The Treatment of Hypochondriasis

By Lori R. Riddle-Walker, MFT

Hypochondriasis is a “preoccupation with fears of having, or the idea that one has, a serious disease based on the person’s misinterpretation of bodily symptoms.” These fears continue even after appropriate medical evaluation shows no illness and, for a diagnosis of hypochondriasis, must cause clinically significant distress or impairment in functioning (American Psychiatric Association, 2002, p 507).

Hypochondriasis develops in the context of a biological predisposition to anxiety, difficult illness or death related experiences and stressful life events (Walker & Furer, 2008) and may be a way of avoiding more pressing issues (Taylor, Asmundson, & Coons, 2005). Research indicates that cognitive behavioral therapy (CBT) is an effective treatment.

The elements included in CBT for hypochondriasis differ. Common techniques include education about symptoms, education about the selective perception of symptoms (bodily sensations increase due to focus, presence of anxiety, and vigilance for new symptoms), persuasion, exposure response prevention, and the prevention of reassurance seeking (Magariños, Zafar, Nissenson, & Blanco, 2002).

Taylor, Asmundson, and Coons (2005) add a reminder about the importance of a medical evaluation first, list relaxation training as well as cognitive restructuring as useful (i.e. keeping negative thought records which are then used to help teach the development of more rational responses). They also include the element of therapist openness, acceptance, warmth and empathy as especially important for hypochondriacs because they generally feel they are not understood by professionals. The importance of eliminating checking behavior, avoidance and other maladaptive behaviors, including conversations about illness, is emphasized. Stimulus control is mentioned as a way to reduce worry (what triggers worry and how it is reinforced).

Another treatment for hypochondriasis that is being researched is interoceptive exposure which, for hypochondriasis, is defined as producing bodily sensations, focusing on the sensations without trying to end them, trying to maintain the sensations and repeating this process until there is no distress from the symptom. A drawback to this approach is that it is difficult to deliberately produce some sensations at will. Techniques that have successfully overcome this difficulty are to 1) focus one’s attention on the associated part of the body, 2) capture the opportunity to focus when the sensations occurs, and 3) use imaginal exposure by creating narratives about the feared symptoms, illness, and outcome (Walker & Furer, 2008).

Other important behavioral techniques that are closely tied to interoceptive exposure are the use of behavioral experiments (i.e. having a healthy patient who fears heart problems do aerobic exercise), response prevention for bodily checking and reassurance seeking, exposure to illness related situations (i.e. hearing or reading about an illness), reduction of safety behaviors (i.e. carrying a cell phone to call for help) and reduction of cognitive distraction during exposure.

For patients with hypochondriasis, distress about bodily sensations can be a vicious cycle. Autonomic arousal due to fear intensifies sensations which then in turn increase fear (Barlow, 2008). Often those who are finally referred by their primary care doctors for psychological treatment are difficult cases due to poor insight and length of illness. It is not unusual for fears about illness to even reach delusional states. An additional challenge in treating this disorder as a non-medical provider is the risk that there is underlying physiological pathology, thus contact with the primary care physician is critical, especially if new concerns arise.

REFERENCES

American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders (4th Edition). Washington, DC: American Psychiatric Association.

Barlow, D. (2008). Clinical Handbook of Psychological Disorders-A Step-by-Step Treatment Manual (4th Edition). New York, NY: The Guilford Press.

Magariños, M., Zafar, U., Nissenson, K., Blanco, C., (2002). Epidemiology and treatment of hypochondriasis. Therapy in Practice, 16(1), 9-22.

Taylor, S., Asmundson, G., Coons, M., (2005). Current directions in the treatment of Hypochondriasis. Journal of Cognitive Psychotherapy: An International Quarterly 19(3), 285-304.

Walker, J., Furer, P., (2008). Interoceptive exposure in the Treatment of Health Anxiety and hypochondriasis. Journal of Cognitive Psychotherapy: An International Quarterly, 22(4), 366-378. doi: 10.1891/0889-8391.22.4.366