria-
needed, as this method of delivery should be sis: A randomised controlled trial. British Journal
more cost-eective. Future studies are also of Psychiatry, 173, 218225.
needed to examine the ecacy of cognitive- Kellner, R. (1983). Prognosis in treated hypochon-
behavioral treatment in cases of hypochondria- driasis. Acta Psychiatrica Scandinavica, 67, 6979.
Kenyon, F. E. (1964). Hypochondriasis: A clinical
sis occurring in medical settings. It may be that
study. British Journal of Psychiatry, 110,
such cases are more dicult to treat, as such pa-
478488.
tients may be more reluctant to consider psy- Lucock, M. P., Morley, S., White, C., & Peake, M. D.
chological treatment. It is also necessary to see (1997). Responses of consecutive patients to reas-
if the approach can be modied for those with surance after gastroscopy: Results of self-
a number of related concernsfor example, administered questionnaire survey. British Med-
those with real physical illnesses whose anxi- ical Journal, 315, 572575.
eties are thought to be excessive, or for those MacLeod, A. K., Haynes, C., & Sensky, T. (1998). At-
presenting in general practice settings with so- tributions about common bodily sensations: their
matic complaints that are not yet as severe as associations with hypochondriasis and anxiety.
hypochondriasis. Psychological Medicine, 28, 225228.
Salkovskis, P. M. (1989). Somatic problems. In K.
Hawton, P. M. Salkovskis, J. W. Kirk, & D. M.
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