Mayo Clin Proc, December 2002, Vol 77
Review
A Contemporary Conceptual Model of Hypochondriasis
JONATHAN S. ABRAMOWITZ, PHD; STEFANIE A. SCHWARTZ, PHD; AND STEPHEN P. WHITESIDE, PHD
Hypochondriasis (HC), which involves preoccupation with
the fear of having a serious illness despite appropriate
medical examination, is often encountered in medical set-
tings. The most conspicuous feature of this disorder is
seeking excessive reassurance from physicians, medical
references, or self-inspection; however, many patients also
fear they will receive upsetting information if evaluated
and thus avoid consultations and remain preoccupied with
physiologic events, believing they are physically ill. Thus,
HC causes personal suffering for the patient and practical
and cost management problems for professionals across
fields of clinical practice. The past 2 decades have seen
considerable improvement in the understanding and treat-
A ccording to the Diagnostic and Statistical Manual of
Mental Disorders, Fourth Edition (DSM-IV),1 the es-
sential feature of hypochondriasis (HC) is a preoccupation
with the (inaccurate) belief that one has or is in danger of
developing a serious illness. In most patients, the disease
conviction is functionally disabling and persists despite
appropriate evaluation and reassurance of good health. The
preoccupation with HC may be symptom based, with a
focus on bodily functions (eg, heartbeat, sweating, peristal-
sis), minor physical abnormalities (eg, a small sore or an
occasional cough), or vague and ambiguous physical sen-
sations (eg, “tired heart,” “aching veins”). The person at-
tributes these signs and symptoms to the suspected disease
and is concerned with their meaning, authenticity, and
origin. Alternatively, the person may have a preoccupation
with a specific organ or a single disease (eg, fear of having
cancer).
Many in the medical field are familiar with individuals
with HC because these patients are often reluctant to regard
their problems as anything other than physical. As a result,
they may make frequent telephone inquiries or office visits
relating to relatively minor (or undetectable) signs and
symptoms. The persistent questioning and seeking of reas-
surance may pose interpersonal and practical management
problems, but these symptoms also lead to a strain on
From the Department of Psychiatry and Psychology, Mayo Clinic,
Rochester, Minn.
Address reprint requests and correspondence to Jonathan S.
Abramowitz, PhD, Department of Psychiatry and Psychology, Mayo
Clinic, 200 First St SW, Rochester, MN 55905 (e-mail: abramowitz
.jonathan@mayo.edu).
Mayo Clin Proc. 2002;77:1323-1330
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
Conceptual Hypochondriasis Model 1323
ment of HC. In this article, we review a contemporary
conceptual model of HC and an effective form of treatment
called cognitive-behavioral therapy that is derived from this
model. Recommendations for presenting this conceptual-
ization to patients and encouraging proper treatment are
also discussed.
Mayo Clin Proc. 2002;77:1323-1330
CBT = cognitive-behavioral therapy; DSM-IV = Diagnostic
and Statistical Manual of Mental Disorders, Fourth Edition;
HC = hypochondriasis; OCD = obsessive-compulsive disor-
der; SSRI = selective serotonin reuptake inhibitor
valuable medical resources, escalation in costs, and expo-
sure of ostensibly healthy patients to iatrogenic risks that
can accompany medical or surgical procedures. Thus, HC
represents a public health and cost concern for many areas
of medical practice.2-4
Although HC lies at the interface between medicine and
psychiatry, it has yet to receive pronounced attention by
researchers and consequently is often misunderstood. Be-
cause patients with primary HC tend to view their problems
as purely physical, they most often present to primary or
specialty medical settings rather than to mental health clin-
ics or psychiatric research programs. When HC is observed
in mental health settings, patients are often being seen for
other psychiatric syndromes, such as panic disorder or
depression.5 Thus, some investigators have proposed that
HC is merely a symptom of a more serious underlying
psychopathologic condition.6 Because of the diagnostic un-
certainty and patients’ reluctance to seek mental health
evaluation, the prevalence of HC is largely unknown. Life-
time prevalence rate estimates vary widely and range from
0.8% to 8.5%, depending on the setting.7,8
According to the DSM-IV,1 HC can begin at any age, but
most commonly HC occurs in early adulthood. Symptoms
often arise during periods of increased stress but may be
more directly influenced by recovery from a serious illness,
diagnosis of an illness in a loved one, or the death of a close
friend or relative.9 Exposure to illness-related information
in the media likely influences onset and focus of severe
health anxiety or HC.
The traditional psychiatric treatments offered to patients
with HC include pharmacotherapy using selective seroto-
1323 © 2002 Mayo Foundation for Medical Education and Research
1324 Conceptual Hypochondriasis Model
nin reuptake inhibitors (SSRIs; eg, fluoxetine) and psycho-
dynamic or supportive psychotherapy. However, these in-
terventions appear to produce only minimal short-term and
long-term improvement in HC symptoms. Instead, the em-
phasis seems to be on symptom management. Only one
randomized placebo-controlled trial of SSRIs for HC has
been reported thus far.10 That study compared fluoxetine
with placebo, and the difference in responder rate between
groups was not significant. This suggests that fluoxetine is
no more effective than placebo in reducing HC symptoms.
It is common practice for psychiatrists to help patients
manage their symptoms by providing support, regular ap-
pointments, and efforts to prevent iatrogenic problems.
Psychodynamic therapeutic approaches, which aim to
identify and address unconscious motivational factors, are
also sometimes used. No research has evaluated the effi-
cacy of psychodynamic therapy for HC, but the accepted
view that such patients are resistant to treatment indicates
that these strategies may not be highly beneficial. A related
problem is that patients with HC, who often are reluctant to
view their symptoms as psychological, frequently reject
psychiatric interventions.5
There is no empirical evidence to substantiate the vari-
ous psychodynamic profiles of patients with HC that have
been proposed.3 The suggestion that interpersonal re-
wards (secondary gain) are important in the maintenance
of HC is widespread in the medical and psychiatric field.
However, although intuitively appealing, this view some-
times has pejorative connotations and sometimes results
in the simple (for the clinician) but disparaging (for the
patient) dismissal of the patient’s problems as a purpose-
ful choice or personality disorder. Not only does such a
formulation lack scientific support, it also overlooks the
need for a more careful idiographic analysis of symptoms,
which has proven highly useful in the management of
HC.
A widespread phenomenon, HC is likely to be encoun-
tered in most specialties of medicine. Moreover, a well-
informed physician is likely to manage such patients suc-
cessfully and facilitate a referral for psychiatric services,
thereby reducing the potentially high interpersonal and
financial burden. Thus, our aim in this article is to provide
front-line clinicians with a more thorough understanding of
HC. Specifically, we describe an empirically grounded
biopsychosocial model that accounts for the development
and maintenance of HC and leads to effective treatment.
When the functional and financial costs (to both patients
and physicians) are considered along with the patient’s
reluctance to view his or her problem as an emotional
disorder, one realizes that timely recognition, appropriate
conceptualization, and suitable referral of patients with HC
are all important.
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
Mayo Clin Proc, December 2002, Vol 77
DEVELOPMENT OF HEALTH ANXIETY
It is widely accepted that anxiety is best understood as a
response to a perceived threat,11 with the degree of anxiety
experienced being proportional to the importance and im-
minence of the perceived threat. Thus, issues perceived as
central to one’s own welfare naturally form the focal point
of problems involving excessive anxiety. Because most
people would consider a threat to their own physical health
as vitally important, it is not surprising that health-focused
anxiety is a common phenomenon.8,12 Thus, it is useful to
conceptualize HC as an extreme manifestation of excessive
and persistent anxiety focused on a perceived threat to
one’s health.13,14 In particular, the central problem is a
relatively enduring tendency to misperceive essentially in-
nocuous bodily symptoms as evidence of serious physical
illness.15,16
The inclination to misinterpret health-relevant informa-
tion as threatening may arise as a consequence of basic, yet
erroneous, assumptions about health and illness or critical
health-related incidents. For example, equating hurt with
harm or observing a loved one’s bout with heart disease
may lead to the misinterpretation of indigestion as signs of
heart failure. General health assumptions can have a vari-
ety of foundations, including information obtained from
media sources or unpleasant personal experiences with
illness. The types of assumptions likely to lead to intense
health anxiety are those that are extreme or rigid. Research
has shown that individuals with HC have overly narrow
concepts of good health, for example, the belief that good
health is symptom free and that any symptoms are therefore
equivalent to illness.17 Most people would consult a physi-
cian if they had unexplained vertigo that persisted for sev-
eral days; however, a person prone to developing HC
would assume that “any light-headedness is always a sign
of serious illness.” The first assumption leads to appropri-
ate medical consultation or intervention, but the second
results in excessive and irrational fear, continuous monitor-
ing of symptoms, and urges to seek medical consultation.
Other problematic assumptions that may lead to mis-
taken interpretations and put someone at risk for develop-
ing HC include beliefs about health care habits, such as
“you shouldn’t waste any time getting to the doctor when
you notice anything unusual or it will be too late.” Beliefs
related to perceived personal weaknesses or vulnerability
to particular illness may function similarly. For example,
“cancer runs in my family,” “my father died when he was
my age,” or “I have a weak heart.” In vulnerable individu-
als, such beliefs may be activated by critical incidents, such
as the diagnosis of disease in a loved one or a well-publi-
cized health issue.
Another hypothesis proposed to account for the devel-
opment of HC is that some people have a genetically inher-
Mayo Clin Proc, December 2002, Vol 77
ited lower pain threshold and therefore are hypersensitive
to and aware of internal sensations that most people do not
notice.18 Such a condition might facilitate misattributions
of unfamiliar sensations to illness. Indeed, such a somato-
sensory amplifying style has been shown to predict the
discomfort and functional effect of illnesses such as respi-
ratory infections.19 Future genomic research will be neces-
sary to examine further the heritability of such a trait.
In summary, we hypothesize that HC develops when
mistaken health-related beliefs lead to misinterpretation of
benign physical signs and symptoms as serious illness.
This misinterpretation results in seeking excessive reassur-
ance of health status (ie, via physicians). Although it may
be interesting to speculate about factors that cause HC
symptoms, our conceptual model places less emphasis on
understanding the etiologic process and a higher premium
on understanding the persistence of HC symptoms.
WHY DOES HEALTH ANXIETY PERSIST DESPITE
REASSURANCE?
Most people at some point in their lives entertain concerns
about their physical health.12 In most instances these con-
cerns diminish when the person realizes they are un-
founded, such as when the patient gets feedback from a
physician or looks up corrective information on a Web site.
However, for patients with HC, even though their concerns
about physical symptoms are inaccurate, something ap-
pears to interfere with the effects of corrective information.
Hence, such patients continue to experience extreme health
anxiety and repeatedly seek medical consultation from
physicians who reassure them that they are not ill. Why do
these patients’ beliefs remain unchanged despite what
would seem to be convincing disconfirmation of their
fears? We describe particular processes that may prevent
patients from correcting their overestimation of health-
related threats, thus leading to the persistence of HC. These
maintenance factors largely belong to 3 domains: physi-
ologic, cognitive, and behavioral.
Physiologic Factors
We propose that the most salient maintenance processes
are those related to the physiologic correlates of anxiety
and stress. Anxiety (including fears concerning the threat
of serious physical illness) invariably results in autonomic
(sympathetic) arousal as part of the body’s normal reaction
to stress. This autonomic arousal serves to protect the
organism from danger and is termed the fight or flight
response because it prepares the organism to take immedi-
ate action (ie, attack or run). When danger is perceived or
anticipated, adrenaline and noradrenaline are released from
the adrenal glands, producing noticeable physiologic ef-
fects. Most people recognize increased heart rate as part of
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
Conceptual Hypochondriasis Model 1325
autonomic arousal, but other cardiovascular effects are less
notorious. These include increased blood flow to large
muscle groups (to prepare for action) and reduced flow to
the skin, fingers, and toes (to guard against blood loss).
Hence, during anxiety the skin may look pale or feel cold,
and fingers and toes may become numb or tingly.
Autonomic arousal also produces hyperventilation to
increase the flow of oxygen to muscle tissue. However, the
increase in speed and depth of breathing often produces
breathlessness, smothering or choking sensations, or even
pain or tightness in the chest. If no actual activity occurs,
the supply of oxygen to the brain is actually decreased with
prolonged hyperventilation. Although this is not a danger-
ous effect, it often produces a collection of temporary and
harmless symptoms including dizziness, blurred vision,
confusion, unreality, and hot flashes. Other effects pro-
duced by the fight or flight response include increased
perspiration, dry mouth, pupillary dilation (which results in
blurred vision or spots), and a decrease in digestive func-
tion (often producing sensations of nausea or constipation).
Finally, the associated muscle tension may result in aches,
trembling, shaking, and general tiredness.
How do these physiologic effects operate to maintain
health anxiety? Although these symptoms are not danger-
ous, they may occur unexpectedly and be uncomfortable.
Not surprisingly, individuals with HC often misinterpret
such symptoms as indicating the presence of severe ill-
ness.15 Thus, at the point that one is becoming anxious or
stressed over one’s health, more of the threatening symp-
toms seem to appear. The result is further anxiety, in-
creased autonomic symptoms, and an upward spiral, lead-
ing to urges to seek evaluation for a suspected medical
problem.
Cognitive Factors
Biases in the way that people with anxiety think about
health-related information also operate to maintain HC.
When anxiety over an illness arises, it is natural for indi-
viduals to search for additional evidence to confirm or
refute their fear. In such situations, most people are in-
clined to err on the side of caution because the costs of a
false-negative decision (assuming good health when an
illness is present) are considerably higher than those of a
false-positive decision (assuming illness when one is
healthy). However, this results in selective attention toward
information that might confirm the presence of sickness
(headache equals brain tumor) and the tendency to discount
information suggestive of good health (brief duration, re-
sponds to aspirin, no other symptoms, feels similar to pre-
vious headaches). Importantly, such selective attention can
bias the effect of information provided by physicians dur-
ing medical consultations. Thus, for individuals with HC,
1326 Conceptual Hypochondriasis Model
evidence of illness strengthens the belief that one is ill,
whereas information that is inconsistent with illness is
overlooked as either inadequate or immaterial. This ex-
plains urges to seek second opinions when physicians con-
clude that no sign of illness is present.
A second cognitive factor that serves to maintain HC
beliefs is body vigilance, which is defined as the tendency
to pay excessive attention to and monitor even slight per-
turbations and fluctuations that occur normally within the
human body.20 If patients are concerned about the presence
of threatening bodily symptoms, they will naturally moni-
tor themselves closely to detect any such signs. Extra atten-
tion may be paid to previously unnoticed normal bodily
changes (eg, gastric distention after eating), leading to
the discovery of “new” symptoms. In a particularly severe
example, constant monitoring of levels of head pain led a
woman with HC to misuse over-the-counter pain medica-
tion. This woman had particular concerns about brain can-
cer and had reasoned (incorrectly) that, if she took acet-
aminophen each time she felt a headache beginning, she
would know for sure that it was not a brain tumor because
the pain would dissipate. She was consuming 10 to 20
acetaminophen caplets per day when she was referred for
evaluation.
Another bias that serves to maintain beliefs in HC is
intolerance of uncertainty. Research of patients with anxi-
ety problems suggests that for such individuals, anything
less than complete certainty is extremely anxiety evoking,
especially if the uncertainty involves issues of perceived
importance.21 Most people accept a certain level of uncer-
tainty in everyday life (including issues related to their
health); however, those with HC interpret any doubts re-
garding their health as highly distressing. To reduce this
doubt and distress, health-anxious people tend to seek reas-
surance. Reassurance may take the form of asking physi-
cians for further evaluation, describing the symptoms to
others, checking medical references, or checking one’s
own bodily signs or symptoms (eg, taking one’s own blood
pressure, checking for lumps). However, perhaps contrary
to intuition, the assurances gained from this behavior serve
to strengthen, not reduce, severe health anxiety.
Behavioral Factors
Acting to bring about safety is a logical and adaptive
response for a person who perceives himself or herself to
be threatened. Such behavior also results in an immediate
reduction in anxiety concerning the potential for threat.
However, if the perception of threat is based on an errone-
ous belief, then the safety-seeking behavior also has the
effect of preventing the person from noticing that the fear
was groundless in the first place. For example, a spider
phobic who avoids spiders will never have a corrective
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
Mayo Clin Proc, December 2002, Vol 77
encounter with a spider through which to learn that spiders
are, for the most part, harmless. Safety-seeking behaviors
in HC may take the form of reassurance seeking to reduce
the fear and uncertainty about medical problems, body
checking or safety self-inspections, and/or avoidance of
situations associated with illness fears.
The most noticeable safety-seeking behavior in HC is
reassurance seeking, which is considered a defining symp-
tom of HC. Indeed, when a person turns to physicians,
medical references, or friends or relatives for reassurance,
he or she often achieves a temporary reduction in anxiety
about illnesses. This kind of reassurance seeking becomes
habitual because of the resulting reduction in health anxiety
and distress. With continued success at gaining reassur-
ance, the person will come to rely on such reassurance to
obtain relief from health anxiety; for example, “hearing Dr
Smith say I do not have cancer is the only way to get me to
stop worrying about it.” This in turn strengthens inaccurate
beliefs about illness. Reassurance seeking can also main-
tain faulty illness-related beliefs if patients receive dif-
ferent information from different resources or, worse, in-
consistent information from the same source on different
occasions.
Some safety-seeking behaviors not only prevent dis-
confirmation of incorrect beliefs but also increase the
symptoms that were the initial source of misinterpretation.
An example of such a behavior commonly observed in HC
is body checking. Patients who are concerned with particu-
lar symptoms (eg, neck soreness) often perform repeated
examinations of affected areas. These checks may range
from frequent manipulation of body parts to excessively
checking one’s own blood pressure or body temperature.
One effect of such checking is that it may augment discom-
fort, which is then misinterpreted as a sign of illness. For
example, one patient was worried that a raised birthmark
on her shoulder was an indication of skin cancer. Despite
reassurance from her physicians that it was benign, she
repeatedly examined the mark, often poking and prodding
it to determine whether it had worsened. Not surprisingly,
the area became infected and painful, and the patient inter-
preted this as a sign she was developing skin cancer.
Avoidance of fear cues represents another realm of
safety-seeking behaviors. We recently evaluated a middle-
aged man who ceased all exercise, believing that such
activity would overstrain his lungs and lead to lung cancer.
Avoidance can also be covert, such as in the case of a
teacher who always wore cotton in her ear for fear that “the
screaming children would lead to progressive deafness.”
Avoidance prevents self-correction of erroneous beliefs
about threat that naturally occurs when feared negative
outcomes do not materialize. In the previous example, the
teacher might report that she never lost her hearing because
Mayo Clin Proc, December 2002, Vol 77 Conceptual Hypochondriasis Model 1327

Notice a pain in my upper chest

“I could have esophageal cancer.

What if I forgot to tell the doctor all my symptoms?
It may be too late.
I will die a slow and painful death.”

Anxiety and uncertainty

Anxious arousal
Dizziness
“This means I have cancer.
Dry mouth or throat
It’s the beginning of the end for me.”
Racing heart
Nausea

Safety behaviors
Monitor throat
Check medical text
Ask wife or physicians
for reassurance

Figure 1. An idiosyncratic model of health anxiety.

she always wore cotton when around the children. Al-
though the probability of incurring hearing loss in such
situations is low, a sure way to avoid it is to plug your ears
with cotton. However, this subtle avoidance of harmless
noise levels prevents the teacher from discovering that
exposure to such noise does not lead to hearing loss,
thereby preserving her mistaken belief and irrational fear of
hearing loss.
TREATMENT
Understanding factors in the development and maintenance
of HC is critical to formulating an effective treatment strat-
egy. It follows from the biopsychosocial formulation pre-
sented herein that treatment must help patients recognize
and modify their incorrect beliefs and assumptions con-
cerning illness and eliminate barriers to self-correction of
such faulty beliefs. This treatment approach, called cogni-
tive-behavioral therapy (CBT), is a set of procedures that
are designed to weaken maladaptive beliefs and behavior-
al responses to specific situations or stimuli. We describe
specific CBT procedures shown to be effective in reducing
symptoms of HC.
Proper Medical Evaluation
Before treatment of HC can commence, a thorough
review of the patient’s medical records and a complete
medical evaluation are required. The possibility of any
coexisting or confounding organic basis for symptoms
(such as illness, injury, medication use, or substance abuse)
must be ruled out. Thus, if not already completed, it is
important for patients to undergo a comprehensive physical
examination before psychotherapy. Information from this
examination should be reviewed with the patient and sent
to the therapist to be used as evidence of good health. Only
after organic pathologic findings have been ruled out
should an assessment of HC be conducted. Additionally,
because severe depression may interfere with response to
CBT, comorbid mood disorders should be assessed and, if
present, pharmacological management considered.
Formulation of an Idiosyncratic Model
The initial step in CBT involves development of an
idiosyncratic model of the patient’s particular HC symp-
toms that will guide the use of specific therapeutic strate-
gies. This blueprint, typically discussed with the patient
and displayed on an easel or whiteboard, diagrams how the
patient’s fears of specific illnesses are influenced by his or
her general health-related assumptions. The model also
illustrates how the physiologic, cognitive, and behavioral
processes serve to maintain erroneous illness-related be-
liefs. An example of such a model for a patient seen in our
clinic is shown in Figure 1. This man’s fear of esophageal
cancer was cued by symptoms associated with acid reflux
diagnosed years earlier. When he felt pain in his upper

For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
1328 Conceptual Hypochondriasis Model
chest he thought, “What if the doctor is wrong and I really
have cancer?” This interpretation led to high levels of
anxious arousal, including dizziness, dry mouth, and upset
stomach, all of which he incorrectly believed were confir-
mation that he had cancer. He also frequently checked
medical references to determine whether his symptoms
were those of cancer and habitually telephoned or visited
his physician to gain reassurance of good health.
Education
Education about bodily symptoms and particularly the
symptoms of anxiety is an important component of CBT.
Patients are taught that anxiety is a normal and adaptive
reaction to a perceived threat that includes behavioral,
mental, and physiologic responses. They are also given an
explanation for the persistence of uncomfortable physi-
ologic symptoms in the context of anxiety: misinterpreta-
tion of normal autonomic responses as threatening leads
to increased anxiety and increased symptoms. Time spent
identifying feared bodily sensations and providing physi-
ologic explanations is time well invested. On the other
hand, the therapist must be sure not to engage the pa-
tient in repeated attempts to gain reassurance via such
discussions.
Modifying Erroneous Beliefs
A number of CBT procedures may be used to modify
patients’ excessive illness-related beliefs and assumptions.
One method, termed cognitive restructuring, is to help
patients identify evidence for and against beliefs that they
are ill.11 Patients with HC have reasons for believing that
their signs and symptoms are indicators of physical ill-
nesses, however strange they may seem. Therefore, the job
of the therapist is to (1) identify the patient’s basis for these
beliefs, (2) detect any contradictory events or experiences,
and (3) help the patient understand the importance of con-
tradictory evidence. For example, a patient who feared that
feelings of dizziness represented a developing brain tumor
found that when she sat down the dizziness (and her fear)
subsided. The therapist may then help the patient under-
stand what this means, perhaps by asking, “Would a cancer
specialist prescribe lots of sitting for someone with brain
cancer? If sitting would not stop a brain tumor, what role
might your sitting play in the symptoms? If the problem
was an erroneous belief about cancer, could it help?”
In addition to modifying overestimates of probability of
illness, it is useful to focus on modifying overestimates of
cost or outcome. The fear of dying is common for patients
with HC, yet many patients with HC have unrealistic be-
liefs about death and the dying process.14 For example, they
may believe that once dead they would feel extreme sorrow
about missing special events, as if still conscious. Thus,
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Mayo Clin Proc, December 2002, Vol 77
patients may benefit from dialogue about their beliefs con-
cerning the costs of dying.
Exposure and Response Prevention
Crucial to successful modification of unrealistic illness
beliefs is direct confrontation with situations or stimuli that
evoke illness fears. In exposure exercises, patients test their
predictions regarding whether, for example, the physical
sensations they experience are part of a severe illness or
merely symptoms of anxious arousal that dissipate after a
brief period. The patient with fears of esophageal cancer
had stopped his daily jogging routine after experiencing a
dry throat, which led to uncertainty about cancer. As an
exposure assignment, he was instructed to jog on a cold
morning and experience the throat discomfort he was
avoiding.
During exposure, it is also important for patients to
refrain from performing any safety behaviors or reassur-
ance seeking (response prevention) that might interfere
with modification of illogical illness beliefs. Thus, our
patient was instructed to refrain from asking his wife about
his symptoms, looking them up in medical dictionaries, or
visiting or calling any of his physicians for assurances. The
outcome of this assignment was that the patient’s discom-
fort dissipated after 15 minutes, and after a discussion with
the therapist, it was agreed that the most likely explanation
was that the pain was caused by the cold air as opposed to
cancer.
How Effective Is CBT for Health Anxiety?
Preliminary research on the use of CBT to treat HC has
provided encouraging results. The first treatment study22
appeared only recently and demonstrated that fewer than
20 sessions of CBT were more effective than no treatment
(wait list). Relative to the control group, patients treated
with CBT evidenced significant decreases on measures of
the need for reassurance, health anxiety, and checking. The
average reduction in general anxiety symptoms was ap-
proximately 70%, and the reduction in depressive symp-
toms was 53%. Moreover, CBT appears to be acceptable to
patients: only 6% of patients recruited for this study re-
fused to begin therapy, and only 6% discontinued therapy
prematurely.
In a subsequent controlled study,23 a regimen of 16
weekly sessions of CBT was shown to have both short- and
long-term efficacy (1-year follow-up) in reducing fears of
illness and unnecessary medical visits. In addition, CBT
was more effective than a control therapy involving the use
of general stress management techniques. This finding sug-
gests that the specific procedures of CBT (ie, cognitive
restructuring, exposure), as opposed to nonspecific factors
(ie, attention from a therapist), are the active ingredients for
Mayo Clin Proc, December 2002, Vol 77
improving HC symptoms. Again, refusal and dropout rates
were low (4%), suggesting acceptability. Although promis-
ing results have been obtained thus far, further research is
needed to extend the benefits of CBT for HC.
IS HC A FORM OF OBSESSIVE-COMPULSIVE
DISORDER?
Obsessive-compulsive disorder (OCD) is an anxiety disor-
der that involves intrusive anxiety-evoking thoughts (ob-
sessions) and urges to perform behavioral or mental rituals
(compulsions) that serve to reduce obsessional anxiety. It
has been suggested that because of similarity in symptoms
HC belongs to a spectrum of OCD-related disorders.24 Spe-
cifically, the unremitting thoughts and fears about illness
that endure despite reassurance in HC patients have been
likened to obsessional thoughts in OCD patients. Similarly,
attempts to seek reassurance by HC patients are reminis-
cent of compulsive checking rituals by OCD patients.25
That is, checking behaviors in HC patients serve as an
escape from preoccupation with illness, much as compul-
sive rituals (eg, washing) serve as an escape from obses-
sional anxiety (eg, germs). Indeed, empirical studies com-
paring symptom characteristics and affective states (ie,
anxiety and depression) in HC and OCD patients support
the notion that these 2 conditions are related.26 However,
there are also some important differences. In particular,
individuals with HC evidence more fears of bodily sensa-
tions and less insight into the senselessness of their fears
compared with individuals with OCD. On the basis of the
general similarities in symptom presentation and the simi-
lar effectiveness of CBT for both conditions,15 HC most
likely represents a form of OCD.27
CONCLUSION
Once considered secondary to other psychiatric illnesses
(ie, mood disorders), HC is now understood to often exist
as a primary problem. Frequently a drain on medical re-
sources, patients with HC can be viewed as essentially
having an anxiety disorder in which intense fear is focused
on the possibility that they might be seriously physically ill.
The processes that contribute to the development and main-
tenance of health anxiety consist largely of erroneous be-
liefs and assumptions about health and exaggerated behav-
ioral responses (eg, body checking, reassurance seeking) to
situations or stimuli that are erroneously perceived as
threatening. There is growing evidence that this concep-
tualization leads to effective reduction in HC symptoms via
CBT. Treatment begins with a precise formulation of the
problem in physiologic, cognitive, and behavioral terms,
followed by the use of various procedures that foster modi-
fication of erroneous beliefs or interpretations and exces-
sive responses.
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
Conceptual Hypochondriasis Model 1329
Table 1. Suggestions for Managing Patients With
Hypochondriasis in Primary and Specialty Settings
Problem Suggestions
Patient repeats Providing repeated assurance of good health
requests for strengthens the patient’s anxiety problem.
reassurance Instead, remind the patient that you have
answered his or her questions before and shift
the discussion to the patient’s concern over his
or her health. For example, “It seems like you
have been worrying a lot about your health
lately. Can you tell me what that has been like?”
Inquire about other forms of reassurance seeking,
such as checking medical references (books,
Web sites), asking friends or relatives about
symptoms, and checking one’s own body for
signs or symptoms
In light of previous false alarms, indicate that the
patient’s concern should be worry over illness
not illness per se. Recommend cognitive-
behavioral therapy as an effective means of
controlling this anxiety
Patient balks at Present a summary of the conceptual model
recommendation described herein. Help the patient understand
to seek therapy his or her tendency to misinterpret benign
symptoms as threatening, resulting in anxiety
and the need for assurances. Do not imply that
the patient has a disease or chemical imbalance
because this is not how health anxiety or
hypochondriasis is understood
Explain that treatment will help the patient over-
come his or her fears and chronic uncertainty
regarding his or her health. Recommend
keeping an open mind
By far, the main obstacle to successful treatment of HC
is the patient’s reluctance to view his or her problem as
anything other than physical. For this reason, it is often the
primary care or specialty physician who can suggest to the
patient that his or her difficulty is psychological in origin.
We are often consulted regarding how best to manage and
facilitate the referral of such patients for our services,
including CBT. Some recommendations that may be useful
to clinicians in similar predicaments are listed in Table 1.
Our experience is that patients appreciate when their physi-
cian shows an understanding of their worry and is able to
offer a logical and coherent explanation and rationale for
the need for psychiatric services.
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