Advances in Psychiatric Treatment (1998), vol. 4, pp. 285-295

Cognitive therapy in the treatment of hypochondriasis Hilary M. C. Warwick

The term hypochondriasis was first coined over 2000 years ago to describe a physical illness afflicting the Previous treatments hypochondrium. Subsequently the term was used for a variety of physical illnesses, until the 17th century when forms of melancholia were labelled as hypo Neither physical medicine nor traditional psy chondriasis. Since then a very large number of chiatry has been able to treat people with hypochon psychiatric disorders have been given the term hypo driasis successfully. It has long been regarded as an chondriasis, for example, a form of schizophrenia, intractable disorder for which there is no effective anxiety neurosis and malingering (Kellner, 1986). treatment, with supportive therapy being the best The position has become clearer, in that hypo that can be offered. In response to the view that chondriasis is now accepted as a false belief in hypochondriasis is always secondary to another illness. That this belief is at the centre of a primary psychiatric disturbance, the concept of masked condition has been open to debate. Kenyon's (1964) depression was used to justify prescription of influential study of patients with hypochondriacal antidepressant medication, in the absence of a beliefs suggested that hypochondriasis is always primary affective disturbance. This approach has secondary to another, primary psychiatric disorder, not been successful in treatment of hypochondriasis usually an affective disorder. It has also been (Kellner étal,1993). suggested that hypochondriacal beliefs occurring Some recent studies have used fluoxetine in a in the absence of affective symptoms are due to the small number of cases and claim promising results, concept of 'masked depression'. Subsequent studies however, its efficacy has yet to be established clearly have identified a primary disorder in which false (Fallónet al, 1996). There have been some uncon concerns about health are the central problem, and trolled case series in which behavioural treatment to which affective symptoms are secondary (Bianchi, of hypochondriasis has had promising results 1971). Primary hypochondriasis is included in both (Warwick & Marks, 1988). the ICD-10 (World Health Organization, 1992) and Behavioural treatment is well established as a DSM-IV (American Psychiatric Association, 1994). successful long-term treatment for obsessive- For a definite diagnosis, ICD-10 suggests that compulsive disorder, and more recently, cognitive- both of the following should be present. behavioural treatment (CBT) has been shown to be effective in treatment of panic disorder. As both these (a) A persistent belief in the presence of at least conditions have phenomenological similarities with one serious physical illness underlying the hypochondriasis, the use of cognitive-behavioural presenting symptom or symptoms, even strategies in this disorder were examined. Salkovskis though repeated investigations and examin & Warwick (1986) reported two cases of hypo ations have identified no adequate physical chondriasis successfully treated with CBT, and explanation, or a persistent preoccupation went on to describe a comprehensive cognitive- with a presumed deformity or disfigurement. behavioural formulation of hypochondriasis (b) Persistent refusal to accept the advice and (Salkovskis, 1989; Warwick & Salkovskis, 1990: reassurance of several different doctors that described below). This is a comprehensive descrip there is no physical illness or abnormality tion of the processes involved in the disorder, underlying the symptoms. including aetiological and maintaining factors.

Hilary Warwick is Senior Lecturer in Psychiatry at St George's Hospital Medical School, Cranmer Terrace, London SW17 ORE. Her research interests include hypochondriasis and obsessive-compulsive disorder, and she is involved in postgraduate training in cognitive-behavioural therapy. APT(ì998),vol.4,p.286 Wanvick/Stem

Avoidant behaviours in health Cognitive-behavioural anxiety formulation of hypochondriasis Bodily checking The individual repeatedly examines the 'afflicted' The central feature of primary hypochondriasis is the enduring tendency to misinterpret innocuous part of the body, looking for changes which might physical symptoms as evidence of physical illness. confirm their fears. They may also further examine Common innocuous interpretations are ignored, their bodies for evidence of generalised illness. A and when the patient perceives a physical symptom, person with abdominal pain who fears cancer, will negative automatic thoughts about the meaning of repeatedly palpate their abdomen checking for that symptom are experienced. For example, a head lumps, while weighing themselves frequently for the ache will be immediately evaluated as evidence of a first signs of weight loss and generalised ill health. brain tumour, and the more common explanations, Checking phenomenologically similar to that in obsessive-compulsive disorder may also occur - one such as tension or a hangover, will be ignored. person had to count to four on each tread of the Powerful images of illness and its consequences are stairs "or else some terrible illness might develop". often experienced. The illnesses feared are those with severe outcomes and consequences, such as Direct checking can also exacerbate concerns, for cancer or multiple sclerosis. These illnesses are instance, repeated palpation of a spot can lead to unlikely to result in immediate catastrophe, which delayed healing and fears of skin cancer. helps to distinguish hypochondriasis from panic. Individuals may fear one illness or several simultan Avoidance eously, or fear several in succession during their While less prominent than checking, people with hypochondriasis, which runs a chronic, fluctuating hypochondriasis avoid situations and activities course. A variety of symptoms can be misinterpreted: which they feel will exacerbate their feared illness those of innocuous illnesses, such as colds; anatom - a person who fears heart disease may avoid all ical variations, such as discrepancies between the exertion. sides of the body; trivial bodily variations, such as aches and pains; and iatrogenic symptoms. Although Reassurance-seeking physical symptoms are the most frequent triggers of health anxiety, information about illness, for The diagnosis of hypochondriasis depends on a example in the media, can lead to such fears. The failed medical intervention, the most commonly used publicity about AIDS in the late 1980s led to psychotherapeutic intervention in medicine, reas numerous cases of unnecessary anxiety about the surance. Reassurance-seeking is one of the most condition. striking features of hypochondriasis, with sufferers In Beck's cognitive theory (Beck et al, 1985) it is of the disorder going to great lengths to gain reassur suggested that thoughts and images relating to a ance that they are not ill. Numerous sources of threat of some type are associated with anxiety. In reassurance may be sought: reading 'home doctor' hypochondriasis, the negative thoughts and images periodicals and use of health phone lines, repeated are of a threat to health, and anxiety results. The questioning of relatives about their perception of the extent of this health anxiety is variable - it may be person's health state, seeking repeated medical slight when the person is distracted, but might reach consultations, examinations and investigations and panic levels when symptoms are present and the the use of 'alternative' treatments, for example, person is considering their consequences. The level homoeopathy or reflexology. Reassurance is often of health anxiety on any one occasion depends on a sought extremely frequently. Some psychiatrists number of factors: the patient's perception of the challenge the view that repeated reassurance exacer likelihood that they are seriously ill, their perception bates hypochondriasis and suggest that reassurance of the possibility that successful treatment is avail should be given regularly. However, Salkovskis & able and their assessment of the likely outcome and Warwick (1986) suggest that reassurance-seeking its effect on themselves and others. Typical cognitive and provision function as opérantsin the same way errors can be identified repeatedly in the thinking of as rituals in obsessive-compulsive disorder and people with hypochondriasis, most frequently jump hence maintain the problem (Warwick, 1992). ing to conclusions and catastrophising. Once health Avoidant behaviours can be so extensive that they anxiety occurs, a number of factors maintain it. dominate the person's activities, putting them, their Avoidant behaviours are among the most frequent families and health services under great strain. and important and include avoidance, checking and A number of cognitive factors also maintain health reassurance-seeking. anxiety. Cognitive therapy for hypochondriasis APT (1998), vol. 4, p. 287

Cognitive factors in health anxiety health anxiety, which pre-dates the depressive symptoms. Preoccupation These behavioural, cognitive, physiological and One of the striking characteristics of people with affective changes maintain anxiety, which in turn hypochondriasis is their preoccupation with their leads to an increase in negative thoughts and hypochondriacal concerns. Speech and thought therefore completes a vicious circle (Fig. 1). content are completely dominated by health and A crucial question is why people with hypo illness, which is extremely distressing for the person chondriasis persistently misinterpret innocuous along with their friends and relatives and those symptoms. It is suggested that this is due to dysfunc involved in their treatment. tional core beliefs and the assumptions, attitudes and rules derived from them. Such faulty beliefs Bodily focusing relating to health and illness may develop from prev ious experience of illness in self, relatives or friends. People with hypochondriasis spend a great deal of Examples include beliefs about the meaning of symp time focusing on their bodies and so become acutely toms, for example: 'Physical symptoms are always aware of any sensations, especially those in the area a sign of physical illness'; vulnerability to illness, of bodily concern. 'I'm like my mother who died of cancer, therefore I will get it too'; and about medical management, 'the Selective attention doctor cannot know that there is nothing wrong, as he did not do any tests'. Faulty beliefs may also con Individuals selectively attend to information about cern general issues: 'Anything bad will happen to me'. health and illness, especially that which they feel When a triggering event occurs (e.g. perception of confirms their concerns. physical symptoms) these beliefs are activated leading to misinterpretation and negative automatic thoughts. Physiological maintaining factors Autonomie symptoms of anxiety, such as dyspnoea and palpitations, are misinterpreted as further Treatment strategies evidence of physical illness.

Affective maintaining factors If the cognitive-behavioural formulation is correct, Belief that a serious illness is present often leads to then treatment strategies derived from the formul secondary depressive symptoms. Individuals are ation should be successful in the treatment of usually clear that their low mood is a result of their hypochondriasis (Box 1).

Dysfunctional beliefs + critical incident (e.g. physical symptoms)

I Negative automatic thoughts of threat to health I Health anxiety

AVOIDANT BEHAVIOURS COGNITIVE CHANGES (bodily checking, reassurance (preoccupation, bodily seeking, avoidance) focusing, selective attention)

AFFECTIVE PHYSIOLOGICAL CHANGES CHANGES (low mood) (autonomie symptoms of anxiety)

Fig. 1 Cognitive-behavioural formulation of hypochondriasis APT(1998),vol.4,p.288 Wanvick/Stem

Prior to assessment, the therapist should clearly Previous attitudes to health + headache establish from discussion and medical records that adequate physical investigations have been carried out and that no underlying physical illness has been This must be a brain tumour missed. The development of the formulation should help to confirm to the therapist that there is a positive psychological diagnosis. If the symptoms do not fit AnxietyÃŽ such a formulation, then the possibility of a physical illness should be reconsidered.

Focusing on headache Reading about cancer Engagement Fig. 2 Simplified example of Perhaps the most important aspect of management cognitive-behavioural formulation occurs before any treatment. People with hypochon- driasis are often extremely reluctant to engage in any psychological treatment, fearing a delay in further which requires further investigations and treatment. physical investigations. They may have been brought The individual will usually accept that following along under protest by relatives or sent by physicians, this approach has not resolved their problems. The who refuse any further physical investigations until psychological formulation is then discussed as a psychological assessment has been carried out. competing hypothesis. If the person accepts the Two main tactics are employed to deal with possibility that their problems could be explained problems engaging in treatment. First, the style of by the psychological formulation, then they are the therapist is crucial. The interview should be con offered a brief course of treatment using psycho ducted without rushing, in a sympathetic manner, logical techniques derived from it. It is stressed that and must culminate in the patient's conviction that if, after this treatment, they are still convinced they all their concerns have been discussed. The thera are physically ill, then they will be able to seek further pist should acknowledge that the patient's physical physical treatment. In this way a surprisingly large concerns are real and are taken seriously. The patient number of people with hypochondriasis have may well have been told previously that their symp accepted psychological treatment. toms were 'all in the mind', and will be watching It is crucial to maintain empathy throughout the for evidence of similar attitudes. When discussing treatment. The therapist must continue to show diagnosis and treatment, it should be stated that the understanding of the patient's situation and therapist has seen similar cases in the past, as people distress. Socratic questioning is very important with hypochondriasis often feel extremely isolated when trying to establish the nature of the patient's and that no-one can help them with their problems. beliefs and the evidence supporting these beliefs. Second, the assessment should be used to A patient with hypochondriacal concerns about construct a comprehensive psychological formul ation of the person's concerns. A version using headaches described a recent episode of severe pain. The therapist, instead of assuming and suggesting actual examples from the individual is drawn up, that the patient feared a brain tumour or a stroke, explaining each step to them (Fig. 2). asked the patient what was going through her mind The individual is then asked to explain their own when the headache was present. The patient replied that: "This headache is so severe it must be a brain hypothesis of their problems, which is usually that tumour, and it's at the side of my head and that's they have an undiagnosed serious physical illness where most brain tumours are". In this way the person with hypochondriasis Box 1. Main components of cognitive- knows their concerns have been heard and two behavioural treatment pieces of faulty information about the nature of headaches have been elicited, which can be Engagement corrected during treatment. Self-monitoring People with hypochondriasis often have a Identification and re-attribution of negative tendency, particularly early in treatment, to try to automatic thoughts extract reassurance repeatedly from the therapist. Modification of abnormal illness-related The therapist must watch out for such attempts, and behaviours by referral back to the formulation, explain to the Identification and re-attribution of patient why giving such reassurance would be dysfunctional beliefs detrimental to treatment. Summaries should be made at regular intervals, by both therapist and patient, Cognitive therapy for hypochondriasis APT (1998),vol. 4,p. 289

to ensure correct understanding of information and tension. A brief behavioural experiment was carried homework instructions. out in which she and the therapist tensed their face and scalp muscles for several minutes. The woman Self-monitoring rapidly developed a headache, with some simil arities to the one that had been troubling her, and her belief that she had a brain tumour fell to 50%. Individuals are asked to monitor episodes of health People with hypochondriasis learn to re-attribute concern, noting triggering symptoms, level of anxiety, their automatic thoughts between treatment ses negative thoughts about health and action taken. sions, and are encouraged to devise their own This provides the therapist with further information behavioural experiments to check the accuracy of and examples to work with in initial cognitive restruc their rational responses. turing. It also helps to confirm to the person that the psychological formulation is correct, and that the suggested sequence of events is actually occurring. Exposure and response prevention Using the example of the woman with a headache, an entry in a diary record might be as shown below: Abnormal illness-related behaviours have a crucial Situation: Watching late-night television. role in the maintenance of hypochondriasis. Approp Trigger: Severe headache. riate graded exposure is used if avoidance is present, Thoughts: "I've got such a bad headache along with response prevention for checking. In it must be a brain tumour". addition, it is important to carry out reassurance- Belief = 90%. prevention by referring the patient to the formulation Emotion: Severe anxiety, rating 90 (visual and explaining the importance of the cessation of analogue rating 0-100). reassurance-seeking. It is often necessary to instruct Action taken: Reread the section in my families how to respond to repeated requests for reassurance. They are taught to reply as follows: medical encyclopaedia about "Hospital instructions are that I should not answer brain tumours and then such questions". Others involved in the patient's checked my vision. A record of a week's activities is kept, along with care should be contacted and asked to carry out no further investigations or examinations that are notes of physical symptoms and anxiety, giving the prompted by anxiety rather than clinical indications. therapist information about triggers of health anxiety. Identification and re-attribution of Cognitive restructuring core beliefs and assumptions

In an early session, the subject must be asked to give a full list of all their 'evidence' for their being physically To prevent future relapse, it is important to identify dysfunctional core and intermediate beliefs, and to ill,along with any evidence that they have that there is correct them using re-attribution and behavioural nothing wrong with them. Some of this evidence may experiments. be idiosyncratic and obviously faulty, but it must all be considered and re-evaluated during the course of For example, the woman with a headache believed that a physical symptom is always caused treatment. The therapist informs the person of the by physical illness. As a homework exercise she was cognitive errors which are apparent in their cognitions asked to construct a list of examples of situations, and teaches them how to recognise errors and to with her husband's help, where this belief is false. construct more rational responses to situations. The She returned with several examples, including therapist must work in collaboration with the patient abdominal discomfort after a heavy meal, and back to enable them to construct their own rational pains after digging the garden or playing badmin responses. This is of particular importance, as people ton. This exercise and others helped her to re with hypochondriasis will often try to gain reassur appraise accurately the dysfunctional belief. ance by receiving answers to their concerns from the therapist. Behavioural experiments are constructed, wherever possible, to test out the rational response. The woman who was 90% convinced that her Treatment studies headache meant that she had a brain tumour was asked to construct a list of causes of headaches. She came up with a lengthy list containing a number of Warwick et al (1996) reported a controlled trial of illnesses, but also a number of innocuous causes, CBT for hypochondriasis in which 32 subjects were such as tension or a hangover. She was asked to randomly assigned to either CBT or a waiting list choose the most common cause and suggested control group (no treatment). CBT consisted of 16 APT(1998),vol.4,p.290 Wanvick/Stem

individual treatment sessions over a four-month Follow-up studies are in progress to examine the period. The waiting list control lasted for four months longer-term efficacy of the approach. Future studies and was followed by 16sessions of CBT.Assessments should attempt to discover which of the components were made before allocation and after treatment or of CBT are most effective, in an effort to make the waiting list. Subjects who had CBT were re-assessed treatment briefer and more easily accessible. three months after completion of treatment. Paired com Similarly, further controlled trials in a group setting parisons on post-treatment/waiting list scores indic are needed, as this method of delivery should be ated that the CBT group showed significantly greater more cost-effective. Future studies are also needed improvements than the waiting list group on all but to examine the efficacy of CBT in cases of hypochon one subject's rating, all therapist ratings and all asses driasis occurring in medical settings. It may be that sor ratings. After three months the benefits of therapy such individuals are more difficult to treat, as they were maintained. Although this suggests that CBT is may be more reluctant to consider psychological effective for hypochondriasis, the study has limitations. treatment. It is also necessary to see whether the There was only one therapist and it is necessary to approach can be modified for use with those with a establish that similar results can be obtained by other number of related concerns, for example, those with suitably trained therapists. The waiting list group did real physical illnesses whose anxieties are thought not control for effects of attention, although it is to be excessive, and those presenting in general unlikely that attention alone could have brought about practice settings with somatic complaints which are the improvements seen in the treated group. not yet as severe as hypochondriasis. In a second controlled study (see Salkovskis & Bass, 1996)CBT was compared with a stress manage ment package and a waiting list control condition. References Preliminary data indicated that both active treatments did significantly better than the waiting list condition, which the authors claimed was not surprising as American Psychiatric Association (1994) Diagnostic and behavioural stress management provided the subjects Statistical Manual of Mental Disorders (4th edn) (DSM-IV). Washington, DC: APA. with a detailed alternative explanation for their Avia, M. D., Ruiz, M., Olivares, M. C., et al (1996) The symptoms and comprehensive treatment based on this meaning of psychological symptoms: effectiveness of a alternative explanation. Further analysis is awaited group intervention with hypochondriacal patients. Behaviour Research and Therapy, 34, 23-31. to determine the relative efficacyof the two treatments. Barsky, A., Geringer, E. & Wool, C. (1988) A cognitive- In an uncontrolled study, Stern & Fernandez (1991) educational treatment for hypochondriasis. Cenerai treated a group of people with hypochondriasis with Hospital Psychiatry, 10, 322-327. Beck, A. T., Emery, G. & Greenberg, R. (1985) Anxiety Disorders CBT. This study had promising results and demon and Phobias:A Cognitive Perspective. Basic Books: New York. strated that group CBT is feasible in a general hospital Bianchi, G. N. (1971) The origins of disease phobia. Australia setting. A controlled trial of group treatment has been and New Zealand Journal of Psychiatry, 5, 241-257. reported, using the cognitive-educational approach Fallón, B. A., Liebowitz, M. R., Salman, E., t'f al (1996) Fluoxetine for hypochondriacal patients without major of Barsky et al (1988) compared with a waiting list depression. Journal of Clinical Pharmacology, 13, 438—441. control (Avia etal, 1996).Treated subjects showed sig Kellner, R. (1986) Somatization and Hypochondriasis. New York: Praeger. nificant reduction in illness fears and attitudes, Kellner, R., Fava, G. A. & Lisansky, J. (1993) Hypochondriacal reported somatic symptoms and dysfunctional beliefs, fears and beliefs in DSM-III melancholia. Journal of Affective while control subjects also changed some illness Disorders, 10, 21-26. Kenyon, F. E. (1964) Hypochondriasis: a clinical study. British attitudes but showed no change in somatic symptoms Journal of Psychiatry, 110, 478-488. and increased their visits to doctors. In a cross-over Salkovskis, P.M. (1989) Somatic problems. In Cognitive- design (Visser & Bouman, 1992)three people received Behavioural Approaches to Adult Psychiatric Disorder: A Practical Guide (eds K. Hawton., P. M. Salkovskis, J. W. exposure and response prevention followed by Kirk, et al), pp. 235-276. Oxford: Oxford University Press. cognitive therapy. Three more subjects were treated & Warwick, H. M. C. (1986) Morbid preoccupations, with cognitive therapy followed by behavioural treat health anxiety and reassurance: A cognitive-behavioural approach to hypochondriasis. Behaviour Research and ment. Four people made significant improvements, and Therapy, 24, 597-602. the behaviour therapy firstoption tended tobe the more — & Bass, C. (1996) Hypochondriasis. In Science and Practice successful. of Cognitive-Behavioural Therapy (eds D. M. Clark & C. G. Fairburn), pp. 313-339. Oxford: Oxford University Press. Stern, R. & Fernandez, M (1991) Group cognitive and behavioural treatment for hypochondriasis. British Medical Journal, 303, 1229-1230. Future research Visser, S. & Bouman, T. K. (1992) Cognitive-behavioural approaches in the treatment of hypochondriasis: Six single case cross-over studies. Behaviour Research and Therapy, 30, 301-306. Further controlled evaluations of CBT for hypochon Warwick, H. M. C. (1992) Provision of appropriate and effective driasis are required to establish its efficacy clearly. reassurance. International Review of Psychiatry, 4, 71-60. Cogllit;vc tlll'rtlpy for11ypocllOlldrins;s APT (1998), vol. 4, p. 291

- & Marks, I. M. (1988) Behavioural treatment of illness 3. Therapists working with hypochondriasis phobia. British Journal of Psychiatry, 152, 239-241. - & Salkovskis, P. M. (1990) Hypochondriasis. Behaviour should: Research and Therapy, 28, 105-117. a not involve relatives in treatment -, Clark, D. M., Cobb, A. M., et al (1996) A controlled trial b discuss appropriate treatment with involved of cognitive-behavioural treatment of hypochondriasis. British Journal of Psychiatry, 169, 189-195. professionals World Health Organization (1992) The Tenth Revision of the c use Socratic questioning International Classification of Diseases and Related Health d not imply that the patient is experiencing real Problems (lCD-10). Geneva: WHO. symptoms e always answer their patients' questions about Multiple choice questions illness. 4. Cognitive-behavioural treatment for hypochon­ 1. In primary hypochondriasis: driasis involves: a sufferers often have high levels of anxiety a homework exercises for the patient b abnormal illness behaviour includes bodily b no 'pure' behavioural strategies checking c no attention to assumptions c sufferers may have secondary depressive d re-attribution symptoms e self-monitoring. d repeated physical examinations should be conducted e dysfunctional assumptions about health are not prominent. MCQanswer 2. People with primary hypochondriasis: 1 2 3 4 a fear immediate death a T a F a a b only ever have concerns about one illness b T b F b T b F c are malingerers c c F c c F d amplify physical sensations d F d d F d T e may have had previous experience of ill- e F e e F e T health.

Cotntnentary Richard Stem

"Hypochondriasis is a condition in which there are people with abdominal pain who had been admitted no established effective treatments" (FaUonet aI, 1991). to a surgical ward. They found that the most common surgical diagnosis was non-specific abdominal Warwick's paper shows how recent advances have pain, closely followed by appendicitis. Those with completely altered the previous therapeutic nihilism non-specific abdominal pain contained a very expressed in the above quotation. Physicians and interesting group of patients: they were predomin­ surgeons have long been aware that medical and antly female, did not have any physical findings, surgical problems turn out to have no organic cause. and were more anxious and conformed to the Joyce et al (1986) from New Zealand examined 105 pattern of patients showing fear of illness. This

Richard Stem is Consultant Psychiatrist, Pathfinder NHS Trust, Springfield University Hospital, 61 Glenbumie Road, London SW17 7OJ. His research and clinical interests include the application of behavioural and cognitive therapy approaches to general psychiatry.