Chapter four

Hypochondriasis

Hilary M.C.Warwick1 and Paul M.Salkovskis2

Introduction

Hypochondriasis is defined in DSM III-R as an unrealistic interpretation of bodily sensations, leading to preoccupation with the fear of, or belief that one has, a serious disease, despite medical reassurance (American Psychiatric Association 1987). There are no reliable estimates of the prevalence of hypochondriasis, but it has been estimated that 30–80 per cent of patients who consult physicians, present with symptoms for which there is no physical basis (see Barsky and Klerman 1983). Despite the implications for resources at all levels of medical practice, current treatment of hypochondriasis is unsatisfactory and its prognosis is generally regarded as poor (Nemiah 1985), indicating the need for new approaches to understanding and treatment of this problem.

We have recently suggested a cognitive-behavioural approach to the condition and reported the successful treatment of two cases using cognitive-behavioural strategies (Salkovskis and Warwick 1986; Warwick and Salkovskis 1985, 1987). This chapter briefly summarises the model and gives a detailed account of assessment and treatment based on it, illustrated by case examples. The hypothesised maintaining factors and the efficacy of the treatment approach have yet to be fully experimentally validated, although preliminary results are encouraging.

As the DSM III-R definition suggests, hypochondriasis can be a fear of or belief in a serious illness. It is not clear whether two distinct subgroups are described within the category. Pilowsky (1967) utilised a factor analytic approach to investigate this question, and found that three dimensions of hypochondriasis could be identified—bodily preoccupation, disease phobia, and disease conviction. His study provides support for the view that separate conditions may exist, consistent with the clinical impression of the validity of such a distinction (e.g. Bianchi 1971; Leonhard 1968; Marks 1987; Ryle 1947). However, no studies have attempted to differentiate hypochondriasis and illness phobia in terms of symptoms experienced and extent of avoidant behaviours exhibited (such as reassurance seeking and avoidance of illness-related situations). It is likely that these behaviours occur to some extent in most patients and it may also be the case that patients fluctuate between disease conviction and fear that they may contract a disease, depending on their levels of anxiety. Table 4.1 summarises the core clinical and psychological features of hypochondriasis from a cognitive-behavioural perspective, derived from a review of the literature (Warwick and Salkovskis 1987).

Table 4.1 Core features of clinical conditions characterised by anxiety about health

1.Preoccupation with health

2.Insufficient organic pathology to account for the concerns expressed

3.Selective attention to bodily changes or features

4.Negative interpretation of bodily signs and symptoms

5.Selective attention to and disbelief of medical and non-medical communications

6.Persistent seeking of reassurance/checking bodily status/information.

Cognitive-behavioural hypothesis

The cognitive hypothesis addresses factors involved both in aetiology and in the maintenance of hypochondriasis. Treatment mostly emphasises the modification of maintaining factors, although for specific patients a formulation in which both are considered is sometimes helpful, as will be described below.

The cognitive view of the development of hypochondriasis set out in Figure 4.1 proposes that attitudes and dysfunctional assumptions related to health are formed, usually, as part of early experience. Note, however, that these assumptions should not be regarded as static and may be modified by later experience and information. Such assumptions can also lead the patient

46 COGNITIVE THERAPY IN CLINICAL PRACTICE

Figure 4.1 Cognitive-behavioural model of the development of hypochondriacal problems

selectively to attend to information consistent with having an illness, and selectively to ignore or discount evidence indicating good health. Thus, particular assumptions tend to produce a confirmatory bias in the patient’s thinking once a critical incident has resulted in the misinterpretation of bodily symptoms and signs as being indications of serious illness. Critical incidents are events which specifically mesh with and serve to activate dysfunctional assumptions. These range from the death of a close relative from a previously undiagnosed illness to hearing information about a particular illness on the radio or television. Sometimes the critical incident is the occurrence of a particular symptom or noticing a bodily change. This leads to the increased likelihood that distressing thoughts (or images) of illness may occur, or that previously unnoticed sensations are focused on and misinterpreted. The physiological, cognitive, affective, and behavioural correlates of these negative thoughts and their interaction with the beliefs held by the patient then play a vital role in the degree to which the anxiety about health persists or simply fades.

The perception of bodily changes or symptoms is followed by negative automatic thoughts concerning danger or threat. Such thoughts are most commonly misinterpretations of normal bodily variations (variations in normal bodily appearance, sensations, or functions). The belief that these sensations are indications of a dangerous physical condition is usually based on what the patient regards as convincing evidence. Such evidence most commonly stems from particular idiosyncratic beliefs about health along with persist symptoms in the absence of any satisfactory and believable alternative interpretation. Information (simple reassurance) will only be helpful at this stage if it is relevant to patients’ evidence that they are ill, and if it is both relevant and new, rather than bland reiteration. Trying to convince such patients that they do not have a particular illness is seldom effective unless accompanied by a satisfactory alternative account of their problem.

We hypothesise that three main mechanisms operate to further increase anxiety, preoccupation with illness, and the misinterpretation of bodily variations and hence result in the persistence and maintenance of anxiety, symptoms, and