56 COGNITIVE THERAPY IN CLINICAL PRACTICE

to swallow reinforced the idea that the cause of her difficulty was the repeated behaviour and preoccupation with the symptom rather than an organic cause. The patient had, in this way, constructed and tested an alternative explanation for her symptoms, and been able to bring about the required reattribution.

After two sessions of monitoring thoughts and testing the effects of her behaviours (continued between the sessions), she was asked to stop the abnormal behaviours related to the symptoms. Despite the success of these interventions, the therapist was not content to continue treatment on this basis alone. Attempting to find an alternative explanation for every feared symptom has a limited usefulness when the patient has fears about a wider range of symptoms than normal because of more general beliefs and assumptions. In the next session, dysfunctional assumptions were considered, focusing on those which were leading to the misinterpretation of normal bodily sensations and variations. We had previously identified the assumption that ‘Both sides of the body must be identical or there is something wrong’ and her initial belief was 100 per cent. She was then asked to look at her hands to see if they were identical, and to check if they felt identical and was able to identify several differences in both appearance and sensations. She was asked to inspect the therapist’s hands to see if they were identical and again found differences. Other evidence, such as taking different sized left and right shoes, was generated. Internal structure was considered, as she regarded internal changes as more dangerous, and the asymmetrical distribution of major organs was explained and accepted. At the end of this session she rated her belief in the original assumption as 30 per cent. Homework was to cease ‘preventive’ ritualising during her daily activites and avoidance.

After three sessions she was much improved but was concerned that her symptoms had not disappeared altogether. Discomfort was associated with the automatic thought ‘It’s come back’ and the urge to check. Further explanation of the frequency of symptoms in normal individuals dealt with this concern.

At the time of writing, the patient does no checking in direct response to symptoms and has stopped 75 per cent of her ‘preventive measures’. The latter had been performed very frequently for a long period and had themselves almost become automatic. As she prevented some behaviours, she became more aware of other behaviours which she had not recalled during initial assessment. She is continuing, with vigilance, to decrease these activities. She rates a 50 per cent improvement in her preoccupation with symptoms and is 100 per cent convinced that the hypothesis generated in the first session adequately explains her problems.

Case 3

This case is an example of disease conviction which was associated with acute distress, depressed mood and fleeting suicidal thoughts, which required rapid treatment. A 29-year-old married ambulance driver had a 15-year history of anxiety associated with intrusive thoughts about his health. In the past he had been afraid that he had contracted hepatitis, cancer, and multiple sclerosis, and exhibited a variety of avoidant behaviours in response to thoughts about illness.

Over the month prior to this consultation, he had become increasingly alarmed that he might contract AIDS. He had no history of homosexual contact, but thought that he might be at risk through contact with infected blood, when dealing with trauma cases. He had worked in Sydney three years previously and dealt with AIDS cases; since that time he had wondered about the risks occasionally and kept a mental note of about half a dozen drug addicts he had dealt with. Publicity about AIDS increased during the weeks prior to consultation and the media gave inconsistent reports of the ways in which the condition could be contracted. A colleague was in hospital with an undiagnosed viral illness and his wife had lost a considerable amount of weight. He began to avoid dealing with high-risk cases whilst at work and refused to touch any patient unless he was wearing two pairs of gloves—in case they had unknowingly had a transfusion of infected blood. On his return from a call he would fill the gloves with water to ensure that they had not been punctured; an action which caused much comment amongst his colleagues. He checked his appearance for evidence of weight loss every thirty minutes, asked his wife for re-assurance frequently and palpated his neck for swollen lymph glands. Sexual contact with his wife was avoided and he was reluctant to touch his daughter.

Following an incident at work when he injured his hand whilst dealing with a homosexual patient, he developed a coincidental viral infection with symptoms of malaise and enlarged lymph glands—both described in the media as typical symptoms of early AIDS infection. He was convinced that he had AIDS and became acutely distressed with fleeting suicidal thoughts.

A cognitive-behavioural analysis of the problem resulted in the following formulation. His previous fears of illness had led to the following dysfunctional assumptions: ‘If I don’t worry about my health, I am more likely to fall ill’, ‘I have a high risk of falling ill’, and ‘Health workers have a very high risk of contracting illness’. These assumptions had been activated intermittently during the preceding weeks by publicity about the condition and he had been experiencing automatic thoughts, e.g. ‘I may have AIDS’. He continued to carry out preventive measures to minimise the perceived risks and to ensure that he did not infect his family. However, the two final critical incidents described above were associated with automatic thoughts, ‘I have got AIDS’, ‘I will have caused my family to become ill and die’. This analysis is summarised in Table 4.3.

HYPOCHONDRIASIS 57

Table 4.3 Cognitive-behavioural analysis of Case 3

At the beginning of the first consultation, depression was rated at 65 on a 0–100 scale; belief that he had AIDS was 100 per cent. Initially, the critical incidents were discussed in an effort to generate rational responses to the automatic thoughts. Evaluating the risk of contact with blood which may have been infected during the critical incident led to discussion of how long the HTLV-III virus could survive in the atmosphere and how big an injury would be necessary to contract AIDS. There was no change in belief or depression—the therapist had fallen into the trap of discussing the probability of intrusive thoughts being true and attempting to provide reassurance that there was no risk of contracting AIDS in this way. Such an intervention is not likely to be effective, as we have already seen (Salkovskis and Warwick 1986; Warwick and Salkovskis 1985). It was then decided to challenge the assumption that health workers are at risk of contracting AIDS. This intervention is summarised in Table 4.4, and was successful; final belief that he had AIDS was 30, and depression rated at 50. He felt able to stop the checking, reassurance seeking and preventive behaviours and resumed normal contact with his family. He stopped wearing gloves for routine cases at work, and dealt with a case of AIDS with no anxiety. Currently, his belief that he has AIDS is rated at 0 and he has no other hypochondriacal concerns.

Table 4.4 Cognitive intervention in Case 3

Evidence for the assumption

1. ? one health worker has contracted the AIDS virus by accidental injection of infected blood.

Evidence against the assumption

1.There is no increased incidence of AIDS in colleagues in Sydney or San Francisco, where they have more cases of AIDS than we do.

2.Paramedics and ambulance men have not changed their practice in Sydney or San Francisco.

3.Paramedics in Sydney and San Francisco do more direct work and have more contact with their cases than British ambulance men.

4.I know that all of my colleagues have cut themselves on duty, so it is reasonable to assume that foreign colleagues have also. Some of my colleagues have been jabbed accidentally with needles, as will have foreign colleagues.

5.Evidence 1–4 applies to doctors and nurses working in Sydney and San Francisco.

6.No increase in AIDS antibodies in health workers in Sydney or San Francisco. They have had the condition for much longer than us and the antibodies are detectable after 3 months, so it would have shown up by now.

7.They are not barrier nursing at new AIDS wards, as they do for hepatitis.

8.No instructions from ambulance service chiefs to change practice.

9.Wife’s family and friends in the Australian health service would have contacted us if there had been any increase.