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Hypochondriasis and Health Anxiety Jonathan S. Abramowitz · Autumn E. Braddock Advances in Psychotherapy Evidence-Based Practice  Hypochondriasis and Health Anxiety This document is for personal use only. Reproduction or distribution is not permitted. From J. S. Abramowitz & A. E. Braddock: Hypochondriasis and Health Anxiety (ISBN 9781616763251) © 2011 Hogrefe Publishing.  About the Authors Jonathan S. Abramowitz, PhD, is Associate Chair of Psychology and Professor and Director of the Anxiety and Stress Disorders Clinic at the University of North Carolina at Chapel Hill. He has authored or edited ten books and over 100 research articles and book chapters on anxiety and related disorders. He serves as Associate Editor of two professional journals: Behavior Research and Therapy and the Journal of Cognitive Psychotherapy. Autumn E. Braddock, PhD, is a clinical health psychologist within the Veterans Affairs Greater Los Angeles Healthcare System, specializing in behavioral medicine and cognitive-behavioral therapy for anxiety disorders. She has multiple publications and has presented her research, pri- marily addressing anxiety within medical populations, at national and international conferences. Advances in Psychotherapy – Evidence-Based Practice Danny Wedding; PhD, MPH, Prof., St. Louis, MO (Series Editor) Larry Beutler; PhD, Prof., Palo Alto, CA Kenneth E. Freedland; PhD, Prof., St. Louis, MO Linda C. Sobell; PhD, ABPP, Prof., Ft. Lauderdale, FL David A. Wolfe; PhD, Prof., Toronto (Associate Editors) The basic objective of this series is to provide therapists with practical, evidence-based treatment guidance for the most common disorders seen in clinical practice – and to do so in a “reader-friendly” manner. Each book in the series is both a compact “how-to-do” reference on a particular disorder for use by professional clinicians in their daily work, as well as an ideal educational resource for students and for practice-oriented continuing education. The most important feature of the books is that they are practical and “reader-friendly:” All are struc- tured similarly and all provide a compact and easy-to-follow guide to all aspects that are relevant in real-life practice. Tables, boxed clinical “pearls”, marginal notes, and summary boxes assist orienta- tion, while checklists provide tools for use in daily practice. This document is for personal use only. Reproduction or distribution is not permitted. From J. S. Abramowitz & A. E. Braddock: Hypochondriasis and Health Anxiety (ISBN 9781616763251) © 2011 Hogrefe Publishing.  Hypochondriasis and Health Anxiety Jonathan S. Abramowitz University of North Carolina at Chapel Hill, NC Autumn E. Braddock Veterans Affairs of Greater Los Angeles Healthcare System, CA This document is for personal use only. Reproduction or distribution is not permitted. From J. S. Abramowitz & A. E. Braddock: Hypochondriasis and Health Anxiety (ISBN 9781616763251) © 2011 Hogrefe Publishing.  Library of Congress Cataloging in Publication is available via the Library of Congress Marc Database under the LC Control Number 2010933424 Library and Archives Canada Cataloguing in Publication Abramowitz, Jonathan S. Hypochondriasis and health anxiety / Jonathan S. Abramowitz, Autumn E. Braddock. -- 1st ed. (Advances in psychotherapy--evidence-based practice ; v. 19) Includes bibliographical references. ISBN 978-0-88937-325-9 1. Hypochondria. 2. Hypochondria--Treatment. 3. Anxiety--Treatment. 4. Cognitive therapy. I. Braddock, Autumn E II. Title. III. Series: Advances in psychotherapy--evidence-based practice ; v.19 RC552.H8A27 2010 616.85’25 C2010-905200-5 © 2011 by Hogrefe Publishing PUBLISHING OFFICES USA: Hogrefe Publishing, 875 Massachusetts Avenue, 7th Floor, Cambridge, MA 02139 Phone (866) 823-4726, Fax (617) 354-6875; E-mail [email protected] EUROPE: Hogrefe Publishing, Rohnsweg 25, 37085 Göttingen, Germany Phone +49 551 49609-0, Fax +49 551 49609-88, E-mail [email protected] SALES & DISTRIBUTION USA: Hogrefe Publishing, Customer Services Department, 30 Amberwood Parkway, Ashland, OH 44805 Phone (800) 228-3749, Fax (419) 281-6883, E-mail [email protected] EUROPE: Hogrefe Publishing, Rohnsweg 25, 37085 Göttingen, Germany Phone +49 551 49609-0, Fax +49 551 49609-88, E-mail [email protected] OTHER OFFICES CANADA: Hogrefe Publishing, 660 Eglinton Ave. East, Suite 119-514, Toronto, Ontario, M4G 2K2 SWITZERLAND: Hogrefe Publishing, Länggass-Strasse 76, CH-3000 Bern 9 Hogrefe Publishing Incorporated and registered in the Commonwealth of Massachusetts, USA, and in Göttingen, Lower Saxony, Germany No part of this book may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, microfi lming, recording or otherwise, without written permission from the publisher. 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You shall not: (1) rent, assign, timeshare, distribute, or transfer all or part of the e-book or any rights granted by this License Agreement to any other person; (2) duplicate the e-book, except for reasonable backup copies; (3) remove any proprietary or copyright notices, digital watermarks, labels, or other marks from the e-book or its contents; (4) transfer or sublicense title to the e-book to any other party. These conditions are also applicable to any audio or other files belonging to the e-book. Format: PDF ISBN 978-1-61676-325-1 This document is for personal use only. Reproduction or distribution is not permitted. From J. S. Abramowitz & A. E. Braddock: Hypochondriasis and Health Anxiety (ISBN 9781616763251) © 2011 Hogrefe Publishing.  Dedication To our respective families: Stacy, Emily, and Miriam; Eric, Alyxzandria, and Sienna. Your love puts everything in perspective. This document is for personal use only. Reproduction or distribution is not permitted. From J. S. Abramowitz & A. E. Braddock: Hypochondriasis and Health Anxiety (ISBN 9781616763251) © 2011 Hogrefe Publishing.  This document is for personal use only. Reproduction or distribution is not permitted. From J. S. Abramowitz & A. E. Braddock: Hypochondriasis and Health Anxiety (ISBN 9781616763251) © 2011 Hogrefe Publishing.  Preface This volume in the Advances in Psychotherapy: Evidence-Based Practice series describes the conceptualization, assessment, and psychological treat- ment of severe health anxiety, hypochondriasis, and related problems using empirically supported cognitive-behavioral therapy (CBT) techniques. The development of effective problem-focused treatments for severe health anxiety has created a growing need for the dissemination of treatment manuals, such as this one, to mental health professionals who want to know how to use these techniques with their patients. This book builds upon psychological principles of behavior change. As such, it assumes that the reader has basic knowledge and some training in psychotherapeutic intervention. It is written for psychologists, psychiatrists, physicians, nurses, physician aides, social workers, students and trainees, and other health care practitioners who encounter patients with unexplained physi- cal complaints. The book is divided into five chapters. The first chapter describes the clinical phenomenon of health anxiety and related problems, and describes em- pirically supported diagnostic and assessment procedures. Chapter 2 reviews what is known about the leading theoretical models of health anxiety and their implications for successful treatment. In Chapter 3, we present a framework for conducting an initial assessment and for deciding whether a patient is a candidate for the psychological treatment program outlined in Chapter 4. Methods for discussing the psychological (as opposed to medical) aspects of treatment, and strategies for getting the patient to “buy in” to a psychological approach are also incorporated in Chapter 3. Chapter 4 presents the nuts and bolts of psychological treatment techniques for health anxiety. It also reviews scientific evidence for the efficacy of this program and describes a number of common obstacles to successful treatment. Finally, Chapter 5 includes a case example of the treatment of severe health anxiety. A variety of forms and pa- tient handouts for use in treatment appear in the appendix. Health anxiety is a heterogeneous clinical condition. Some patients experi- ence fears of dying a slow death due to cancer, while others have recurring, anxiety-evoking doubts that their unexplained pain or other bodily sensations are symptoms of a rare or previously undiscovered disease. At the time of this writing, the DSM-V Task Force on Somatoform Disorders is considering a new diagnosis, Complex Somatic Symptom Disorder, which would be even more heterogeneous and subsume a number of DSM-IV-TR conditions, such as hypochondriasis, somatization disorder, pain disorders, and undifferentiated somatoform disorder. Although a systematic and multicomponent treatment approach is advo- cated in this book, we do not intend it to be a “cookbook.” Rather, it guides the clinician in tailoring specific treatment components to individual patients’ needs. It provides a practical and structured approach with supporting didactic materials for both clinicians and patients. This document is for personal use only. Reproduction or distribution is not permitted. From J. S. Abramowitz & A. E. Braddock: Hypochondriasis and Health Anxiety (ISBN 9781616763251) © 2011 Hogrefe Publishing.  Advances in Psychotherapy: Hypochondriasis and Health Anxiety viii Acknowledgments We are indebted to many people, including series editor Danny Wedding, asso- ciate editor Ken Freedland, and Robert Dimbleby of Hogrefe Publishing, for their invaluable guidance and suggestions. We also appreciate Kristy Gura’s hard work in helping us prepare this book for publication. The pages of this volume echo clinical insights we acquired during our work at the Mayo Clinic in Rochester, Minnesota. We are grateful for the support of terrific colleagues including Stephen Whiteside, Sarah Kalsy, Brett Deacon, Katherine Moore, Kristi Dahlman, and Jill Snuggerud. Dr. Braddock acknowledges the professional mentorship of Gary Wolfe, PhD, and Lisa Altman, MD, who have given unwavering support of pri- mary care psychology and patient-centered care within the VA of Greater Los Angeles Healthcare System. She also thanks her colleagues Kellie Condon, PhD; Leigh Anne Selby, PsyD; and Mike Young, LCSW, and the numerous primary care providers, for their ongoing collaboration, guidance, and friend- ship. Jointly, we dedicate this book to the brave patients who came to us – sometimes unwillingly – when their search for a medical explanation for their bodily complaints turned up empty. Not knowing what to expect, they cou- rageously challenged themselves to embrace a psychological perspective on their complaints. They accepted their bodily sensations as benign, confronted their fears, and defeated their anxiety. They believed in us, confided in us, challenged us, and educated us. We thank them for their willingness to open their minds to our approach. This document is for personal use only. Reproduction or distribution is not permitted. From J. S. Abramowitz & A. E. Braddock: Hypochondriasis and Health Anxiety (ISBN 9781616763251) © 2011 Hogrefe Publishing.  Table of Contents Dedication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .viii 1 Description of Health Anxiety 1.1 Terminology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1.2 Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1.3 Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 1.4 Course and Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 1.5 Differential Diagnoses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 1.5.1 Somatization Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 1.5.2 Somatic Delusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 1.5.3 Illness or Disease Phobia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 1.5.4 Panic Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 1.5.5 Obsessive-Compulsive Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 1.5.6 Generalized Anxiety Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 1.5.7 Pain Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 1.6 Comorbidity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 1.7 Diagnostic Procedures and Documentation . . . . . . . . . . . . . . . . . . . 7 1.7.1 Structured Diagnostic Interviews . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 1.7.2 Semi-Structured Symptom Interviews . . . . . . . . . . . . . . . . . . . . . . . 8 1.7.3 Self-Report Inventories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 1.7.4 Documenting Changes in Symptom Levels . . . . . . . . . . . . . . . . . . . 9 2 Theories and Models of Health Anxiety 2.1 Development of Health Anxiety . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 2.1.1 The Human Body Is “Noisy” . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 2.1.2 Beliefs and Interpretations Lead to Health Anxiety . . . . . . . . . . . . 10 2.1.3 Origins of Dysfunctional Core Beliefs . . . . . . . . . . . . . . . . . . . . . 12 2.2 Maintenance of Health Anxiety . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 2.2.1 Physiological Maintenance Factors . . . . . . . . . . . . . . . . . . . . . . . . 13 2.2.2 Cognitive Maintenance Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 2.2.3 Behavioral Maintenance Factors . . . . . . . . . . . . . . . . . . . . . . . . . . 15 2.3 Treatment Implications of the Model . . . . . . . . . . . . . . . . . . . . . . . 16 3 Diagnosis and Treatment Indications 3.1 Review of Medical Records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 3.2 Self-Report Inventories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 3.3 The Clinical Interview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 3.3.1 Chief Complaint and History . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 3.3.2 Mood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 3.3.3 Social Functioning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 3.3.4 History and Previous Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 3.3.5 Family Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 This document is for personal use only. Reproduction or distribution is not permitted. From J. S. Abramowitz & A. E. Braddock: Hypochondriasis and Health Anxiety (ISBN 9781616763251) © 2011 Hogrefe Publishing.  Advances in Psychotherapy: Hypochondriasis and Health Anxiety x 3.4 Identifying the Appropriate Treatment . . . . . . . . . . . . . . . . . . . . . . 20 3.4.1 Medications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 3.4.2 Cognitive Behavior Therapy (CBT) . . . . . . . . . . . . . . . . . . . . . . . . 21 3.5 Factors that Influence Treatment Decisions . . . . . . . . . . . . . . . . . 21 3.6 Presenting the Recommendation for CBT . . . . . . . . . . . . . . . . . . . 22 3.6.1 Getting a Foot in the Door . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 3.6.2 The Mind-Body Connection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 3.6.3 Body Vigilance and Body Noise . . . . . . . . . . . . . . . . . . . . . . . . . . 23 3.6.4 Effects of Behavioral Responses . . . . . . . . . . . . . . . . . . . . . . . . . . 23 3.6.5 Presenting the Treatment Rationale . . . . . . . . . . . . . . . . . . . . . . . . 23 3.6.6 Eliciting “Change Talk” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 4 Treatment 4.1 Methods of Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 4.1.1 Functional Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 4.1.2 Self Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 4.1.3 Psychoeducation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 4.1.4 Cognitive Therapy Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 4.1.5 Exposure and Response Prevention . . . . . . . . . . . . . . . . . . . . . . . . 47 4.1.6 Implementing Appropriate Self-Care Behaviors . . . . . . . . . . . . . . 58 4.2 Mechanisms of Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 4.3 Efficacy and Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 4.4 Variants of the Treatment Procedures . . . . . . . . . . . . . . . . . . . . . . . 59 4.5 Problems in Carrying Out Treatment . . . . . . . . . . . . . . . . . . . . . . . 60 4.5.1 Nonadherence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 4.5.2 Arguments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 4.5.3 Unbearable Anxiety Levels During Exposure . . . . . . . . . . . . . . . . 62 4.6 Multicultural Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 5 Case Vignette . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 6 Further Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 7 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 8 Appendices: Tools and Resources . . . . . . . . . . . . . . . . . . . . 70 This document is for personal use only. Reproduction or distribution is not permitted. From J. S. Abramowitz & A. E. Braddock: Hypochondriasis and Health Anxiety (ISBN 9781616763251) © 2011 Hogrefe Publishing.  1 Description of Health Anxiety 1.1 Terminology Anxiety is a cognitive, emotional, physiological, and behavioral response to the perception of threat. It occurs when one doubts his or her ability to cope with the perceived threat. Health anxiety refers to inappropriate or excessive health-related fears based on misperceptions of innocuous bodily cues and sensations as indicative of a serious medical problem. Moreover, the individual with health anxiety perceives him or herself as unable to cope with or prevent the perceived threat, in this case the presence of a serious medical illness. 1.2 Definition Anxiety is an adaptive response which prepares us to take action when con- fronted with possible danger (i.e., the fight or flight response). Some degree of health-related anxiety may therefore be constructive if it motivates a person to take appropriate measures or seek proper medical attention. For example, apprehension concerning shortness of breath in a person with asthma can lead to prompt administration of inhalant bronchodilator medication to prevent respiratory fatigue or even death by suffocation. Clinical health anxiety, on the other hand, is extreme in relation to the actual degree of threat (if any threat even exists). It causes distress and interferes with various domains of functioning, including interpersonal relationships, self-care, work or school, and leisure. Hypochondriasis. Hypochondriasis is classified as a somatoform disorder in DSM-IV-TR (American Psychiatric Association [APA], 2000) and character- ized by a preoccupation with fears of having, or the idea that one has, a serious medical condition such as a chronic, life threatening or life-altering sickness (see Table 1). This “disease conviction” is (a) based on a misinterpretation of harmless or minor bodily sensations or perturbations and (b) persists in spite of appropriate medical evaluation and reassurance of good health. The health-related preoccupation might concern specific bodily functions such as peristalsis or heart beat; slight benign abnormalities, signs, and sensa- tions such as an occasional cough, pulled muscle, mole, or bruise on the skin; vague and ambiguous complaints such as “a hollow head” or “weak spine;” or specific organs (e.g., kidneys), body parts (e.g., prostate gland), or diseases (e.g., rabies, cancer). Definition of health anxiety and hypochondriasis This document is for personal use only. Reproduction or distribution is not permitted. From J. S. Abramowitz & A. E. Braddock: Hypochondriasis and Health Anxiety (ISBN 9781616763251) © 2011 Hogrefe Publishing.  Advances in Psychotherapy: Hypochondriasis and Health Anxiety 2 Patients with clinical health anxiety often fixate on the cause, meaning, and authenticity of their complaints. Common expressions of this fixation include excessive seeking of reassurance about the physical complaints (e.g., repeated doctor visits and unnecessary tests), asking questions of medical profession- als, seeking information from medical texts and websites, and extensive body checking (e.g., inspecting the skin, inspecting excrement, repeatedly measur- ing vital signs). Some patients avoid external triggers of health anxiety (e.g., hospitals, people with illnesses). Table 2 lists some common hypochondriacal and health anxiety-related behaviors. Table 1 Summary of the DSM-IV-TR Diagnostic Criteria for Hypochondriasis A. Preoccupation with fears of having, or the idea that one has, a serious disease based on the person‘s misinterpretation of bodily symptoms. B. The preoccupation persists despite appropriate medical evaluation and reassurance. C. The belief in criterion A is not a delusion and is not restricted to a circumscribed concern about appearance (as in Body Dysmorphic Disorder). D. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. E. The duration of the disturbance is at least 6 months. F. The preoccupation is not better accounted for by another Axis I disorder such as Generalized Anxiety Disorder, Obsessive-Compulsive Disorder, Panic Disorder, a Major Depressive Episode, Separation Anxiety, or another Somatoform Disorder. Adapted from the DSM-IV diagnostic criteria for hypochondriasis (American Psychiatric Association [APA], 1994). Adapted with permission. Clinical Pearl Hypochondriasis Versus Health Anxiety The term “health anxiety” is beginning to replace the term “hypochondriasis” for the following reasons: 1. “Health anxiety” provides a clearer and more meaningful description of the emotional and behavioral aspects of this problem. “Hypochondriasis,” on the other hand, derives from the Greek hypo (below) and chondros (cartilage of the breast bone) and was used by ancient Greek physicians to describe unexplained stomach pains. During the 19th Century, this became the male counterpart to hysteria. 2. Hypochondriasis is but one of several clinical disorders that involve health- related fears and worries. Thus, health anxiety is not a clinical diagnosis per se, but rather a phenomenon that can be present in a number of psychological conditions as well as medical diagnoses that often present with overlapping psychological symptoms (as we describe below). 3. Whereas the term “health anxiety” is more or less value neutral, “hypo- chondriasis” has pejorative connotations. This document is for personal use only. Reproduction or distribution is not permitted. From J. S. Abramowitz & A. E. Braddock: Hypochondriasis and Health Anxiety (ISBN 9781616763251) © 2011 Hogrefe Publishing.  1. Description of Health Anxiety 3 Poor Insight. Some individuals with hypochondriasis recognize that their health-related fears, preoccupations, and behaviors are excessive (i.e., they have “good insight”). The DSM-IV-TR diagnostic specifier, “with poor insight” is reserved for those who, most of the time, do not realize that their health-related fears and concerns are unrealistic. 1.3 Epidemiology The lifetime prevalence of hypochondriasis in the general population has been estimated at anywhere between 0.02% and 7.7%. In primary care set- tings, estimates range from 0.8% to 8.5%. The estimated prevalence is 1.2% among cardiology outpatients and 1.0% among chronic pain patients. Men and women are about equally likely to be affected (APA, 2000). Patients vary in terms of their insight into the excessiveness of their health concerns Table 2 Examples of Common Hypochondriacal and Health Anxiety-Related Behaviors Checking and assurance-seeking • Repeated visits to doctors to have symptoms checked • “Doctor-shopping” to check if the diagnosis is correct • Repeated Internet searches to find information about a certain symptom • Repeatedly discussing or asking questions about the feared problem • Reviewing test results and notes taken during doctor visits • Persistently mentioning and describing symptoms to others • Repeatedly reviewing medical texts or journal articles for information about illnesses or body symptoms Body checking • Repeatedly measuring heart rate, blood pressure, temperature, etc. • Constantly monitoring levels of “throat tightness,” dizziness, or pain • Frequently palpating the throat or breasts for lumps • Checking urine and stool for blood and consistency • Frequent inspections of sores and moles on the skin Safety signals • Remain within a certain distance of the doctor’s office, hospital, or medical center • Keep medications on hand at all times • Swallowing until it feels “normal” • Rigid adherence to a strict diet Avoidance • Hospitals • People with illnesses • Television shows, movies, news articles, and other stories about sick people, illnesses, or death • Physical exertion • Routine physical exams • Self-examinations (e.g., breast, testicles) • Funerals and cemeteries This document is for personal use only. Reproduction or distribution is not permitted. From J. S. Abramowitz & A. E. Braddock: Hypochondriasis and Health Anxiety (ISBN 9781616763251) © 2011 Hogrefe Publishing.  Advances in Psychotherapy: Hypochondriasis and Health Anxiety 4 1.4 Course and Prognosis Although symptoms of health anxiety may be present at any age, little is known about the average age of onset, or about the prevalence of health anxi- ety among children. Onset usually occurs in early adulthood, which coincides with the time at which most people assume greater responsibility for maintain- ing personal health. Other potential onset triggers include increased life stress, a personal experience with illness, the illness or death of a loved one, and exposure to mass media coverage of illnesses. Some health anxiety patients endure a long-term burden of functional impairment and personal distress if effective treatment is not sought. 1.5 Differential Diagnoses Health anxiety is not a DSM-IV-TR diagnosis. Rather, it is a collection of signs and symptoms featuring medically unexplained physical complaints; fears, con- cerns, and preoccupation with health and illness; and behaviors such as avoid- ance, checking, and other types of reassurance-seeking. Hypochondriasis can be Most patients with health anxiety require professional help to avoid long- term suffering A number of psychological disorders involve health anxiety to one degree or another Table 3 Proposed Diagnostic Criteria for Complex Somatic Symptom Disorder (CSSD) in DSM-V Criteria A, B, and C are necessary: A. Somatic symptoms: Multiple somatic symptoms that are distressing, or one severe symptom B. Misattributions, excessive concern or preoccupation with symptoms and illness: At least two of the following are required to meet this criterion: 1. High level of health-related anxiety. 2. Normal bodily symptoms are viewed as threatening and harmful 3. A tendency to assume the worst about their health (catastrophizing). 4. Belief in the medical seriousness of their symptoms despite evidence to the contrary. 5. Health concerns assume a central role in their lives C. Chronicity: Although any one symptom may not be continuously present, the state of being symptomatic is chronic and persistent (at least 6 months). The following optional specifiers may be applied to a diagnosis of CSSD where one of the following dominates the clinical presentation: 1. Multiplicity of somatic complaints (somatization disorder in DSM-IV) 2. High health anxiety (hypochondriasis in DSM-IV) [If patients present solely with health-related anxiety in the absence of somatic symptoms, they may be more appropriately diagnosed as having an anxiety disorder.] 3. Pain disorder. This classification is reserved for individuals presenting predominantly with pain complaints who also have many of the features described under criterion B. Patients with other presentations of pain may better fit other psychiatric diagnoses such as major depression or adjust- ment disorder. This document is for personal use only. Reproduction or distribution is not permitted. From J. S. Abramowitz & A. E. Braddock: Hypochondriasis and Health Anxiety (ISBN 9781616763251) © 2011 Hogrefe Publishing.