Académique Documents
Professionnel Documents
Culture Documents
Until relatively recently, the treatment of hy- tients with hypochondriacal beliefs suggested
pochondriasis was not considered to be an im- that hypochondriasis is always secondary to an-
portant issue, as this condition was regarded as other primary disorder, usually depression. It
invariably being secondary to depression or was subsequently suggested that hypochondri-
anxiety. Kenyons (1964) inuential study of pa- acal beliefs occurring in the absence of aective
353
SALKOVSKIS, WARWICK, AND DEALE
symptoms were due to masked depression. sis dictates that the preoccupation has to cause
More recently, studies have convincingly identi- clinically signicant distress or impairment in
ed a primary disorder in which false concerns social, occupational, or other important areas of
about health are the central problem, to which functioning.
aective symptoms are secondary (Bianchi, Despite the considerable health care resources
1971). The paper by Barsky and Klerman (1983) utilized by people with hypochondriasis, nei-
marked the reestablishment of hypochondriasis ther physical medicine nor psychiatry has pre-
not only as a recognizable clinical condition but viously established an eective treatment.
also as an important research topic (e.g., As- Hypochondriasis has long been regarded as an
mundsen & Cox, 2001). Primary hypochondri- intractable disorder, with supportive therapy
asis is now included in both ICD 10 (World and reassurance the best that can be oered. To
Health Organization) and DSM-IV (APA, 1994). some extent it has at times also been seen as a
Although hypochondriasis is now accepted nuisance, with some considering it to be akin to
as a primary problem, its taxonomy remains factitious problems and malingering.
controversial. Debate continues as to whether Recently, well-dened cognitive-behavioral
it is best seen as a somatoform disorder (as theories of hypochondriasis have been de-
presently classied) or as an anxiety disorder scribed, and treatment strategies derived from
(Salkovskis & Warwick, 1986; Warwick & Sal- them have been empirically tested in random-
kovskis, 1990). To place this debate in con- ized controlled trials. The evidence from this re-
text, let us examine the diagnostic criteria search strongly suggests that this approach is
presently used. According to DSM-IV, hypo- eective both in engaging these patients in
chondriasis is characterized by preoccupa- treatment and ameliorating the clinical symp-
tion with fears of having, or the idea that one toms. The cognitive-behavioral theory of
has, a serious disease, based on the persons hypochondriasis provides a comprehensive ac-
misinterpretation of bodily symptoms. Thus, count of the psychological processes involved in
the problem is characterized as a cognitive one, the disorder, including etiological and main-
involving erroneous appraisals. Note that this taining factors. Modication of the important
denition bears a strong resemblance to the psychological factors involved in the mainte-
cognitive theory of panic disorder (Clark, 1986; nance of each case should lead to a resolution of
Salkovskis, 1989). The denition requires that the central problemthat is, a false belief that
the preoccupation persist despite appropriate the patient is physically ill, based on the misin-
medical evaluation and reassurance, meaning terpretation of innocuous physical symptoms or
that the failure of a psychological intervention signs, and based on health-related information
(reassurance) by a doctor is required for the di- from professionals, the media, and the Internet.
agnosis to be made. In addition, formal diagno-
Controversial Issues
From the Department of Psychology, Institute of Psychiatry,
Kings College, London (Salkovskis and Deale); from the
Some authors have suggested that health con-
Department of Psychiatry, St.Georges Hospital Medical
School, London (Warwick). cerns are not central to the problem and that it
Contact information: Paul Salkovskis, PhD, Department is not uncommon for secondary gain to be sug-
of Psychology, Institute of Psychiatry, Kings College,
London, SE5 8AF, UK. E-mail: p.salkovskis@iop.kcl.ac.uk. gested as an important motivating factor in
Tel: (+44) 020 7848 5039. Fax: (+44) 020 7848 5037. these cases (see Warwick & Salkovskis, 1990).
2003 Oxford University Press No evidence has been found to support any role
of secondary gain, and ill-judged attempts to ening the hypochondriacal concerns. Lucock,
nd hidden motives for their presentation can Morley, White, and Peake (1997) examined the
alienate patients. In fact, doing so may actually time course and prediction of eectiveness of
increase their fears because they believe that responses to reassurance in 60 patients after
they are unlikely to be taken seriously by those gastroscopy showing no serious illness. Physi-
seeking to help them. Patients feel that their cian and patient rated the extent of reassurance
health concerns are not being given proper con- at the time of the consultation. Patients then
sideration and are likely to seek other sources rated their anxiety about their health and ill-
of physical investigations and help. Patients ness belief at the time of consultation and at four
would understandably be angered by such ap- follow-up sessions: 24 hours, 1 week, 1 month,
proaches and may be hostile to future attempts and 1 year. While health anxiety and illness
to engage them in psychological treatment. Pro- belief decreased markedly after reassurance,
bably the main function of this type of con- patients with high health anxiety showed a
ceptualization is to relieve the clinician of re- signicant resurgence in their worry and ill-
sponsibility for the failure of the patient to re- ness belief at 24 hours and 1 week, which was
spond to their therapeutic eorts. Sadly, maintained at 1 month and 1 year. Those with
variations are all too common on the following low levels of health anxiety maintained low
theme: the patients didnt get better, despite health worry and illness belief throughout. The
my best eorts, because they needed their authors concluded that reduction in worry
problem and therefore couldnt let it go. This and illness belief after reassurance may be very
is not to say that motivational factors never short term and that measurable individual dif-
play a role; however, they are rare, and a good ferences in health anxiety predict response to
therapist should be able to detect these at assess- reassurance.
ment or engagement. That is, there are always
straightforward ways of establishing such func-
tional factors. Development of Cognitive-
To successfully reassure a patient is one of the Behavioral Approaches
most common aims in medicine, and indeed the
diagnosis of hypochondriasis can only be made Some uncontrolled case series have demon-
when this basic medical intervention has failed. strated behavioral treatment of hypochondria-
Some authors (e.g., Kellner, 1983) suggest that sis with promising results (e.g., Warwick &
repeated reassurance should be a component Marks, 1988). Salkovskis and Warwick (1986)
of psychological treatment for hypochondriasis. reported two cases of hypochondriasis that
On the other hand, it has been demonstrated were successfully treated with cognitive-
(Salkovskis & Warwick, 1986; Warwick & Sal- behavioral treatment using a single-case exper-
kovskis, 1985) that repeated reassurance con- imental design with alternating treatments. Not-
taining no new information may lead not only to ing the similarities between hypochondria-
short-term decrease in health anxiety but also a sis and other conditionssuch as panic and
longer term increase in that anxiety and need obsessive-compulsive disorder, in which psy-
for reassurance. They suggest that therapists chological approaches have been successful
who repeatedly carry out discussions, examin- a cognitive-behavioral formulation of the dis-
ations, and investigations in response to the order was developed (Salkovskis, 1989; Salkov-
patients anxiety, rather than clinical indica- skis, Warwick, & Clark, 1993; Warwick & Sal-
tions, may inadvertently be maintaining or wors- kovskis, 1990).
FIGURE 1
Cognitive-Behavioral Model of the Development and Persistence of Health Anxiety (Hypochondriasis)
should lead the patients to reinterpret their in- ect schema-based problems in people suer-
nocuous symptoms and attribute them to a less- ing from health anxiety.
threatening cause. It will also demonstrate that
behaviors such as bodily checking and other
maintaining factors serve to make their prob- Cognitive-Behavioral Treatment
lems worse and should therefore be terminated.
A further intriguing possibility consistent What follows is necessarily a brief overview
with the cognitive-behavioral view described of cognitive-behavioral treatment. The reader
here is raised by the series of studies con- is referred to other sources for more detailed
ducted by Sensky and colleagues (MacLeod, accounts of assessment and treatment (e.g.,
Haynes, & Sensky, 1998; Sensky, MacLeod, & Salkovskis, 1989; Salkovskis & Bass, 1997; Sal-
Rigby, 1996), who noted that patients high in kovskis & Warwick, 1988; Warwick, 1995).
health anxiety found it more dicult than
comparison groups to generate innocuous ac-
General Issues in Assessment
counts of somatic symptoms. This nding
could, of course, be a state eect, so that ele- The principal aim of assessment is to obtain a
vated health anxiety diminishes the accessibil- thorough description of the patients problems
ity of alternative attributions; or it may also re- and psychopathology, which can then be ex-
pressed as the patients own version of the with the extent of their reassurance-seeking be-
cognitive-behavioral formulation. This formula- haviors. Patient and therapist usually commence
tion often identies aspects of the origins and assessment with very dierent expectations and
precipitants of the persons health anxiety. More agendas. The therapist often believes that the
crucially, it incorporates an account of key fac- patient has a psychological problem and that
tors involved in the maintenance of the patients cognitive-behavioral treatment is just what they
health anxiety. In addition, the formulation of- need. Unfortunately, the patients are convinced
ten provides an account of the basis of many of that they have a physical illness and that the last
the symptoms that the patient is experiencing. thing they need is a psychological treatment.
The use of the patients account of episodes of Hence engagement in psychological treatment is
intense health anxiety leads to the development likely to be problematic.
of a comprehensive psychological formulation The therapist must be well aware of these con-
that clearly describes the psychological proces- icting agendas. The style of the therapist as
ses and conrms a positive psychological di- demonstrated in the initial interview is crucial.
agnosis. If the symptoms do not t such a for- The interview should be conducted with pa-
mulation, then the therapist should consider the tience and sympathy, and it must culminate in
genuine possibility of a physical illness. the patients conviction that all their concerns
have been properly considered. The therapist
should acknowledge that the patients physical
Goals of Assessment and
concerns are real and are to be taken seriously.
Engagement
Such patients may well have been previously
Assessment has the following aims: told that their symptoms are all in the mind;
subsequently, they will be watching for evi-
Completion of a thorough comprehensive dence of similar attitudes. Frequent use of sum-
cognitive-behavioral analysis of the pa- maries by the therapist will encourage the
tients problemsincluding symptoms, patients that their concerns are being taken
beliefs, behaviors, and consequences seriously. When discussing the diagnosis and
Identication of the psychological processes treatment, the therapist should communicate to
involved in the case; deciding if a positive the patient that the therapist has seen similar
diagnosis of hypochondriasis can be made cases in the past; doing so is helpful because pa-
Construction of psychological formulation, tients often feel extremely isolated and feel that
developed as a shared understanding with no one can help them with their problems. The
the patient assessment should be used to construct a com-
Helping the patient feel understood prehensive psychological formulation of the pa-
Enabling the patient to consider (a) a pos- tients concerns. A version using actual ex-
sible noncatastrophic (psychological) alter- amples from the patient is drawn up, explaining
native explanation for their problems, and each step to them.
(b) the suggested treatment rationale and
strategies that ow from it
Specifics of Assessment
The specic assessment usually begins once the
Engagement in Assessment
therapist is condent in rmly establishing ba-
Some patients may be too embarrassed to de- sic clinical details and that health anxiety is a
scribe the illnesses that concern them, along major problem for the patient. The therapist
then helps the patients identify a relatively re- gressing to specic anticipated eects, namely:
cent episode during which they were troubled What did that do? At that time, what was the
by high levels of health anxiety. Memory is eect of . . . on the belief that you had multiple
primed by having the patient describe the con- sclerosis?
text. Where were they? Who were they with? Over the period of 30 minutes to an hour, a
What were they doing? Was there an obvious preliminary maintenance formulation is thus
trigger? derived, identifying
The rst signs that an episode of increased
health anxiety are identied; these are usually triggers;
physical symptoms, although sometimes they meaningincluding perceived probability,
may be information about someone elses being cost, coping, and rescue factors; and
ill, information in the media, or it may even maintenance factorsthose directly driven
be emotional stress not directly related to the by negative meanings and those motivated
health anxiety (such as a marital argument). by them.
Once the initial trigger is identied, questioning
takes the form of guided discovery that pro- All of which form the basis of the subsequent
gresses toward an interlocking set of idiosyn- engagement eorts.
cratic vicious circles (based on the model in Fig-
ure 1); the maintenance cycles are often referred
Engagement
to as a vicious ower formulation, referring to
the structure of the basic feedback loops illus- The patients previous, illness-based view of
trated in the patient example shown in Figure 2. their problems is then elicited and discussed.
These are derived through carefully sequenced The patients usually accept that following this
questioning, namely: So the rst thing you no- approach has not resolved their problems. The
ticed was tingling ngers. When you noticed psychological formulation is then discussed as
your ngers tingling, what went through your an alternative hypothesis. If, on the basis of this
mind at that time? discussion, the patients accept the possibility
If the answer is vague, the questioning is that their problems could be explained by the
pressed, as in And at that time, did that seem to psychological formulation, then they are oered
you to be the very worst thing this tingling a brief course of treatment using psychological
could mean? A belief rating (0100) for the de- techniques. The therapists need to stress that if,
rived illness-related belief is taken. The ques- after the treatment, the patients are still con-
tioning continues by eliciting the responses vinced they are physically ill, then they will be
to the negative interpretation: When you able to seek further physical treatment.
thought this tingling meant you had Multiple
Sclerosis, how did that aect you at that mo-
From Formulation to Therapy
ment? A range of specic follow-up questions
are used to elicit the main response domains: Therapy is uid, idiosyncratic, and formulation-
How did it make you feel? What did you do? led. Initial sessions focus on testing out the
What did you pay attention to? How did you try vicious ower formulation and accumulating
to deal with it? The way in which these re- evidence for an anxiety-based, rather than a
sponses aected the interpretation and symp- disease-based, explanation. This objective takes
toms themselves are then probed, again starting place through an interweaving of discussion
with a more general open query and then pro- and behavioral experiments. As therapy pro-
FIGURE 2
Specific Application of the Cognitive-Behavioral Model to a Clinical Case
ceeds, safety behaviors are dropped, and other anxiety occur. Doing so provides information
maintaining factors reversed. In later sessions, about the particular triggers for health anxiety.
assumptions are examined, and a relapse pre- It also shows up (a) activities that may be re-
vention plan is developed. stricted or avoided as a direct result of health
anxiety (e.g., fear of having heart disease leads
to avoidance of exertion), and (b) those that are
Self-Monitoring
carried out only because of the health concern
Once a preliminary vicious ower formula- (e.g., taking pulse, going to the doctor). Pa-
tion has been drawn up in session, patients are tients may express surprise when they see how
often asked to draw out more vicious ow- much time and eort they devote to health
ers for further episodes of health anxiety that anxiety, which can provide useful evidence
occur during the week. Doing so helps to so- regarding the eects of attention and bodily
cialize them into the vicious ower model focusing.
and to nd out how well it ts with their ac- Second, patients may be asked to monitor
tual experiences. The information gathered the next few episodes of health anxiety. They
can be fed into a generic vicious ower, with are provided with a record sheet (see Table 1)
more petals. in which they record triggering symptoms or
Patients may also be asked to monitor two as- events, level of health anxiety, thoughts about
pects of their problem. First, they may keep a health, and action taken. Like all negative auto-
brief record of a complete weeks activities, matic thoughts, health-anxious thoughts can be
noting when physical symptoms and health dicult to access at rst. Patients are asked to
plain away every symptom is that it can become clude tensing muscles to bring on pain, or run-
a form of reassurance. Questioning beliefs about ning up and down stairs to bring on breathless-
symptoms is best used as a springboard for be- ness and chest pain. If the exact or similar sen-
havioral experiments. The results of verbal reat- sations to those involved in the patients con-
tribution and behavioral experiments can be col- cerns can be reproduced, it helps to disconrm
lected in an ongoing log, such as the dual model a catastrophic interpretation and thus build up
strategy (Wells, 1997). This log collates evi- belief in the alternative explanation.
dence that supports both a disease-based and
cognitive-behavioral explanation, and includes Dropping Safety-Seeking Behaviors. Safety be-
a reframing of each piece of evidence that sup- haviorschecking, reassurance seekingmain-
ports a disease-based explanation. tain health anxiety. Patients can test out the
eects of these behaviors for themselves by
conducting an alternating treatment experi-
Behavioral Experiments
ment. This experiment involves, rst, increasing
Behavioral experiments can help the target behavior for a daysuch as bodily
checking and information seekingand, sec-
1. establish that a feared catastrophe will not ond, monitoring anxiety, bodily symptoms, and
happen; strength of belief at regular intervals. On the
2. discover the importance of maintaining next day, the patient has to completely ban car-
factors; rying out the target behavior; but once again,
3. discover the importance of negative anxiety, symptoms, and strength of belief are
thinking; monitored at intervals. The resulting data is re-
4. nd out whether an alternative strategy viewed and graphed at the next session. Patients
will be of any value; and are often surprised at how much worse they feel
5. generate evidence for a non-disease-based on the day in which the target behavior is in-
explanation. creased, and this experiment normally leads to a
decision to drop the target behavior completely.
tion can then be scheduled as worry time, proaches usually leads to the decision to reduce,
prior to phasing it out altogether. and then stop, reassurance seeking.
Images associated with health anxiety can be Relatives and friends of those suering hypo-
powerful and convincing. They may be seen as chondriasis are often bombarded with requests
predictive, and they may stop short before, or for reassurance, from the blatantDo you
at, a catastrophic point. The procedure just de- think this lump is cancer?to the more
scribed can be helpful in demonstrating the covertjust mentioning something (I noticed
eect of imagery on anxiety and disease convic- a lump here, but Im not worried about it) or
tion. The patients may be encouraged to either showing an area that is causing concern but
nish out the image by visualizing what hap- without saying anything. It is very helpful to in-
pens next or modify the image and note the vite relatives to a session in which reassurance is
eect on anxiety and disease conviction. discussed. The patient can be asked to describe
what they have learned about how reassurance
maintains health anxiety, and to list for the rel-
Persistent Reassurance Seeking
atives all the dierent ways in which reassur-
Managing persistent requests for reassurance ance is sought. Patients are given the responsi-
has several components. The formulation is usu- bility for withholding requests for reassurance,
ally the rst step in demonstrating the adverse but they and their relatives may need to identify
eects of reassurance. This step can be taken other topics of conversation. They may need to
forward by enquiring about what happens to rehearse ways of talking about the health anxi-
symptoms when patients receive reassurance. If ety and being supportive without asking for or
the symptoms get better, what does that suggest giving reassurance.
about the cause? Would a serious disease work
this way? Patients may believe that reassurance
Dealing with Medical Consultations
is helpful, as it makes them feel better. It is im-
portant to draw out the short-term nature of any Other professionals may unwittingly be pro-
benets and its addictiveness. One technique viding repeated inappropriate reassurance and,
for doing so is to oer the patient a session of hence, reinforcing the problem. These profes-
unlimited reassurance, provided they will guar- sionals should be contacted and asked to carry
antee that it will last for the rest of the year (see out tests and examinations only when clinically
Salkovskis & Bass, 1999, for an example). This indicated, not when prompted by the patients
technique usually results in patients identify- anxiety. Patients are asked to reduce the fre-
ing for themselves that the eect is short-lived. quency of consultation: many will worry that
It is often helpful to carry out a detailed cost- doing so may lead to something important being
benet analysis of reassurance seeking. The aim missed. This anxiety can be addressed through
is to contrast the small number of short-term programmed postponement, which intro-
benets with the immediate, longer-term costs duces a delay between noticing and acting on
to both patients and their families. Patients may symptoms. A time period is agreed, based on the
write this exercise out on a ashcard, to use length of time it normally takes for a symptom to
when they are trying to break the habit of reas- die down (e.g., 10 days). When patients become
surance seeking. It can be followed with an al- concerned about a new or more intense symp-
ternating treatment experiment involving a day tom, they are asked to make a note in their diary
of reassurance seeking followed by a day with- for 10 days ahead. At this time, if the symptom
out reassurance. A combination of these ap- is still present, they will take action (e.g., visit
ment, possible triggers should be identied. The play an important part in severe and persistent
waiting-list control lasted for 4 months and was health anxiety.
followed by 16 sessions of cognitive-behavioral In an uncontrolled study, Stern and Fernan-
treatment. Assessments were made before allo- dez (1991) treated a group of patients with hypo-
cation and after treatment or waiting-list con- chondriasis with cognitive-behavioral treat-
trol. Patients who had cognitive-behavioral ment. This study had promising results and
treatment were reassessed three months after demonstrated that group cognitive-behavioral
completion of treatment. Paired comparisons treatment is feasible in a general hospital set-
on posttreatment/wait scores indicated that ting. A controlled trial of group treatment has
the cognitive-behavioral group showed signi- been reported, using the cognitive-educational
cantly greater improvements than the wait list approach put forward by Barsky, Geringer, and
on all but one patient rating, on all therapist rat- Wool (1988) compared with a waiting list con-
ings, and on all assessor ratings. After 3 months, trol (Avia et al., 1996). Experimental subjects
the benets of therapy were maintained. showed signicant reduction in illness fears and
While this study suggests that cognitive- attitudes, and they reported somatic symptoms
behavioral treatment is an eective therapy for and dysfunctional beliefs. Waiting-list controls
hypochondriasis, the study has limitations. changed some illness attitudes, but they showed
First, only one therapist was used. It is neces- no change in somatic symptoms and hence in-
sary to establish that similar results can be ob- creased their visits to doctors. In a crossover de-
tained by other suitably trained therapists. Sec- sign (Visser & Bouman, 1992), 3 patients re-
ond, the waiting-list group did not control for ceived exposure and response prevention fol-
the eects of attention, although it is unlikely lowed by a block of cognitive therapy. Three
that attention alone could have brought about more patients were treated with cognitive ther-
the improvements seen in the treated group. apy followed by behavioral treatment. Four pa-
In a second controlled study (Clark et al., 1998), tients made signicant improvements, with the
a number of therapists carried out cognitive- behavior therapy as rst option tending to be
behavioral treatment that was compared with a the more successful strategy. The description of
stress-management package and a waiting-list cognitive therapy used in the study suggests
control. At the end of active treatment, both that its components diered from that used in
treatments did signicantly better than the wait- other studies, thus making the results hard to
ing-list condition, while cognitive-behavioral interpret.
treatment was signicantly better on several
key measures. At the 1-year follow-up, the di-
erences between the two treatments were Future Research
greatly diminished. The authors suggested that
this result was not surprising, as behavioral Further controlled evaluations of cognitive-
stress management provides patients with a de- behavioral treatment of hypochondriasis are re-
tailed alternative explanation for their symp- quired to clearly establish its ecacy. Follow-up
toms and a comprehensive treatment based on studies are in progress to examine the longer-
this alternative explanation. This treatment in- term ecacy of the approach. Future studies
cluded the engagement strategies developed as should attempt to discover which of the com-
part of cognitive therapy to ensure nondieren- ponents of cognitive-behavioral treatment are
tial dropout rates. This study also raises the most eective, in an eort to make the treatment
intriguing possibility that general stress may briefer and more easily accessible. Similarly,
further controlled trials in a group setting are Two psychological treatments for hypochondria-
needed, as this method of delivery should be sis: A randomised controlled trial. British Journal
more cost-eective. Future studies are also of Psychiatry, 173, 218225.
needed to examine the ecacy of cognitive- Kellner, R. (1983). Prognosis in treated hypochon-
behavioral treatment in cases of hypochondria- driasis. Acta Psychiatrica Scandinavica, 67, 6979.
Kenyon, F. E. (1964). Hypochondriasis: A clinical
sis occurring in medical settings. It may be that
study. British Journal of Psychiatry, 110,
such cases are more dicult to treat, as such pa-
478488.
tients may be more reluctant to consider psy- Lucock, M. P., Morley, S., White, C., & Peake, M. D.
chological treatment. It is also necessary to see (1997). Responses of consecutive patients to reas-
if the approach can be modied for those with surance after gastroscopy: Results of self-
a number of related concernsfor example, administered questionnaire survey. British Med-
those with real physical illnesses whose anxi- ical Journal, 315, 572575.
eties are thought to be excessive, or for those MacLeod, A. K., Haynes, C., & Sensky, T. (1998). At-
presenting in general practice settings with so- tributions about common bodily sensations: their
matic complaints that are not yet as severe as associations with hypochondriasis and anxiety.
hypochondriasis. Psychological Medicine, 28, 225228.
Salkovskis, P. M. (1989). Somatic problems. In K.
Hawton, P. M. Salkovskis, J. W. Kirk, & D. M.
References Clark (Eds.), Cognitive-behavioural approaches to
adult psychiatric disorder: A practical guide. Ox-
American Psychiatric Association. (1994). Diagnos- ford: Oxford University Press.
tic and statistical manual of mental disorders (4th Salkovskis, P. M. (1996). Cognitive-behavioral ap-
Ed.). Washington, DC: APA. proaches to the understanding of obsessional
Avia, M. D., Ruiz, M., Olivares, M. C., Guisado, problems. In R. Rapee (Ed.), Current controversies
A. B., Sanchez, A., & Varela, A. (1996). The mean- in the anxiety disorders (pp. 103133). New York:
ing of psychological symptoms: eectiveness of a Guilford Press.
group intervention with hypochondriacal pa- Salkovskis, P. M., & Bass, C. (1997). Hypochondria-
tients. Behaviour Research and Therapy, 34, 2331. sis. In D. M. Clark & C. G. Fairburn (Eds.), Science
Barsky, A., Geringer, E., & Wool, C. (1988). A and practice of cognitive behaviour therapy. Ox-
cognitive-educational treatment for hypochon- ford: Oxford University Press.
driasis. General Hospital Psychiatry, 10, 322327. Salkovskis, P. M., & Warwick, H. M. C. (1986). Mor-
Barsky, A. J., & Klerman, G. L. (1983). Overview: bid preoccupations, health anxiety and reassur-
Hypochondriasis, bodily complaints, and somatic ance: A cognitive-behavioural approach to
styles. American Journal of Psychiatry, 140, hypochondriasis. Behaviour Research and Ther-
273283. apy, 24, 597602.
Beck, A. T., Emery, G., & Greenberg, R. (1985). Salkovskis, P. M., & Warwick, H. M. C. (1988). Cog-
Anxiety disorders and phobias: A cognitive perspec- nitive therapy of obsessive-compulsive disorders.
tive. New York: Basic Books. In C. Perris, I. Blackburn, & H. Perris (Eds.), The
Bianchi, G. N. (1971). The origins of disease phobia. theory and practice of cognitive therapy. Heidel-
Australia and New Zealand Journal of Psychiatry, burg: SpringerVerlag.
5, 241257. Salkovskis, P. M., Warwick, H. M., & Clark, D. M.
Clark, D. M. (1986). A cognitive approach to panic (1993). Panic disorder and hypochondriasis.
disorder. Behaviour Research and Therapy, 24, Advances in Behavior Research and Therapy, 15,
461470. 2348.
Clark, D. M., Salkovskis, P. M., Hackmann, A., Sensky, T., MacLeod, A. K., & Rigby, M. F. (1996).
Wells, A., Fennell, M., Ludgate, J., et al. (1998). Causal attributions about common somatic sensa-
tions among frequent general practice attenders. Warwick, H. M. C., Clark, D. M., Cobb, A. M.,
Psychological Medicine, 26(3), 641646. & Salkovskis, P. M. (1996). A controlled trial of
Stern, R., & Fernandez, M. (1991). Group cognitive cognitive-behavioural treatment of hypochondri-
and behavioural treatment for hypochondriasis. asis. British Journal of Psychiatry, 169, 189195.
British Medical Journal, 303, 12291230. Warwick, H. M. C., & Marks, I. M. (1988). Behav-
Visser, S., & Bouman, T. K. (1992). Cognitive- ioural treatment of illness phobia. British Journal
behavioural approaches in the treatment of of Psychiatry, 152, 239241.
hypochondriasis: Six single case cross-over stud- Warwick, H. M. C., & Salkovskis, P. M. (1985).
ies. Behaviour Research and Therapy, 30, Hypochondriasis. British Medical Journal, 290,
301306. 1028.
Warwick, H. M. C. (1995). Assessment of Warwick, H. M. C., & Salkovskis, P. M. (1990).
hypochondriasis. Behaviour Research and Ther- Hypochondriasis. Behaviour Research and Ther-
apy, 33(7), 845853. apy, 28, 105117.