the client willingly explore the possibility that their illness beliefs might be better accounted for by explanations other than physical illness. This is a necessary first step that must be successful before cognitive modification, re- sponse prevention, and exposure can be initiated. Given Mrs. A.'s presentation, it is likely that our approach, or something along these lines, will be successful. Indeed, t reatment strategies derived from the CB model of health anxiety have recently been shown to be effective in ran- domized controlled trails (e.g., Clark, Satkovskis, et al., 1998). On a case-by-case basis, review of personal moni- toring and reapplication of relevant self-report instru- ments (as described above) can be used to evaluate treat- men t progress. Preventing relapse, however, will involve not only additional follow-up contact with Mrs. A. but also restructuring of the style in which her physician and significant others respond to her illness concerns.
R e f e r e n c e s
Asmundson, G.J.G., Taylor, S., Sevgnr, S., & Cox, B.J. (2001). Health anxiety: Conceptual, diagnostic, and epidemiological issues. In G.J .G. Asmundson, S. Taylor, & B.J. Cox (Eds.), Health anxiety: Clinical and research perspectives on hypochondriasis and related disor- ders (pp. 3-21). London: Wiley.
Clark, D. M., Salkovskis, E M., Hackman, A., Wells, A., Fennell, M., Ludgate,J., Ahmad, S., Richards, H. C., & Gelder, M. (1998). Two psychological treatments for hypochondriasis. British Journal of Psychiatry, 173, 218-225.
Derogatis, L. R. (1975). SCL-90-IL" Administration, scoring and plocedures manual-II for the revised version and other instruments of the psychopa- thology ratingscale series. Towson, MD: Clinical Psychometric Research.
Fava, G. A., & Grandi, S. (1991). Differential diagnosis of hypochondri- acal fears and beliefs. Psychotherapy and Psychosomatics, 55, 1 l 4-119.
First, M. B., Spitzer, R. L , Gibbon, M., & Williams,J. B. W. (1996). Struc- tured Clinical interview for Axis-I DSM-IV Disorders-Patient Edition (SCID-I/P Version 2.0). New York: Biometrics Research Depart- ment, NewYork State Psychiatric Institute.
Furer, E, Walker, J. R., & Freeston, M. H. (2001). Approach to inte- grated cognitive-behavior therapy for intense illness worries. In G.J .G. Asmundson, S. Taylor, & B.J. Cox (Eds.), Health anxiety: Clinical and research perspectives on hypochondriasis and related condi- tions (pp. 161-192). Wiley: NewYork.
Hadjistavropoulos, H. D., Hadjistavropoulos, T, & Quine A. (2000). Health anxiety moderates the effects of distraction versus atten- tion to pain. Behaviour Research and Therapy, 38, 425-438.
Kellner, R. (1986). Somatization and hypochondriasis. NewYork: Praeger- Greenwood.
Kellner, R., Abbott, P. Winslow, W. W., & Pathak, D. (1987), Fears, beliefs, and attitudes in DSM-II1 hypochondriasis. The Journal of Nervous and Mental Disease, 175, 20-25.
Lucock, M. E, & Morley, S. (1996). The Health Anxiety Questionnaire. British Journal of Health Psycholog); 1, 137-150.
Marks, I. M. (1987). Fears, phobias, and rituals. New York: Oxford Uni- versity Press.
McCabe, R. E., & Antony, M. M. (2004). Challenges in the assessment and treatment of health anxiety: The Case of Mrs. A. Cognitive and Behavioral Practice, 11, 102-106.
Noyes, R., Jr. (2001). Hypochondriasis: Boundaries and comorbidities. In G.J.G. Asmundson, S. Taylor, & B.J. Cox (Eds.), Health anxiety: Clinical and research perspectives on hypochondriasis and related disor- ders. London: Wiley.
Pilowsky, I. (1967). Dimensions of hypochondriasis. British Journal of Psychiatry, 113, 89-93.
Rief, W., Hiller, W., & Margraf, J. (1998). Cognitive aspects of hypo- chondriasis and the somatization syndrome. Journal of Abnormal Psychology, I OZ 587-595.
Salkovskis, E M. (1989). Somatic problems. In K. Hawton, P. M. Salkovskis, J. Kirk, & D. M. Clark (Eds.), Cognitive therapy for psychiatric problems: A practical guide (pp. 235-276). Oxford: Oxford University Press.
Salkovskis, E M., & Warwick, H. M. C. (2001). Making sense of hypochon- driasis: A cognitive model of health anxiety In G.J.G. Asmundson, S. Taylor, & B. J. Cox (Eds.), Health anxiety: Clinical and research perspectives on hypochondriasis and related disorders. London: Wiley.
Speckens, A. E. M., van Hemert, A. M., Spinhoven, P., & Bolk, J. H. (1996). The diagnostic and prognostic significance of the White- ley Index, the Illness Attitude Scales, and the Somatosensoty Amplification Scale. Psychological Medicine, 26, 1085-1090.
Stewart, S. H., & Watt, M. C. (2001). Assessment of health anxiety In G.J .G. Asmundson, S. Taylor, & B.J. Cox (Eds.), Health anxiety: Clinical and research perspectives on hypochondriasis and related dis- orders. London: Wiley.
Taylor, S., & Asmundson, G.J .G. (2004). Treating health anxiety: A cog- nitive-behavioral approach. New York: The Guilford Press.
Walker, J. R., Vincent, N., Furer, E, Cox, B. J., & Kjernisted, BL D. (1999). Treatment preference in hypochondriasis. Journal of Be- haviour Therapy and Experimental Psychiatry, 30, 251-258.
Address correspondence to Gordon J. G. Asmundson, Ph.D., Anxiety and Illness Behaviours Laboratory, University of Regina, Regina, SK Canada $4S 0A2; e-mail: gordon.asmundson@uregina, ca.
Received: May 24, 2001 Accepted: June 29, 2001
• • • • • • • • • • • • • •
Response Paper
Understanding and Treating Health Anxiety:
A Cognitive-Behavioral Approach
Steven Taylor University of British Columbia
Mrs. A. presents with a textbook case o f hypochondriasis. A n addi t ional diagnosis o f OCD does not enhance our unders tanding or treatment o f her problems, a n d is not indicated according to DSM-IV. Cognitive-behavior ther- apy (CBT) is effective in treating hypochondriasis, al- though it is necessary to devise a case formula t ion for each pat ient to determine which interventions to use and how to best implement them. A detailed cognitive and be- havioral assessment is essential to successful treatment. In this commentary, I describe the important assessment areas that need to be covered to better unders tand Mrs. A. "s problems and the obstacles to assessment that might be encountered. A tentative case formula t ion is presented, based on the available information, and a tentative C B T protocol is derived. Likely obstacles to successful treat- ment, such as Mrs. A. 's poor insight into her d isord~ need to be more thoroughly assessed in order to devise
strategies for circumventing these difficulties.
C o g n i t i v e a n d B e h a v i o r a l P r a c t i c e ! 1, I 1 2 - 1 2 3 , 2 0 0 4
a • X I E T Y ABOUT HEALTH is something we all experi- ence at various times in our lives. In its mild forms
health anxiety is adaptive, serving as a motivator for seek- ing appropriate health care and for avoiding things that are harmful to health. Severe forms of health anxiety are less c o m m o n in the general population, but are often en- countered in clinical practice, particularly by clinicians working in anxiety disorder clinics and in consultation- liaison services in general hospitals. The case of Mrs. A. is useful because it raises many of the important issues that clinicians encounter when assessing and treating people with severe health anxiety.
Mrs. A. presents with long-standing health anxiety, which has worsened in recent years. Her main problems are as follows: various somatic symptoms (e.g., pain in various bodily regions), numerous health-related fears (e.g., fears of having serious, undiagnosed diseases), chronic anxiety and health-related worries (e.g., worry that doctors are no t sufficiently competen t to make a cor- rect diagnosis), and health-related safety behaviors. That is, behaviors in tended to avoid or escape aversive stimuli (e.g., walking slowly up the stairs in order to avert a heart attack; seeking reassurance f rom doctors to allay her health concerns; avoiding air travel because of the per- ceived risks of breathing "recycled air"). She also seeks out various safety signals to reduce her health concerns. That is, stimuli she associates with the absence o f health- related danger (e.g., carrying nitroglycerin spray that she could use in the event of a heart attack). Extensive medi- cal testing has been unable to explain her somatic symp- toms and has not reduced her health anxiety. She has poor insight into the excessive nature o f her concerns.
Diagnostic Issues
A diagnostic formulation is insufficient for under- standing the causes of Mrs. A.'s problems and is insuffi- cient for planning treatment. Nevertheless, the process of making a diagnosis is an important first step for under- standing and treating her problems. The task of assessing DSM-IVAxes I and II encourages the clinician to look be- yond the patient's most salient problems. This helps the clinician identify psychiatric problems that might other- wise be missed. Diagnoses also facilitate communicat ion among health-care professionals. That is, diagnoses rep- resent a c o m m o n language that can be used to communi- cate information about the patient's primary problems. In the case of Mrs. A., diagnoses are important for com- municat ing whether her problems are due to a general medical condit ion in need of a surgical or pharmacologi- cal intervention, or whether her problems are psycholog- ical in nature and therefore in need of some kind of psy- chotherapeutic or psychopharmacological intervention.
I agree with much of the diagnostic formulation of- fered by McCabe and Antony (2004). The authors make a good case for ruling out various disorders such as specific phobia and generalized anxiety disorder. I agree that Mrs. A.'s primary problem is hypochondriasis. In fact, she has a textbook case hypochondriasis. But is it useful or necessary to assign an additional diagnosis of obsessive- compulsive disorder (OCD)? McCabe and Antony be- lieve so. These authors point out that Mrs. A. has symp- toms suggestive of OCD: i.e., recurrent intrusive thoughts, rumination and doubting, and compulsions. But all o f these symptoms are health-related. Her intrusive thoughts are about death and dying, her rumination and doubting are about health-related threats (e.g., doubts about the accuracy of medical tests), and her compulsions involve the search for reassuring health-related information or efforts to avoid health risks (even her concern about a gas leak at home is health-related). Mrs. A. does not appear to have any nonhealth-related obsessions or compulsions.
An additional diagnosis of OCD does no t enhance our unders tanding of Mrs. A.'s problems or facilitate treat- men t planning. Her putative OCD symptoms are com- monly associated with hypochondriasis (Asmundson, Taylor, & Cox, 2001; Kellner, 1986). In fact, inventories designed to measure the major facets of hypochondriasis include subscales and items assessing these symptoms; e.g., subscales assessing recurrent thoughts of death, doubts about medical tests, and excessive reassurance seeking (Asmundson et al., 2001). Contemporary cognitive- behavioral therapy (CBT) for OCD is in many ways simi- lar to contemporary CBT for hypochondriasis (compare, for example, the hypochondriasis protocols in Taylor & Asmundson, 2004, with the OCD protocol in Taylor, Thor- darson, & S6chting, 2001). So, for Mrs. A., an additional diagnosis of OCD does not indicate any interventions that we would not already use in the t reatment o f hypo- chondriasis. In fact, a diagnosis of OCD may be more hin- drance than help. Such an additional diagnosis carries the implication that Mrs. A. has nonhealth-related obses- sions or compulsions, thereby misleading clinicians who receive information about her disorders. An additional diagnosis of OCD is also inconsistent with DSM-[V. Ac- cording to DSM-IV (and the text revision, DSM-IV-TR), Mrs. A. does no t qualify for an additional diagnosis of OCD because all her symptoms are health-related:
Individuals with Hypochondriasis may have intru- sive thoughts about having a disease and also may have associated compulsive behaviors (e.g., asking for reassurances). A separate diagnosis of Obsessive- Compulsive Disorder is given only when the obses- sions or compulsions are no t restricted to concerns about illness (e.g., checking locks). (American Psy- chiatric Association, 2000, p. 506)
114 Taylor
A further concern is that the diagnostic evaluation is incomplete. No information is given about whether Mrs. A. has an Axis II disorder. To unders tand her problems and to plan an effective treatment, it would be useful to know whether she has a coexisting personality disorder. For ex- ample, is her excessive reassurance-seeking part of a long- standing pattern of interpersonal dependency, as in de- penden t personality disorder? Is her tendency to doubt and mistrust doctors part of a broader tendency to dis- trust and disbelieve people, as in paranoid personality disorder? If her health-related problems are associated with the interpersonal and cognitive styles characteristic of personality disorders, then these styles may need to be addressed during treatment.
F o r m u l a t i o n - B a s e d A s s e s s m e n t
I m p o r t a n t Variables to Assess Assessment is, at least in part, a conceptually driven
venture, where theories o f a given disorder determine what is impor tant to assess. The fruits of the assessment process are then used to develop a case formulation or working hypothesis about the causes of a patient's prob- lems (Persons & 2bmpkins, 1997). Case formulations are important for t reatment planning, even for disorders like hypochondriasis, for which there are empirically sup- por ted CBT protocols. These protocols provide useful templates for developing treatment plans, hut they offer few guidelines about how and when to select interven- tions, or how to select t reatment targets. Formulations are needed to determine the pacing, difficulty level, and timing of interventions, and are useful for predicting and preparing for obstacles to successful therapy. Thus, formulations can be used to apply empirically supported t reatment protocols to specific cases (see Taylor, 2000, for an extended discussion of these issues). A good assess- m e n t is essential for developing a useful case formulation.
The formulation attempts to explain the causes of long-standing problems (e.g., Mrs. A.'s persistent pre- occupation with health) and the causes of acute problems (e.g., discrete episodes of especially intense health anxi- ety). More generally, formulations seek to explain the four Ps of clinical causation: the predisposing, precipitating, perpetuating; and protective factors in clinical problems. Predisposing factors are diatheses or vulnerability factors. Precipitating factors are those stimuli or circumstances that trigger or worsen the problems. Perpetuating factors are those that maintain the problems. Protective fac- tors either prevent problems from developing or prevent them from getting worse. Protective factors may not he present in every case.
To identify these factors in the case of Mrs. A., it is use- ful to draw on contemporary cognitive-behavioral models of hypochondriasis (see Wells, 1997, and the chapters in
Asmundson et al., 2001, particularly the chapter by Sal- kovskis and Warwick). The similarities of these models out- weigh their differences. The emphasis is on identifying-- typically by interviews or se l f -moni tor ing-- the following:
• Maladaptive beliefs about health, disease, and death, and associated beliefs about medical tests and medi- cal practitioners. Such beliefs can predispose a per- son to develop hypochondriasis.
• Learning expe*~ences about health and disease, which can give rise to maladaptive beliefs. These experi- ences can provide patients with "evidence" to sup- port their beliefs.
• Bodily changes and sensations that the patient has experienced, which can precipitate discrete, intense episodes of health anxiety, and can contribute to hypochondriasis in other ways.
* Misinterpretations that the pat ient makes about bodily changes, sensations, and medical tests, and threatening health-related images that can intrude into the patient 's stream of consciousness. Images and misinterpretations can serve as both precipitating and perpetuat ing factors in hypochondriasis.
• Safety signals and safely behaviors. The former are stimuli that provide the patient with a sense of safety from health-related threats (e.g., carrying bottles of prescrip- tion medications). The latter are behaviors used to avert feared outcomes (e.g., reassurance seeking, checking medical textbooks, avoiding "sickly" people). Both can play a role in perpetuating hypochondriasis.
Contemporary cognitive-behavioral approaches to hy- pochondriasis propose that heahh-related maladaptive beliefs lead the person to overestimate the threat value of health-related stimuli. The available information on Mrs. A. (e.g., f rom her self-monitoring) indicates that she proba- bly believes that "unexpected pain is a symptom of seri- ous disease." This belief would lead her to misinterpret, for example, the significance o f proctalgia fugax (tran- sient, benign pain in the lower rectum). The occurrence of this sensation would probably give rise to a misinter- pretation, "I have bowel cancer," and may be associated with upsetting images (e.g., images of her undergoing bowel surgery and the subsequent discomfort and embar- rassment of needing a colostomy bag). Thus, the interac- tion between maladaptive health-related beliefs and threatening health-related stimuli leads to health misin- terpretations, aversive images, and associated worry and fear. The person attempts to cope with the threat by seek- ing safety signals (e.g., remaining in the vicinity of a hos- pital) and by performing safety behaviors (e.g., checking medical texts on the causes of rectal pain in a effort to de- termine whether the pain is benign). Safety signals and safety behaviors prevent the maladaptive beliefs f rom
Response: CBT Approach 115
being disconfirmed, thereby perpetuat ing health-related misinterpretations and associated worry and fear (Astound- son et al., 2001; Wells, 1997). In treatment, it is important to wean patients off their safety signals and eliminate their safety behaviors in o rder to correct their maladaptive beliefs and misinterpretations.
Self-Monitoring The self-monitoring procedure described by McCabe
and Antony (2004) is important for assessing bodily changes, sensations, misinterpretations, images, safety be- haviors, and safety signals. Themes in the misinterpreta- tions can be extracted to identify maladaptive beliefs. These themes should become clear after a few weeks of monitoring. For Mrs. A., continued monitoring might re- veal beliefs such as, "I will get sick if I 'm not vigilant for health risks." Serf-monitoring should be continued through- out t reatment so as to obtain information about the valid- ity of the case formulation and to assess the effects of treatment on maladaptive beliefs and other variables. The formulation may be modified as information accrues.
Facilitating the Identification of Beliefs and Behaviors What are Mrs. A.'s health habits, in terms of physical
exercise, smoking, drinking alcohol, and eating a bal- anced diet? People with hypochondriasis tend to have no better health habits than other people (American Psychi- atric Association, 2000). A review of her health habits can provide information about her health-related beliefs. Mrs. A. might avoid things that produce bodily changes or sensations (e.g., drinking coffee or rapidly ascending stairs), yet she might have a poor diet (e.g., f requent con- sumption of fatty red meat). Such inconsistencies might reveal maladaptive health beliefs. For example, perhaps she believes that "symptoms are the most important indi- cators of one's health status."
A sound therapeutic relationship is important for comprehensively assessing the cognitive and behavioral aspects of hypochondriasis. It is not u n c o m m o n for pa- tients to be embarrassed about discussing their health- related beliefs and behaviors. Mrs. A. reports concerns that she may have undiagnosed rectal cancer. She may engage in a variety of behaviors to check for cancer, such as examining her stools each day. It is important that the therapist identify these safety behaviors because these be- haviors can maintain Mrs. A.'s health preoccupation. She is unlikely to disclose such information if she does not have a trusting relationship with her therapist. To this end, the therapist could empathize with Mrs. A.'s distress, and offer to help her discover the causes of the distress- ing bodily changes or sensations. Strategies for engaging Mrs. A. in CBT are discussed later in this commentary.
Even when there is a good therapeutic relationship, it is not u n c o m m o n for patients to neglect to ment ion vari-
ous safety signals and safety behaviors, unless the thera- pist makes specific inquiries. In some cases, the seeking of safety signals and the performance of safety behaviors are done so often that they become routine, automatic actions that the patient performs without much conscious awareness. Mrs. A. is fr ightened of acquiring all kinds of diseases, and so she probably seeks a variety of safety sig- nals. Medications are c o m m o n safety signals. Mrs. A. might carry prescription medications (e.g., medication for hypertension), over-the-counter preparations (e.g., aspirin, which she might take to ward off angina), or herbal remedies (e.g., "heart tonics" sold in health food stores). Mrs. A. also probably engages in many different kinds of safety behaviors. Some are ment ioned in the case report (e.g., walking slowly up stairs, keeping drapes open, checking medical textbooks). She probably en- gages in all kinds of other, less obvious safety behaviors (e.g., before brushing her teeth each morn ing she might engage in all kinds of checking, such as inspecting her sa- liva, tongue color, pupil dilation, and skin tone). A de- tailed inquiry about the patient's daily activities can en- able the therapist to identify safety signals and safety behaviors. The assessment process is expedited if the ther- apist knows what kind of signals and behaviors to look for. It can be helpful for the therapist to examine the descrip- tive literature on hypochrondriasis (e.g., Kellner, 1986; Ladee, 1966) and the CBT literature on this disorder (e.g., Wells, 1997; Taylor & Asmundson, 2004) to get an idea of the c o m m o n safety signals and safety behaviors.
As a means of identifying potentially important health beliefs, the therapist could explore with Mrs. A. the meaning of the loss o f her mother. On the surface it seems to have confirmed for her the value of worry, even when other people think her worry is excessive. There might be additional important things she derived from this experience. Mrs. A. began to worry when she could not reach her mother by telephone. Mrs. A.'s concerns were vindicated, because her mother had died. This may have convinced Mrs. A. of the importance of relying on intuition or "bad feelings" (emotional reasoning) instead o f evaluating health risks in terms of objective informa- tion. If further assessment supports this conjecture about Mrs. A.'s thinking, then her health anxiety might be re- duced by including interventions that challenge emo- tional reasoning (e.g., see Burns, 1981).
Assessing Contextual Variables Another important assessment issue concerns the con-
text in which Mrs. A.'s problems arose. This provides im- por tant information about predisposing and protective factors. As ment ioned earlier, it would be useful to know whether her health anxiety arose in the context of a long- standing, maladaptive interpersonal and cognitive style (i.e., a personality disorder). This is relevant to under-
116 Taylor
s tanding her interact ions with previous medical profes- sionals and for ant ic ipat ing any prob lems that might emerge in the psychotherapeut ic relat ionship.
Mrs. A.'s social and occupat ional history also can pro- vide impor t an t in format ion about the origin and perpet - uat ion of he r hea l th anxiety, such as data about maladap- tire beliefs and salient l ea rn ing experiences . There are several avenues worth explor ing. For example , I note that Mrs. A. re t i red f rom he r school teaching posi t ion when she was about 58 years old. The usual r e t i r emen t age is 65. Why did she ret i re early? She might have done this in o r d e r to avoid the stresses of work, perhaps because she bel ieved that occupat ional stress can ha rm one 's physical health. Explora t ion of the reasons for early r e t i r emen t may provide impor t an t in format ion about he r health- re la ted beliefs and behaviors.
Assessing o the r aspects o f her social and occupat ional func t ion ing may also prove informative, such as informa- tion about he r ch i ldhood, he r mari ta l re la t ionship and subsequent divorce, her chi ld-rear ing experiences , and her occupat iona l experiences . For example , he r parents might have had excessive heal th anxiety and might have m o d e l e d hypochondr iaca l attitudes. He r early experi- ences with he r ill b ro the r also could be exp lo red in detail to assess the possible effects on her heal th-re la ted beliefs.
Mrs. A. raised three chi ldren and had previously worked as a school teacher. She therefore must have been exposed on many occasions to illnesses, such as bouts of inf luenza sweeping th rough the school, and illnesses ac- qu i red by her ch i ld ren and passed on to o ther family members . How did she cope with these episodes? It is possible that she found these bouts of illness to be un- pleasant but tolerable. Perhaps the episodes served to re- mind her that she could survive everyday epidemics. These per iodic reminders may have served as protective factors that prevented her heal th anxiety from worsening. Retire- men t and the associated social isolation removed her from this source of corrective information. Mrs. A. could be in- terviewed to see if this conjecture is correct. If it is correct (as I suspect it is), then her heal th anxiety might be allayed if she was to re turn to some form of activity that br ings he r into daily contact with others (e.g., volunteer ing at a school, or teaching courses at a local communi ty center) .
To fur ther unde r s t and the factors that might p romo te the reduc t ion in Mrs. A.'s hypochondriasis , one could as- sess whe ther there was a pe r iod in which Mrs. A. was free of hea l th anxiety. What were he r circumstances at the time? To what does she at t r ibute the lack of anxiety? An- swers to these questions can aid in the deve lopmen t of a t r ea tment plan.
Assessing Prognostic Variables The available research suggests that hypochondr ias is
has favorable prognosis when the following condi t ions
are met: acute onset, br ie f dura t ion , mild hypochondr ia - cal symptoms, the presence of genera l medical comor- bidity, the absence of a comorb id menta l disorder, and the absence of secondary gain (American Psychiatric As- sociation, 2000). Mrs. A. has few of these features, a l though some need to be assessed in more detail. In particular, there may be environmental contingencies that positively reinforce aspects of her hypochondriasis (i.e., provide "see- ondary gains"). For instance, she might only receive atten- tion from her adul t chi ldren and estranged husband when she complains about her health. It is impor tant for the cli- nician to be aware of such cont ingencies because they can play a role in pe rpe tua t ing Mrs. A.'s hypochondriasis .
McCabe and Antony ident i f ied two o the r factors that could in ter fere with Mrs. A.'s t rea tment : (a) the s t rength of he r heahh-anxie ty convictions (the fact that she's 95% convinced that he r illness beliefs are wel l - founded and necessary), and (b) he r ongoing medical investigations. To deal with these potent ia l obstacles, it is first necessary to unde r s t and them. Fur the r assessment is n e e d e d to de- te rmine why her heal th beliefs r emain so strong. Mrs. A. has been told that he r bodi ly changes and sensations are no t due to a serious disease, but perhaps she has never re- ceived a good explana t ion of what is causing the changes and sensations. Mrs. A. is no t 100% convinced that she has a serious disease. The basis of the uncer ta in ty could be explored. What in format ion is most po ten t in lead ing her to doub t that she has someth ing medical ly wrong with her? Belief s t rength in hypochondr ias is typically fluctuates over t ime and circumstance, with disease con- viction be ing s t ronger on some occasions than others. To unde r s t and what influences Mrs. A.'s beliefs, the thera- pist could assess the circumstances associated with the s t rengthening and weakening of disease conviction. As m e n t i o n e d earlier, it could be that he r conviction is weak- est when she is e x p o s e d - - w i t h o u t h a r m - - t o illness dur- ing school epidemics.
The basis for he r ongoing medical investigations should be similarly assessed in detail. The cognitive-behavioral therapis t t reat ing Mrs. A.'s hypochondr ias is should con- sult with he r physicians to assess the ra t ionale for fur ther medical investigations. Given Mrs. A.'s age, regular medi- cal check-ups are required , bu t he r cur ren t r eg imen o f medical testing is apparent ly excessive. Are the unneces- sary tests pe r fo rmed simply to placate Mrs. A.? Are some physicians fuel ing her hea l th anxiety by a t tempt ing to rule out every medical disorder, no mat te r how rare? Once the reasons for ongo ing testing are unders tood , then the therapis t is in a posi t ion to modify the variables pe rpe tua t ing Mrs. A.'s heal th anxiety. Similarly, it can be fruitful to obta in more informat ion on the na ture of he r interact ions with fr iends and family members . Are these peop le pe rpe tua t ing he r p rob lems by repea ted ly inquir- ing about he r heal th and reassuring her?
Response: CBT Approach 117
Treatment Motivation The therapis t should assess the circumstances sur-
r o u n d i n g he r cur ren t referral. If Mrs. A. is so convinced that she has und iagnosed disease(s), then why is she pre- sent ing to a specialized anxiety clinic? Was she coerced by doctors or family member s to a t tend this clinic? Is she willing to consider, even provisionally, the possibility that he r bodi ly changes and sensations might be due to anxi- ety or o ther ben ign factors? Explor ing her motivat ion for t r ea tment is impor t an t for deve loping strategies for en- gaging her in t rea tment .
Case Formulation
As we have seen in the p reced ing discussion, fur ther assessment is n e e d e d to fully unde r s t and the cognitive and behavioral factors involved in Mrs. A.'s hypochondr i - asis. Given this constraint , the following formula t ion is offered tentatively. It is based on the informat ion pro- vided in the case r e p o r t and would probably need to be revised dur ing the course of t rea tment , as the therapis t gains more informat ion abou t he r problems.
Predisposing Factors The available in format ion suggests that Mrs. A. had
several heal th-re la ted learn ing exper iences that may have given rise to maladapt ive hea l th beliefs. She was report - edly sickly as a child. Regardless of whe the r she was truly sickly ( compared to o the r chi ldren) o r whe ther she (or he r parents) perce ived her as sickly, he r early experi- ences may have led he r to acquire beliefs like "My heal th is fragile" and " I 'm more vulnerable to illness than o the r people ." Her b ro the r had a cardiac condi t ion that re- qui red Mrs. A. to stay away from him when she was ill. This may have led he r to believe that diseases spread ext remely easily.
As an adult , Mrs. A. had several exper iences that may have con t r ibu ted to he r skepticism about the compe- tency of medical tests and medical pract i t ioners. Her m o t h e r compla ined of chest pain to he r doctor, bu t was sent home only to la ter die. Mrs. A. may have in te rp re ted this as evidence of medica l incompetence . In he r 30s Mrs. A. had a s t i l lborn daughter , despi te a "normal" preg- nancy. Exper iences such as these may have led he r to ho ld beliefs like the following: "Normal test results can ' t be trusted because the test may have failed to detect a med- ical problem," "Only abnormal results can be trusted," "Doctors often make serious mistakes," "Since I can ' t always rely on doctors, I need to play an active role in my health care," and "Checking my body and collecting health- related information is the best way to ward off illness." These beliefs may have predisposed her to develop various safety behaviors (e.g., excessive checking and reassurance seeking) in response to bodi ly changes or sensations.
Precipitating Factors For Mrs. A., it is likely that the occurrence of bodily
changes or sensations and exposure to a larming health- related informat ion played a role in precipi ta t ing her hy- pochondriasis and a role in tr iggering acute exacerbations in he r hypochondr iaca l problems. Bodily changes, sensa- tions, and a la rming informat ion have these effects when the person catastrophical ly mis in terpre ts them. Misinter- pretat ions are part icularly likely to occur when the person has maladaptive heal th beliefs, such as those descr ibed earlier.
The available evidence suggests that Mrs. A. has wor- r ied about he r hea l th ever since she was a child, and that these worries escalated into hypochondr ias is du r ing the past 5 years, especially since retiring. Thus, r e t i r emen t appears to be a factor in prec ip i ta t ing her hypochondr ia - sis. Why would r e t i r emen t have this effect? Par t of the an- swer has to do with a t tent ional capacity. This capacity is l imited and so in ternal and external stimuli compete for at tent ion. The de tec t ion of bodi ly changes or sensations therefore depends , in part , on the person 's focus of at- tent ion. At tent ion to stimuli outside one 's body decreases the l ike l ihood of de tec t ing bodi ly changes or sensations. At tent ion d i rec ted inward increases the odds of de tec t ing these sensations (Pennebaker , 1982). For Mrs. A., he r re- t i r ement may have been associated with a r educ t ion in a t ten t ion-grabbing external stimuli (such as a reduc t ion in social contacts and a reduct ion in engaging tasks or projects) , thereby increasing the relative sal ience of inter- nal stimuli. Thus, r e t i r emen t probably increased the like- l ihood o f de tec t ing the sensations, thereby increas ing the odds that Mrs. A. would catastrophical ly mis in te rp re t them. Re t i rement also probably provided he r with more t ime to devote to safety behaviors, which c o m p o u n d e d he r problems, as discussed below.
Perpetuating Factors Mrs. A.'s hypochondr ias is is p robably ma in ta ined by
he r seeking of safety signals (e.g., n i t roglycer in spray) and by he r rel iance on safety behaviors (e.g., checking medical texts; seeking reassurance f rom he r doctors) . These prevent he r maladapt ive beliefs f rom be ing discon- f irmed. For example , wear ing gloves in church prevents he r f rom lea rn ing that there is little or no danger in touching objects that have been touched by others.
People with hypochondr ias is typically engage in disease-related checking in an effort to convince them- selves that their bodi ly changes or sensations are not indi- cations of serious disease. This strategy often backfires, leading the person to learn that the bodi ly changes or sensations can be indicat ions o f rare, le thal diseases. For Mrs. A., the increased free t ime afforded by her ret ire- m e n t may have increased the a m o u n t of t ime she could devote to checking, thereby increas ing the chances that
118 Taylor
she would encoun te r a la rming heal th-re la ted informa- tion. This would pe rpe tua t e he r hypochondriasis .
To illustrate, cons ider the following scenario. Mrs. A. awakens one morn ing to f ind her jaws are stiff and pain- ful. He r first t hough t is that the sensations are due to tee th g r i n d i n g (bruxism) while she slept. She dec ides to search the In te rne t for in format ion on jaw pain, '~just to be sure" that it 's only due to bruxism ("better to be safe than sorry"). To her dismay, she learns of a string of dan- gerous maladies associated with jaw pain, inc luding vari- ous cancers, nerve disorders, and degenerat ive bone dis- eases. She becomes worr ied and anxious, and starts pa lpa t ing her jaws to search for "irregularities." Her m o u t h becomes t ende r and increasingly sore f rom re- pea ted palpat ion. She in terpre ts the increased pain as a "confi rmat ion" that someth ing is seriously wrong. Her anxiety escalates and she te lephones he r doc to r for an ur- gent appo in tmen t . She regards this episode as fur ther ev- idence that he r heal th is fragile and that she needs to be vigilant for signs of disease.
There is ano the r impor t an t way in which her checking of textbooks and o ther sources o f medical informat ion probably increases the l ike l ihood that she will catastroph- ically mis in te rp re t bodily changes or sensations. This works by way of the availability heuristic, which is a decision- making strategy that peop le use, part icular ly u n d e r con- di t ions of uncer ta in ty (Tversky & Kahneman, 1973). A person is said to use this heurist ic when the probabi l i ty of a given ou tcome is es t imated by the ease with which in- stances or examples can be b rough t to mind. Availability is of ten a useful guide for assessing probabi l i ty because instances of c o m m o n events are usually more easily re- trieved f rom memory than instances of in f requent events (Tversky & Kahneman, 1973). However, if Mrs. A. spends a good deal of t ime read ing about lethal diseases, then when she notices a bodi ly change or sensation she is more likely to th ink of lethal causes than nonle tha l causes, and will therefore j u d g e the lethal causes as more likely. For example , if she notices a small skin lesion on her hand, she may be more likely to th ink of serious dis- eases (e.g., various sorts of carcinomas) ins tead of ben ign causes (e.g., a m i n o r abras ion caused by hand washing), and therefore more likely to seek out fur ther medical testing or reassurance. Thus, re l iance on the availability heurist ic can mainta in he r hypochondriasis .
Unnecessary medical tests can pe rpe tua te he r mal- adaptive beliefs in several ways:
1. F requen t medical tests serve as r ecu r ren t re- minders of he r vulnerabil i ty to disease and death.
2. The medical testing can convey the message to he r that he r heal th concerns are realistic ("They wouldn ' t do more testing unless they thought some- th ing was wrong with me").
3. Ongoing testing provides opportuni t ies for Mrs. A. to misinterpret medical communicat ions (e.g., over- in terpret ing the significance of "mildly elevated" lab- oratory results).
4. The greater the number of medical tests, the greater the chances of a false-positive test result. Such a re- sult would suppor t Mrs. A.'s maladaptive beliefs about her health fragility.
Biases in the med ia also may cont r ibute to the mainte- nance of Mrs. A.'s hypochondriasis . Given the sensational na ture of medical mistakes, such mishaps are often re- po r t ed in the med ia (e.g., reports of bo t ched surgeries). Pallid events, such as the correct diagnosis and t reatment of everyday ailments, are rarely deemed newsworth~ Thus, Mrs. A.'s tendency to check health-related media articles increases the l ikel ihood that she will obtain a biased view of the competence of medical practitioners. This maintains her bel ief that doctors and medical tests are unreliable.
Mrs. A.'s social env i ronment may" fur ther cont r ibute to the pe rpe tua t ion of he r hypochondriasis . For example , she might have friends or family members who frequently inquire about her heal th and thereby maintain her pre- occupat ion with her health. As men t ioned earlier, it could be that Mrs. A. gets a t tent ion f rom family member s only when she complains abou t he r health. This would simi- larly pe rpe tua te he r hypochondriasis .
Anxiety-related factors are also likely to pe rpe tua te he r hypochondriasis . Mrs. A. appears to believe that he r heal th can be ma in ta ined by be ing vigilant for bodi ly changes and sensations and by worrying about her health. Worry and vigilance for threat can mainta in he r hypo- chondriasis because they increase the odds that she will de tec t (and thereby mis interpre t ) bodi ly changes and sensations. As she becomes anxious abou t he r health, she experiences sensations associated with autonomic arousal (e.g., gastrointestinal sensations, palpitations, and tension- re la ted pain in various body areas). The more often she becomes anxious about he r health, the more often she ex- per iences arousal-related sensations, which she may mis- in te rp re t as signs of disease. Thus, a vicious cycle devel- ops, where arousal-related sensations are mis in te rp re ted as signs of disease (cf. Asmundson et al., 2001; Wells, 1997). This leads he r to become increasingly anxious and thereby increases the l ike l ihood that she will cont inue to have recurrent arousal-related sensations. 1 Ongoing stresses can also lead to arousal-related bodi ly sensations. It is un- clear whether Mrs. A. has such stresses in he r life. Given that she has ret ired, she might have ongo ing financial stress that could play a role in p roduc ing arousal-related sensations, thereby main ta in ing her hypochondriasis .
1 Other anxiety-related disorders have similar mechanisms. Reviews of the similarities and differences are presented elsewhere (e.g., Asmundson et al., 2001; Taylor, 2000; Wells, 1997).
Response: CBT Approach 119
Protective Factors There is little evidence of factors that currently protect
Mrs. A.'s hypochondriasis, a l though further assessment is needed. She might engage in social activities, hobbies, or other recreational pursuits that divert her attention (at least temporarily) away from her health. These may be pro- tective to the extent that they prevent her hypochondriasis from getting worse. Prior to her retirement, full-time em- ployment might have protected her from the development o f hypochondriasis. A componen t of t reatment might involve building up or reestablishing protective factors.
Treatment Plan
The treatment plan for Mrs. A. follows contemporary cognitive-behavioral guidelines for treating hypochondri- asis (see Wells, 1997, and the chapters by Furer et al. and Salkovskis & Warwick in Asmundson et al., 2001). As men- t ioned earlier, there is a good deal that we need to learn about Mrs. A. and her problems before we can devise a well-informed case formulation. Therefore, any treat- ment plan will be necessarily tentative at this stage. The t reatment format could be either individual or group therapy, conducted on a short-term basis (e.g., 16 ses- sions). Further sessions could be added as necessaI y. The provisional case formulation suggests that the following interventions may be useful:
• Therapy socialization strategies, which are forms of cognitive restructuring used to engage Mrs. A. in t reatment by helping her unders tand the cognitive- behavioral approach to her problems. Such strate- gies are particularly important, given her poor in- sight into her hypochondriasis.
• Other cognitive restructuring exercises, more specif- ically in tended to alter Mrs. A.'s misinterpretations of bodily changes and sensations and her maladap- tive health-related beliefs.
• Behavioral experiments to further test her beliefs and misinterpretations and to help her unders tand the effects of seeking safety signals and engaging in safety behaviors.
• A plan for appropriate medical care, including guidelines about when to seek medical attention.
• Enlisting the assistance of Mrs. A.'s significant others in treatment.
• Encouraging Mrs. A. to engage in personally mean- ingful, fulfilling activities that will divert her atten- tion away f rom her body.
Therapy Socialization Strategies Treatment could begin by asking Mrs. A. to describe
her health-related t reatment goals and then discussing whether CBT could be useful in addressing those goals.
This strategy can be used to engage patients in CBT. McCabe and Antony's case report suggest that Mrs. A.'s goals would probably include the following:
• To be free o f "symptoms" (bodily changes and sensations).
• To be free of anxiety and health-related fear. • To receive an explanation of what is causing the dis-
tressing symptoms.
Once the goals are identified, the therapist and Mrs. A. can review the extent that Mrs. A.'s previous (medical) t reatment has achieved these goals. Given that she is still experiencing upsetting bodily changes or sensations and is still preoccupied with her health, the chances are that her t reatment goals have been largely unattained. The therapist can then suggest that perhaps it is time for her to consider a different approach to treatment. The self- moni tor ing exercise used by McCabe and Antony could be cont inued for a few weeks to help educate her about the causes of her bodily changes and sensations. This would provide an avenue for introducing her to the cognitive-behavioral formulation of her problems, includ- ing the role of anxiety and other benign factors in pro- ducing the feared sensations, and the effects of safety behaviors in maintaining her problems. Her feedback about the formulation would be elicited, including any concerns she has about its accuracy (e.g., her possible ob- ject ion that symptoms are not caused by stressful events). Cont inued self-monitoring can be used to test her con- cerns (e.g., to test whether she has more bodily sensa- tions during or after an encounter with a stressful event).
The important point is to provide Mrs. A. with a com- pelling explanation of what /s causing her disturbing bodily changes or sensations (e.g., things like stress, anx- iety, fatigue, fasting, selective attention). This is probably something that she has not received in the past. The thera- pist should empathize with Mrs. A.'s frustration (or anger) about the way that other health care professionals have dealt with her. The therapist can emphasize that he or she believes that Mrs. A.'s problems are not trivial, and that it is important to identify the source of her difficulties. Ap- proaches such as these could help engage Mrs. A. in CBT.
Early in t reatment the therapist could also explore Mrs. A.'s other treatment goals. She could be led to under- stand that her goal of being "symptom free" is unrealistic, because everyone (including healthy people) experiences bodily sensations. Socratic dialogue and information gath- ering could be used to help her unders tand this point.
T: Do you think it's ever possible to be completely free of bodily sensations, such as aches and pains?
P: I hope so. T: Do you think that healthy people experience these
sensations?
120 Taylor
P: I d o n ' t see why a heal thy person would have these sensations.
T: Let 's draw an analogy. Have you ever had a noisy car?
P: No, but my ref r igera tor is very noisy. It keeps me awake at night.
T: And is it working properly? P: Yes, it 's fine. I 've had it checked and the r epa i rman
says that there is no th ing wrong. T: So you can have a fr idge that 's noisy, even though
it's in good working order? P: Yes. T: Do you th ink the same thing could apply to o the r
people? That is, do you th ink that some people have noisy bodies, which p roduce a lot of sensations even though they ' re physically healthy?
P: I d o n ' t see how that could be. I th ink it's unlikely. T: OK, I apprec ia te you tel l ing me that. But if this
"noisy body" idea tu rned out to be true, how would that make you feel?
P: I guess I wouldn ' t get so upset when I not iced a symptom.
T: Right. So it sounds like the "noisy body" idea is someth ing that 's impor t an t to check out. How could we go abou t col lect ing evidence to see if this idea is true?
The "noisy body" analogy is a useful means of socializ- ing Mrs. A. to a cognit ive-behavioral app roach to he r problems. This is a re f raming exercise, where bodi ly sen- sations are re labe led as "bodily noise" ra ther than indica- tions of bodi ly dysfunction. Notice that dur ing the early stages of t r ea tment the therapis t is no t push ing this idea and is not directly chal lenging Mrs. A.'s beliefs. She is simply be ing asked to cons ider the not ion of a "noisy body" and collect some data on whe ther the idea has merit . If the therapis t had pushed this idea too forcefully, then a p h e n o m e n o n known as reactance may have oc- curred, where vigorous a t tempts to change Mrs. A.'s be- liefs lead her to de fend and thereby s t rengthen he r con- victions. Reactance is especially likely to be a p rob lem for peop le who have very s t rong beliefs, such as Mrs. A. (see Chadwick & Lowe, 1994).
Other Cognitive Restructuring Exercises Therapy socialization strategies are typically the first
sorts o f cognitive res t ructur ing exercises used to t reat hypochondrias is . Once Mrs. A. has begun to c o n s i d e r - - even p rov i s ionaI ly - -a cognit ive-behavioral formula t ion of he r problems, then addi t ional res t ructur ing exercises can be in t roduced to more directly target he r misinter- pre ta t ions of bodi ly changes or sensations and the associ- a ted maladapt ive beliefs. The therapis t and pa t ien t work collaboratively to cons ider the evidence for and against
various beliefs and in terpreta t ions . To avoid p rob lems with reactance, the therapist is careful no t to push his or he r ideas too forcefully. Rather, the therapis t uses So- cratic dia logue to encourage Mrs. A. to examine he r be- liefs and in terpre ta t ions (see Taylor, 2000, chap te r 12, for details on how to conduc t Socratic d ia logue) .
Mrs. A. could be asked to consider what she would f ind to be persuasive evidence for or against he r beliefs (i.e., he r epistemology). Chances are that she has no t cons idered this before. A discussion of this topic might reveal, for example , that she has unrealistically high stan- dards of evidence (e.g., requi r ing absolute certainty that a medical test result is accurate) . Such a discussion serves two purposes. First, it helps Mrs. A. unde r s t and that her th inking pat terns (e.g., evidence requi rements) play a role in causing some of he r p rob lems (e.g., he r worry, anxiety, and checking) . Second, it provides an oppor tu- nity for fur ther cognitive restructuring. For example , if she has an i r ra t ional d e m a n d for certainty, then the ther- apist could, via Socratic dialogue, he lp Mrs. A. under- s tand that this is an unat ta inable goal. Relatedly, cogni- tive res t ructur ing could focus on Mrs. A.'s "recipe for living." Tha t is, given that she (like the rest of us) has a l imited life span, she could be asked to cons ider how her t ime could be fruitfully spent. She could devote he r t ime to worrying about he r hea l th and checking for disease, or she could choose to spend more t ime on o the r produc- tive or enjoyable activities. Thus, Mrs. A. could be asked to do a cost-benefit analysis of the value of excessively worrying about h e r health.
The therapis t and Mrs. A. could also review Mrs. A.'s list of bo the rsome bodi ly changes and sensations and her various heal th-re la ted fears in o rde r to identify o the r as- pects of he r heal th-re la ted thinking. The following is a meta-cognit ive in tervent ion that would he lp he r th ink about he r own thinking, and could be used to improve h e r ins ight in to the excessive na tu r e o f h e r hea l th worries.
T: If we look over your self-monitoring for the past couple of weeks, do you see any pat terns emerging?
[Patient and therapist spend a few minutes reviewing the monitoring]
P: I only see that I 've had lots of symptoms. T: And do you not ice that you've also had lots of fears.
For example , when you had a pa in in your s tomach you feared that you might have s tomach cancer. When you not iced your hear t bea t ing rapidly you feared that you might be having a hea r t p rob lem. A n d when you not iced a spot on your h a n d you feared that you might have skin cancer. I 'm wonder ing if there 's a pa t t e rn here. What do you think?
P: I guess it means that I have a lot of fears.
Response: CBT Approach 1211
T: Right. Imagine for a m o m e n t that tomorrow you expe r i enced a new sensation, such as t ingling in your feet. How would you in te rp re t that sensation?
P: I guess I would worry that someth ing is wrong. T: Like whaO P: Like my nerves were deter iorat ing. T: Do all these fears suggest a th inking pa t te rn that
you somet imes have? P: I guess so. I not ice a symptom and then I assume
the worst. T: So, assuming the worst is a th inking pa t te rn that
you have, which makes you feel anxious and worried. Maybe your main p rob l em has to do with bad th inking habits ins tead of bad health. What do you th ink o f that possibility?
[Patient and therapist continue to explore this idea.]
A review of Mrs. A.'s th inking pat terns also can be used to he lp he r identify impor t an t heal th-re la ted beliefs that she might hold, such as "My heal th is fragile" and " I 'm more vulnerable to illness than o the r people ." Mrs. A. can then be asked to examine the evidence for and against these beliefs. Alternative beliefs can be ident i f ied (e.g., " I 'm heal thy for my age") and evidence for and against these beliefs can be reviewed. To chal lenge he r specific mis in terpre ta t ions o f bodi ly changes or sensa- tions, a self-monitoring form can be devised, consist ing of three columns: (1) BODILY "SYMPTOM," (2) INTERPRETA- TION OF " S Y M P T O M , " and (3) EVIDENCE F O R AND A G A I N S T
INTERPRETATION. Mrs. A. is likely to write down a lot of catast rophic misinterpreta t ions . For those cases she could be asked to also write down an alternative (benign) in terpre ta t ion , a long with the evidence for and against this in terpre ta t ion . The self-monitoring can be reviewed each week dur ing therapy sessions. Catastrophic images o f disease or dea th can be a l t e red by various image- modi f ica t ion exercises (see Taylor & Asmundson, 2004).
Behavioral Experiments Mrs. A. could be encouraged to engage in various ac-
tivities to test out he r beliefs and misinterpreta t ions . These would involve her refra ining f rom seeking safety signals and refra ining f rom pe r fo rming safety behaviors. For example:
• Walking quickly up and down the stairs in o rde r to test the be l i e f tha t v igorous activity will cause he r to collapse. This cou ld be done in a g r adua t ed fash- ion, in which safety signals (e.g., ni t roglycerin spray, open drapes) were gradual ly faded out in o r d e r to general ize he r t r ea tment gains (i.e., so she is no longer re l iant on safety signals).
• Going to church without wearing her gloves, and en- sur ing that she touches doorknobs , railings, etc., with he r bare hands (without washing afterwards).
Walking th rough the recep t ion area o f a genera l hospital (i.e., where sick peop le are seated). Refrain f rom all forms of checking (e.g., checking he r body, checking medical texts, reassurance seek- ing) to test the effect that this has on he r somatic preoccupat ion . This would be used to chal lenge be- liefs that checking and bodi ly hypervigilance are essential to he r health.
The results of these exper iments would be reviewed dur ing therapy sessions and combined , as needed , with cognitive restructuring. The la t ter would be used to weaken her conviction in maladaptive beliefs (e.g., "Check- ing is essential to my health") and to strengthen adaptive beliefs (e.g., "All I need is a month ly checkup from my doctor") . Cognitive res t ructur ing can also be used to in- crease the l ike l ihood that Mrs. A. will par t ic ipate in the behavioral exper iments . She is unlikely to do so unless she receives a convincing rat ionale. I t would probably be necessary to spend a few sessions on therapy socialization and o the r forms of cognitive res t ructur ing before Mrs. A. is willing to pe r fo rm any behavioral exper iments .
Planning Appropriate Medical Care The cognitive-behavioral therapis t should lialse with
the pract i t ioners involved in Mrs. A.'s medical care. The case formula t ion would be shared with them, and the cognit ive-behavioral t r ea tment would be summarized. The untoward effects of reassurance and fur ther medica l test ing would be discussed. Typically, med ica l pract i - t ioners can apprec ia te the p rob lems with ongo ing reas- surance and unnecessary medica l testing, and are willing to suspend these in tervent ions at least for the du ra t ion of CBT.
It is also impor t an t to devise, with the inpu t of Mrs. A. and her medica l doctors, an appropr i a t e p lan for on- going medical care. Given that she is 60 years old, she will require per iod ic medical investigations (e.g., cancer screens). Appropr i a t e guidel ines should be negot ia ted for the f requency o f these investigations. Guidel ines can also be devised to de te rmine when she should or shouldn ' t seek additional medical attention. The cognitive-behavioral therapis t and Mrs. A. could develop a list of "symptoms" that do not warrant immedia te consul ta t ion with a medi- cal doctor. Mrs. A. might come up with examples such as brown saliva, b l o o d s h o t eyes, t rans ien t s tomach pain, m i n o r rashes, and so forth. If she notices such bodi ly changes and exper iences an urge to consul t a doctor, she could be encouraged to write down the "symptom" (e.g., on her self-monitor ing forms) and then wait a week be- fore dec id ing on whether o r no t to consul t a doctor. Dur- ing this t ime Mrs. A. should not check the t roublesome symptoms (e.g., she should no t pa lpa te lumps or pick at skin blemishes) and should no t engage in any o the r form
122 Taylor
of checking behavior. This in tervent ion is a form of expo- sure and response prevent ion, similar to that used in the t r ea tment of OCD. This in tervent ion can be conceptual- ized as a behavioral exper iment , because it encourages Mrs. A. to collect informat ion on the mean ing of the symptom (i.e., by waiting for 1 week she will learn whether he r minor ailments are transient and innocuous). Mrs. A. could also draw up a list of signs and symptoms that do
warrant p r o m p t medical a t tent ion (e.g., crushing chest pain, b loody stools, b roken bones, etc.). The goal is to he lp Mrs. A. to use medical resources in an appropr ia te , responsible manner .
Enlisting the Assistance o f Significant Others Mrs. A.'s social contacts could be cont r ibu t ing to the
pe rpe tua t ion of he r somatic preoccupat ion , to the extent that significant others frequently inquire about he r hea l th or provide he r with a t tent ion and sympathy when- ever she has hea l th complaints . This potent ia l p rob l e m can be addressed first by raising the issue with Mrs. A. and encourag ing her to refrain f rom talking about he r symp- toms with peop le in he r social network. It is impor t an t that Mrs. A. under s t and the ra t ionale for this. If neces- sary, par t of a therapy session could be devoted to social skills training, where she is he lped to genera te a list of al- ternative topics of conversat ion that have no th ing to do with he r physical health.
The second way of address ing this issue is to have, with Mrs. A.'s permission, one or more of he r significant others j o i n he r for a conjo in t therapy session. Let us as- sume, for example , that Mrs. A. has a part icularly close re- la t ionship to he r brother , whom she visits a couple of times each week. Mrs. A.'s heal th might be the main topic of their conversations, perhaps because her b ro the r is deeply concerned about Mrs. A.'s health. A conjoint ther- apy session could be a r r a n g e d with Mrs. A. and he r brother. The therapist could explain the untoward effects of continually discussing Mrs. A.'s health, and the bro ther could be asked to avoid discussing this topic. With Mrs. A.'s permission, the b ro ther also could be asked to refrain from giving her health-related reassurance. For instance, if Mrs. A. asked he r b ro the r whether a yellowish bruise on her a rm could be a sign of cancer, he could say that it is "doctor 's orders" that they do not discuss he r health.
Activity Scheduling It is quite likely that now Mrs. A. has re t i red and lives
alone, she has a good deal of spare t ime on her hands, which gives he r ample oppor tun i ty to a t tend to and worry about bodi ly changes or sensations, and to engage in checking behavior (e.g., checking medical texts). To re- duce her somatic p reoccupa t ion and to more general ly improve the quality of he r life, Mrs. A. should be encour- aged to engage in activities that b r ing her a sense of mas-
tery or pleasure. These are much the same as the behav- ioral activation exercises used in CBT for depress ion (e.g., Beck, Rush, Shaw, & Emery, 1979). Mrs. A. could be encouraged to pursue activities outside of the home, such as enrol l ing in courses at a local communi ty center, exercise classes (e.g., j o in a walking club), par t ic ipat ion in activities at he r local church (e.g., Bible study group) , and volunteer ing (e.g., teaching weekend courses). To get the most out of these exercises, she should no t talk about he r heal th with o ther peop le and she should no t engage in safety behaviors (e.g., slow walking, reassur- ance seeking) or seek out safety signals. Note that behav- ioral exper iments are buil t into this form of activity scheduling, because the activities provide he r with fur- ther evidence that it is unnecessary to seek out safety sig- nals or engage in safety behaviors. Increased social con- tact (without safety signals and behaviors) no t only helps reduce he r focus on her body, bu t also per iodical ly pro- vides corrective informat ion (e.g., she might learn that she can socialize, wi thout harm, with a person who has a cough or cold). Dur ing therapy sessions, the therapis t and Mrs. A. could review the effects of these divert ing ac- tivities on her perceived health. If she notices a decrease in bodi ly sensations dur ing these activities, then this can be p resen ted to her as fur ther evidence for the cognitive- behavioral formula t ion of her problems.
T r e a t m e n t O b s t a c l e s
I agree with McCabe and Antony's assessment that the main obstacles to successful t r ea tment are Mrs. A.'s p o o r insight and her ongoing medical tests. He r poo r insight increases the risk that she will premature ly terminate CBT. The ongoing medical testing reinforces he r maladaptive beliefs and thereby hampers CBT. The insight p rob lem could be addressed by, first, conduct ing a thorough assess- ment to de te rmine why her maladaptive beliefs are so strong and, second, to use this information to devise a cognitive-behavioral intervention to weaken these beliefs. Therapy socialization strategies, as discussed above, may be useful in this regard. Selection o f the opt imal strategy will d e p e n d on what factors are main ta in ing the beliefs.
To address the p rob lem of ongo ing medical testing, the CBT therapis t should liaise with Mrs. A.'s medical pract i t ioners , as men t ioned earlier. Reasons for ongo ing testing should be discussed, and the cognit ive-behavioral therapis t can share the CBT formula t ion and h ighl ight the consequences of unnecessary testing. This provides a basis for developing a plan for l imit ing or delaying any fur ther testing.
As a fur ther safeguard against addi t ional , unnecessary medical testing, it would be impor t an t that Mrs. A. re- frain f rom "doctor shopping." The therapis t and Mrs. A. could review the pros and cons of repea ted ly changing
Response: CBT Approach 123
doctors. The cons include the lack of consistent medical care, the time wasted by the pat ient and the practi t ioner (e.g., each new pract i t ioner will need to do an intake evaluation), and the fact that Mrs. A.'s cur rent doctors have a more detailed knowledge of her problems than a new doctor. Mrs. A. might object that her current doctors are no t taking her seriously. This objection could be ad- dressed by poin t ing out that one of the goals of CBT is to help her learn how to best make use of her medical doc- tors (e.g., when to seek medical care) and how to refrain from behaviors that create problems in the doctor- pat ient relationship (e.g., strategies for refraining from unnecessary reassurance seeking).
Expected Outcome
If the above-ment ioned obstacles are no t overcome, then Mrs. A. is likely to either drop out or adhere poorly to CBT. If the obstacles are circumvented, and if she is able to complete a course of br ief (e.g., 16 session) CBT, then her hypochondriasis is likely to be substantially im- proved. The prognostic indicators reviewed earlier, along with the t reatment outcome literature (e.g., Taylor & Asmundson, 2004) and my clinical experiences, suggest that it is unlikely that Mrs. A. will be completely free of hypochondriacal problems by the end of treatment. The best realistic outcome is that her problems will be greatly reduced, bu t not eliminated. Booster sessions, in the form of periodic cognitive-behavioral checkups, can be scheduled to promote t rea tment gains and to help her deal with any emergent problems (e.g., to help her deal with any recurrent health anxiety if she was to genuinely develop a serious medical problem, or any increase in health anxiety when she turns 62, which was the age at which her mother died). Booster sessions could be sched- uled 3, 6, and 12 months after the end of CBT, with addi- tional sessions scheduled as needed. Long-term outcome may be further enhanced by having her write out what
she has learned dur ing CBT, along with a written plan for dealing with future episodes of health anxiety (i.e., re- lapse prevent ion strategies). Details for developing and structuring these plans are presented elsewhere (see chapter 15 in Taylor, 2000; Taylor & Asmundson, 2004).
References
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Taylor, S. (2000). Understanding" and treating panic disorder: Cognitive- behavioural approaches. New York: Wiley.
Taylor, S., & Asmundson, G.J.G. (2004). Treating" health anxiety: A cog- nitive-behavioral approach. New York: The Guilford Press.
Taylor, S., Thordarson, D., & S6chting, I. (2001). Assessment, treat- ment planning, and outcome evaluation for obsessive-compulsive disorder. In M. M. Antony & D. H. Barlow (Eds.), Handbook of assessment and treatment planning for psychological disorders. New York: The Guilford Press.
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Address correspondence to Steven Taylor, Ph.D., Department of Psychiatry, University of British Columbia, 2255 Wesbrook Mall, Vancouver, BC, V6T 2A1, Canada; e-mall: [email protected].
