Behav. Res. Ther. Vol. 24, No. 5, pp. 597-602,1986 53.00+ 0.

03
OOOS-7967/86
Printed in Great Britain Pcrgamon Journals Lt

CASE HISTORIES AND SHORTER COMMUNICATIONS

Morbid preoccupations, health anxiety and reassurance:

a cognitive-behavioural approach to hypochondriasis

PAUL M. SALKOVSKIS* and HILARY M. C. WARWICK?

Deportment of Liaison Psychiatry, General Infirmary at Lee&, Great George Street,
Lee& LSl 3EX, England

(Received 27 January 1986)

Summary-The concept of ‘hypochondria&’ is examined and an alternative cognitivebehavioural

approach to health preoccupation is proposed. Avoidance behaviour (reassurance seeking and checking
bodily status) IS suggested as an unportant mamtatmng factor. In two single case experiments, short- and
long-term effects of medical reassurance are assessed in ‘hypochondriacal’ patients; results are fully
consistent with the model. Treatment designed to eliminate reassurance and hence to facilitate self-directed
exposure and cognitive change proved rapidly effective.

IlWRODUCTlON
Hypochondriasis as a psychiatric concept and diagnosis has been the subject of considerable controversy over many years.
Behaviour therapists seldom use this label, preferring less obviously ambiguous constructs such as anxiety or illness phobia
(Marks, 1981). This is understandable, as the term ‘hypochondriasis’ has come to have pejorative connotations.
Furthermore, it has often implied mechanisms and constellations of symptoms which cannot be justified on the basis of
empirical evidence (Barsky and Klerman, 1983). Nonetheless, there does appear to be a phenomenon which defies more
simple explanation, manifesting as anxiety about health, an apparently low threshold for the perception and report of bodily
sensations and frequent seeking after evidence of health status by medical consultation, reassurance seeking and checking
bodily state. This pattern of behaviours appears to follow a continuum, running from mild concern about some unusual
bodily sensation or observation and culminating in those individuals who are preoccupied with and fearful of bodily
symptoms so that much of their thought and activity is centred around illness. This latter group includes those who currently
receive a DSM-III diagnosis of hypochondriasis and for whom prognosis is considered to be poor (Nemiah, 1985), whilst
in milder form the problem is very common in non-psychiatric clinics and constitutes a major drain on time and resources.
We suggest that ‘health preoccupation’ may be a more useful concept, with ‘morbid health preoccupation’ representing
the more extreme disturbances of bchaviour observed in hypochondriacal patients. Rachman (1974) has previously defined
morbid preoccupations, and attempted to differentiate these from obsessional thoughts. Morbid preoccupations are said
to be repetitive, exclude other mental activity and am associated with difficulties in maintaining concentration and disturbed
mood. The content differentiates them from obsessional intrusions, in that the ideas are consistent with the personality and
experiences of the individual concerned, and are regarded as sensible, while obsessional thoughts are regarded as senseless
and are usually inconsistent with experiences and personality. In this particular respect, it is significant that past experience
of true organic disease in self or a family member has been identified as a predisposing factor for hypochondriasis (APA,
1980, DSM-III, p. 250). It is certainly the case that many authors have identified the two key elements of ‘hypochondria&’
as being: (a) preoccupation with bodily health ‘out of proportion to existing justification’; and (b) the pursuit of reassurance
(Baker and Mersky, 1983; Barsky and Klerman, 1983; Kenyon, 1964, 1976; Mayou, 1976; Mechanic, 1972; Pilowsky, 1967).
We suggest that the concept of preoccupation with (ill) health is a key cognitive element in such patients, and that a
behavioural component, the seeking of reassurance from physicians and others as well as repeated checking on bodily state
and symptoms by the patient themselves, serves an important maintaining function in clinical cases where preoccupation
with health is both persistent and disabling.
We have suggested elsewhere that intrusive and upsetting thoughts may play a major role in the clinical presentation
of physical disorders in particular and health fears in general (Warwick and Salkovskis, 1985). Further clarification of the
processes involved in non-obsessional intrusive thoughts, particularly about health concerns, would therefore seem very
important in the area of behavioural medicine, given the high frequency of consultation because of worries about health
rather than physical illness per se (Lloyd, 1985; Mayou, 1976). Those working in general medical settings will be familiar
with the frequent occurrence of patients whose original presentation was with minor physical symptoms allied with relatively
high levels of anxiety. Patients whose anxieties lead them to catastrophic interpretations of symptoms may not be satisfied
by the clinical diagnosis, often focusing their anxiety and dissatisfaction on the investigations carried out by medical staff.
Over the course of weeks, months and sometimes years, physical and clinical investigations (sometimes including
unnecessary surgical procedures) are carried out with no improvement or worsening of anxiety. Such a situation may be
further complicated by a reciprocal relationship between such anxiety and the presenting physical symptomatology, as, for
instance, in irritable bowel syndrome @timer, 1981). Although on occasion it is considered that the repeated investigations
and reassurance offered may be making the patient worse, the reasons for this do not appear to be understood and as such
are seldom acted upon by clinicians. As such behaviour becomes more extreme, it may come to be labelled ‘attention

*tPresent addresses: *University of Oxford Department of Psychiatry, Wameford Hospital, Headington, Oxford OX3 7JX,
England; TMaudsley Hospital, London, England.

597
598 CASE HISTORIES AND SHORTER COMMUNlCATlONS

seeking’ or as arising from a ‘personality disorder’ or some other ‘underlying mental illness’. The result of this failure of
understanding is that the psychological processes operating are only recognized in the more extreme and intractable -s,
where the problem begins to assume some of the characteristics of ob~~iv~mpulsive disorder, but may be better
described as morbid preoccupations.
Our own work (Sdkovskis, 1985; Warwick and Salkovskis, 198s) has led us to the view that there are three loosely
associated reasons for medical consultation: (a) the handicap, inconvenience and physical discomfort arising directly from
the symptoms day to day; (b) anxiety and intrusive thoughts about the possible cause of the problem, especially catastrophic
interpretations of the nature of the symptoms; (c) discomfort at the possible negative consequences of not taking further
action, such as seeking consultation. It is the latter two which we suggest give rise to a range of avoidance behaviours
(particularly medical consultation and reassurance seeking) which, by their severity and prominence, ultimately lead to
jdentifi~tion of the psy~hologic~ component of the problem. Such attempted avoidance of potential disaster, triggered
by intrusive thoughts, closely resembles obsessional behaviour without the perception of irrational content.
This analysis leads to two predictions for such patients:
(a) Prevention of reassurance seeking and provision coupled with proper explanation of the nature of
the problem as described above should be an effective treatment for such patients.
(b) Attempts at providing reassurance should have the same effect as compulsive behaviour in
obsessions; that is, immediate relief followed by a longer-term return of anxiety (Rachman, de Siiva and
Roper, 1976). (This wilt not be the case when the transmission of new and relevant i~fo~atjon the patient
does not already possess or understand is involved.)
This study reports two single-case experiments designed to investigate these hypotheses in patients fulfilling the DSM-III
diagnostic criteria for hypochondriasis.

CASE 1
A is a 32-yr-old married engineer. He developed an acute urticarial rash, consisting of typical eruptions of intensely itchy
weals surrounded by red areas. (Urticaria may occur as a sensitivity response to certain foods or as a reaction to drugs
such as penicillin; however, in 50% of chronic cases, a cause is never found. It is not associated with any malignant
condition.) His rash persisted for several months despite advice and treatment from his family doctor and dermatologist.
He had had a previous episode of urticaria, which was salicylate induced, but apart from this had been completely healthy.
Physical examination and investigations revealed no significant abnormality, and a diagnosis of idiopathic urticaria was
made. Despite this reassurance, he became increasingly anxious that he had a serious underlying condition such as leukemia,
and sought repeated consultations. His belief in the idea that he had leukemia had arisen in the first instance because a
skin specialist had attempted to reassure him by giving him some medical details. Specifically, this doctor had told him
that the rash arose because his white blood cells wwc attacking foreign matter in his blood cells. The patient had interpreted
this a~ meaning that there was something wrong with his white blood cells, signifying that he had leukemia. He inspected
his rash frequently, read textbooks in an effort to discover ‘the real cause’ and could talk of little else to his wife, family
and friends. Eventually, he became suicidal, unable to work and was admitted psychiatrically.

Procedure
Two weeks after admission, there had been no improvement, and he remained distressed and im~~uning. He considered
that his problems were not being dealt with properly as the routine physical examination performed on admission was not
repeated. He maintained that his anxiety would be totally resolved if only a ‘specialist’ would see him about his rash, and
that the anxiety was not his problem. Ratings of his anxiety, illness conviction and need for reassurance were taken, using
100-point scales anchored at one end by, for instance, ‘I do not believe this at all’ and at the other by ‘I am completely
convinced by this’. After recording had been started, the dermatologist who had referred the patient came to review his
case and the effect of this consultation on his beliefs and anxiety was closely monitored. Ratings were taken immediately
after the visit of the dermatologist, 12 and 24 hr later. Figure 1 shows the results of this-a clear short-term decline in all
three variables, followed by a return to baseline levels and above. A repeatap~intment was arranged to review his physical
state as a replication. The results of this second consdtation were identical to the first.
These results were discussed with the patient using the framework of cognitive therapy (Beck and Emery, 1979). The
patient agreed on two competing hypotheses: (a) that he was suffering from a life-threatening physical illness which had
not been detected by repeated medical consultation; (b) that he had a problem with anxiety, which was maintained by
repeated medical consultation, checking and avoidance behaviour and his incessant discussion and preoccupation. The
evidence for each was reviewed, and the extent to which each hypothesis had received adequate test was evaluated. He agreed
on this basis to change his behaviour as a test of the second hypothesis, whilst monito~ng continued and a prediction of
declining anxiety and illness conviction was made. After detailed discussion and observation, many examples of behaviour
likely to maintain his anxieties were identified. Previously he had spent a great deal of his time repeatedly checking the
progression of his rash, regularly counting and measuring the extent of his lesions. He agreed not to do this and practical
steps were taken to help; for example, covering the mirror in his room. Another troublesome behaviour was protracted
scratching, which increased both his physical and psychological distress-he was instructed to pat itchy lesions (Watson,
Tharp and K&berg, 1972). Reading medical textbooks was forbidden. He was asked to join in ward activities on a regular
basis, rather than waiting round the nurses’ station for the arrival of a doctor who he thought might tell him he had a
carcinoma. This strategy, he later told us, had also distracted him from the telephone; he had previously worried that every
call might bear bad news.
A major concern was to deal with persistent requests for reassurance. When a new lesion developed he became severely
anxious and constantly showed the afflicted area to staff and requested physical checkups. He was encouraged to control
these behaviours himselc on the few occasions he was unable to do so, his requests were dealt with by a standard response
and staff refused to look at the proffered area. A crucial issue was to inform all staff involved, including dermatologists,
doctors on call and changes of nursing shift, so that no reassurance was available from any source. It should be stressed
that reassurance seeking occurs in many ways, and is not limited to hospital statX hence his wife was fully involved and
instructed how to respond when he asked for reassurance [see Marks (1981, p. s4) for a detailed account ofsuchrespond&&
His family doctor was also briefed appropriately. The results of this approach can be seen in the treatment phase of Fig. 1.
 CASE HISTORIES ANDSHORTER COMMUNICATIONS 599

Baulin Reossumncc Tnotment I ne rrossumnce I

Boseline Reossumnce Treatment (no reossumhce)

Borlim Reauumaer Treatment t 110reassumncs 1

Fig. 1. Visual analogue scale (VAS) ratings of health anxiety, need for reassurance and illness conviction
for Case 1. Arrows indicate medical reassurance (0 - -- l immediate response to reassurance).

CASE 2
B is a 26-yr-old married manual worker. He developed headaches whilst on holiday abroad, probably due to excessive
exposure to direct sunlight. These persisted, and he also developed precordial pain associated with a range of other bodily
symptoms, particularly dixziness breathlessness and weakness. Physical investigations by a number of physicians including
cardiologists and neurologists (prompted by his symptoms) revealed no physical basis for his symptoms, and he was referred
to the department of clinical psychology after a further series of tests (including a brain scan) which were carried out with
the explicit purpose of reassuring him. He was on sick leave from work, spent much of his time in a prone position, and
frequently called out the emergency services. He also asked his wife constantly for reassurance, to take his pulse and not
to leave him alone in the house. At referral he complained that the doctors were missing something and was eager for more
tests to be carried out. The most probable causes of his symptoms were identified by the patient as heart disease, a brain
tumour or some other cancer. He complained of depressed mood because of his perceived physical condition and the
resultant deterioration in lifestyle, but showed no other depressive symptoms.
600 CASE HiSTORIES AND SHORTER COMMUNICATIONS

Y
Baseline Reassurance Treatment tna reassurance)
t
c mo- I I
e _
SW
$ w-
c m-
-b$ 60-

LW
3 40-
.$ SO-
%
L 20-
WI IO-
s
o-

Baseline Reassurance Trcatmcnt ( no nassuranccl

IOO-
Y

A
0- A

WeekSI 2 ‘GSms.

Baseline Reassurance Treatment I na reassurance I

I I

I
I
1

/-+-y/j

j?
ji
v
I
i
A A
L

Weeks 1 2 ;, ;t ; :; i ; ‘%Smo

Fig. 2. Visual analogue scale (VAS) ratings of health anxiety, need for reassurance and illness conviction
for Case 2. Arrows indicate medical reassurance (0 --- l immediate response to reassurance).

Procedure
The patient was asked to keep diary records of his anxiety about health, his need for reassurance and his belief that he
was suffering from a terminal illness. A 3-week baseline was recorded followed by procedures identical to those used in
Case 1. In this instance, two doctors who had not met the patient before were asked to see him in order to carry out a
physical examination and to reassure the patient as appropriate. They had full knowledge of the previous history and
investigations, and the patient was described to them as anxious about his health. As in the first case, both patient and
doctors considered this to be an exercise directed at anxiety reduction. Figure 2 shows the effects of these interventions
on long- and short-term ratings. On each measure employed, reassurance reduced anxiety over a period of 12 hr. The
longer-term effect of this intervention was to increase the need for reassurance during this phase.
A shorter-term increase in the illness conviction also appears to occur throughout the reassurance phase, although this
is less sustained than the increase in need for reassurance.
Treatment was commenced along identical lines to that used in Case 1, with the close involvement of the patient’s wife
throughout the programme. However, at the end of Week 8, the patient, although continuing to improve with respect to
his general anxiety and acceptance of the nature of his problem, was continuing to experience episodes of panic anxiety.
 CASE m~0m.s AND SHORTER C~~NI~ATIONS 601

He accepted that these attacks were anxiety related and specific cognitive treatment was commenced (Clark, Salkovskis
and Chalkley, 1985) with a reduction in panic frequency from ‘I/week to none by the end of Week 9. This makes the
interpretation of the follow-up data more difficult, although there is little doubt that the first intervention was effective in
the shoit :e*zir.
DISCUSSION
The results of this study show that, for the patients described here, reassurance produced an immediate but transient
reduction in anxiety. However, there was evidence that providing this reassurance may have enhanced anxiety, increased
the urge to seek reassurance and strengthened negative cognitions over the ensuing 24 hr. This was SOeven when both doctor
and patient expected an enduring decrease. It is clear that the likely consequence of this would be for the patient to seek
further reassurance; in this fashion, reassurance giving could lead to reassurance seeking and unwitting maintainance of
the patient’s problem. The institution of a treatment package which included the specific prevention of reassurance seeking
and giving was followed by clear clinical improvement. Such treatment procedures have been used successfully in the
treatment of obsessional ruminations (Hallam, 1974) and obsessive-compulsive disorder (Marks, 1981; Salkovskis and
Warwick, 1985), but have not previously been systematically employed in the treatment of morbid preoccupations with
health. However, we suggest that an important element in the treatment outlined here was the specific a’emonsrrarion ro
rhe patients rhar rhe alleviation of anxiety produced by reassurance was rransienr and, on some measures, resulted in a
longer-rerm worsening. The results should be interpreted on this basis, so that treatment of similar cases should directly
follow similar behavioural experiments, with cognitive strategies being based on direct demonstrations of the importance
of psychological factors in the maintenance of the problem.
The apparent similarity to the phenomena observed in obsessive-compulsive disorder is compelling. Rachman et al.
(1976) noted that allowing compulsive behaviour produced a short-term reduction in anxiety, but that such anxiety
invariably returns after a period which varies between a few minutes to several hours or even days. This paper also
demonstrated that response prevention resulted in a decay of discomfort and the urges associated with compulsive
behaviour. The single-case experiments described here provide support for the view that reassurance seeking in patients
with morbid preoccupations with health is in this way functionally similar to compulsive behaviour in patients with
obsessionalcompulsive disorder. This leads to the view that the reassurance seeking is a form of avoidance behaviour which
serves to maintain the preoccupation with health in these patients in the fashion so familiar in behavioural formulations
of other anxiety disorders (Rachman, 1976; Reiss, 1980). Furthermore, the treatment programme described here has the
effect of fully-exposing patients to their feared stimuli and hence allows enduring anxiety reduction to take place. From
a cognitive perspective, it could be argued that the treatment employed was effective because it made an anxiety-based
explanation of the patients’ current difficulties appear more probable to them, thereby allowing them to engage in more
direct testing of such an alternative hypothesis. Previous attempts at repeated reassurance appear to have increased the
acessibility of life-threatening interpretations of signs and symptoms and decreased the perceived probability of alternative
explanations in which anxiety and attentional factors account for their problems and symptoms. It is therefore important
to distinguish between the clear and understandable provision of relevant information which the patient does not already
know or understand (and which is likely to result in enduring reductions in the perceived probability of life-threatening
consequences) and frequent attempts to provide reassurance through unnecessary tests and repeated provision of redundant
or irrelevant information. The latter strategy may worsen anxiety by: (i) increasing the perceived probabiliry of pre-existing
interpretations, e.g. “These tests are completely unnecessary, but we’ll do them just to make absolutely certain”; (ii)
increasing the range of such interpretations as new, poorly understood and ambiguous information is provided, e.g. “This
blurring of vision is not due to cataract, and can’t be a brain tumor because you don’t have dizziness or headache”.+ If
this is so, it invites redefinition of the DSM-III diagnostic criteria for hypochondriasis; rather than
“C. The unrealistic fear or belief of having a disease persists despite medical reassurance and causes
impairment in social or occupational functioning.” (APA, 1980, p. 251, emphasis added)
it may be more appropriate to consider that the unrealistic fear or belief persists because of repeated medical reassurance!
There are many implications of this view; clinicians who are not medically qualified and are working in medical settings
frequently request that physicians should ‘take another look’ at a patient in whom somatic symptoms are proving
particularly persistent, or request that an organic condition be ‘ruled out’ before behavioural treatment commences.
(Behavioural medicine has increasingly involved the parallel medical and psychological treatment of patients with
identifiable organic pathology.) Such requests are most likely to follow periods of prolonged discussion of the patient’s
physical status, and attempts at reassurance by the therapist. With the present report, the possibility of an unwitting causal
link is.suggested. The situation is yet more complicated, or course. None of us wish to miss serious organic illness, and
there is evidence of high rates in psychiatric settings (Koranyi, 1979). The solution to this problem is unlikely to be simple,
particularly in settings where litigation may determine overcautious behaviour on the part of physicians. Nonetheless, the
onus remains on physicians, who, despite the increasing range of investigations available, must base their interventions on
clinical indications and not on the anxiety expressed by their patients. The most obvious and acceptable solution lies in
the clear and positive formulation of patients’ problems in cognitive, physiological and behavioural terms, and in such a
way as to allow the direcr resting of clearly formulated psychological hypotheses.

Correspondence-Requests for reprints should be addressed to P. M. Salkovskis at his Oxford address.

REFERENCES

APA; American Psychiatric Association (1980) Diagnosric and Srarisrical Manual of Menral Disorders, 3rd edn. APA,
Washington, DC.
Baker B. and Mersky H. (1983) Classification and associations of hyprochondriasis in patients from a psychiatric hospital.
Can. J. Psychiar. 28, 629-634.
Barsky A. J. and Klerman G. L. (1983) Overview: hypochondriasis, bodily complaints and somatic styles. Am. J. Psychiar.
140, 273-283.
*The authors are grateful to David M. Clark for his helpful comments and clarification of this point.
602 CASE HISTORES AND SHORTER COMMUNlCAllONS

Beck A. T. and Emery G. (1979) Cognitive therapy anxiety and phobic disorders. Unpublished Manuscript, Center for
Cognitive Therapy, Univ. of Pennsylvania, Philadelphia, Pa.
Clark D. M., Salkovskis P. M. and Chalkley A. J. (1985) Respiratory control as a treatment for panic attacks. J. Behav.
Ther. exp. Psychiaf. 16, 23-30.
Hallam R. S. (1974) Extinction of ruminations: a case study. Behau. Ther. 5, 565-568.
Kenyon F. E. (1964) Hypochondriasis: a clinical study. Br. J. Psych&t. 110, 478-488.
Kenyon F. E. (1976) Hypochondriacal states. Br. J. Psychiat. 129, l-14.
Koranyi E. K. (1979) Morbidity and rate of undiagnosed physical illness in psychiatric clinic population. Archs gen.
Psychiar. 36, 414-419.
Latimer P. R. (1981) Irritable bowel syndrome: a behavioral model. Behau. Res. Ther. 19, 475-473.
Lloyd G. G. (1985) Emotional aspects of physical illness. In Recenr Aduances in Clinical Psychiatry, Vol. 5 (Edited by
Granville-Grossman K.). Churchill-Livingstone, London.
Marks 1. M. (1981) Cure and Care of Neurosis. Wiley, New York.
Mayou R. (1976) The nature of bodily symptoms. Br. J. Psychiat. 129, S-60.
Mechanic D. (1972) Social psychological factors affecting the presentation of bodily complaints. New Engf. J. Med. 286,
1032-1039.
Nemiah J. C. (1985) Somatoform disorders. In Comprehensive Texrbook of Psychiatry, Vol. IV (Edited by Kaplan H. I.
and Saddock B. J.). Williams & Wilkins, Baltimore, Md.
Pilowsky I. (1967) Dimensions of hypochondriasis. Br. J. Psychiut. 113, 89-93.
Rachman S. J. (1974) Some similarities and differences between obsessional ruminations and morbid preoccupations. Can
Psychiar. Ass. J. 18, 71-73.
Rachman S. J. (1976) The passing of the two stage theory of fear and avoidance: fresh possibilities. Behau. Res. Ther. 14,
125-131.
Rachman S. J., de Silva P. and Roper G. (1976) The spontaneous decay of compulsive urges. Behau. Res. Ther. 14,445-453.
Reiss S. (1980) Pavolvian conditioning and human fear; an expectancy model. Behau. Ther. 11, 380-396.
Salkovskis P. M. (1985) Obsessional-compulsive problems: a cognitivebehavioural analysis. Behau. Res. Ther. X$571-583.
Salkovskis P. M. and Warwick H. M. C. (1985) Cognitive therapy of obsessive-compulsive disorder: treating treatment
failures. Behaol Psychother. 13, 243-255.
Warwick H. M. C. and Salkovskis P. M. (1985) Reassurance. Br. med. J. 290, 1028.
Watson D. L., Tharp R. G. and Krisberg J. (1972) Case study in self modification: suppression of inflammatory scratching
while awake and asleep. J. Behav. Ther. exp. Psych&. 3, 213-215.