Paul Salkovskis (a frequent contributor to this forum) has written and excellent chapter on "Somatic Problems" which discusses the treatment of hypochondriasis in detail. It can be found in: Hawton, K., Salkovskis, P.M., Kirk, J. & Clark, D.M. (Eds.) (1989). Cognitive BehaviourTherapy for Psychiatric Problems: A Practical Guide. from Oxford University Press. I'll summarize his main points and add a few comments of my own.

Hypochondriasis can be understood in terms of a self-perpetuating cycle: (1) a triggering event (possibly new information, an event, an illness, a symptom, an image, ...) leads the individual to conclude that they face a threat to their health, (2) the perception of threat leads to apprehension and anxiety, (3) this anxiety produces physiological arousal, an increased focus on bodily sensations, and checking behavior and/or reassurance-seeking, (4) these three factors contribute to preoccupation with perceived alterations or abnormalities in bodily sensations, and (5) the individual interprets these bodily sensations as indicating a serious illness. This interpretation increases the individual's perception of threat, which results in greater apprehension and anxiety, greater physiological arousal, focus on bodily sensations, and checking and/or reassurance-seeking, greater preoccupation, etc. Salkovskis argues that both misinterpretation of symptoms and checking and/or reassurance-seeking are particularly important factors in hypochondriasis.

Many individuals who see their problems as medical react to a referral to a therapist as though they are being told that they are "crazy" or that "it's all in your head." It is important to lay a foundation for working collaboratively with the client by:

• Making it clear that you are taking them seriously and treating them with respect.


• Explaining that psychological interventions can be useful with many medical problems.


• Emphasizing that the initial goal is to develop an understanding of their problems and to figure out whether psychological interventions can be helpful to them.

Salkovskis proposes eight general principles for CBT with somatic problems (including hypochondriasis):

1. The aim is to help the patient identify what the problem is, not what the problem is not.


2. Acknowledge that the symptoms really exist - and that the treatment aims to provide a satisfactory explanation for the symptoms.


3. Distinguish between giving relevant information as opposed to reassuring with irrelevant or repetitive information.


4. Treatment sessions should never become combative; questioning and collaboration with the patient is the preferred style, as in Cognitive Therapy in general.


5. The patient's beliefs are invariably based on evidence which they find convincing; rather than discounting a belief, discover the observations which the patient believes to be evidence of illness and then work collaboratively with the patient on that basis.


6. Set a limited period contract which fulfils the therapist's requirements while respecting the patient's worries.


7. The selective attention and suggestibility typical of many patients should be used to demonstrate the way in which anxiety can arise from inoccuous circumstances, symptoms, and information.


8. What the patients have understood about what has been said during treatment sessions must always be checked by asking them to summarize what has been said and its implications for them.

With hypochondriasis it is important to identify the patient's misinterpretations of symptoms and sensations and to collaboratively look critically at the evidence which convinces them that these symptoms and sensations are signs of serious illness. It is also important to help them realize that constantly checking on their health status and seeking reassurance is counterproductive. These behaviors are typically intended to reduce anxiety but inadvertantly increase anxiety overall. Once the patient understands this, it can be very useful to have them intentionally refrain from checking and reassurance-seeking and tolerate the temporary increase in their anxiety which results. This approach is based on the same principles as exposure and response-prevention for obsessive-compulsive disorder and produces the same improvement if the patient can persistently refrain from checking and reassurance-seeking (and the therapist can refrain from providing reassurance and instead help the patient cope effectively with their oncerns).

If the patient believes that their worry, vigilance, checking, or other precautions have been "keeping them safe" from disaster, it is important to test this belief and eliminate the avoidance behavior. It sometimes can be useful to help patients formulate adaptive "rules of thumb" regarding how to cope effctively with concerns and symptoms. It can also be helpful to help the client learn effective techniques for coping with anxiety, such as exercise, relaxation techniques, worry-time, etc.