By making patients aware of their automatic thoughts, feelings, behaviors, and underlying beliefs, CBT helps them normalize and cope with their illness anxiety. CBT techniques can be applied in a predetermined course of therapy (such as 12 sessions with a mental health clinician), in a group setting, or piecemeal by any health care provider.
Effective strategies. In a review of 30 controlled trials of CBT for somatoform disorders, Looper17 showed overall effect ranging from 0.38 to 2.5, where 0.2 was defined as a small effect, 0.5 as medium, and 0.8 as large. Hypochondriasis, somatization disorder, body dysmorphic disorder, chronic pain, chronic fatigue, and noncardiac chest pain were included in this review. The most effective strategies:
- included 6 to 16 treatment sessions
- were symptom-focused as opposed to providing general relaxation training
- included maintenance sessions after the initial series.
Four factors of health anxiety. CBT primarily targets the patient’s false beliefs that he or she is physically ill. These beliefs are based on how the patient misinterprets innocuous physical symptoms and responds to them.18 The cognitive theory of health anxiety holds that health anxiety severity is affected by four factors:
- perceived likelihood of illness
- perceived burden of illness
- perceived ability to cope with illness
- perception of the extent to which external factors will help.19
Table 1
Common dysfunctional beliefs of somatizing patients
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The first two factors worsen and the latter two mitigate health anxiety. An individual patient’s presenting fears often suggest which factors to address. For example, Mrs. M may describe the burden of illness as the focus of her fears (“If I have a heart attack, who will care for my children?”). This information cues you to shift the focus of therapy to helping her cope with child care needs despite her recurring symptoms.
If she focuses on her likelihood of illness, then uncoupling the symptoms from the diagnosis could be more productive. When she reports palpitations, diaphoresis, and dizziness, have her do breathing exercises that induce those symptoms without producing a heart attack.
Table 2
Journaling homework: 5 questions for patients to answer about one symptom each day
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She might describe feeling unable to cope when she feels symptoms or when cardiologists tell her nothing is wrong with her heart. In that case, focus on relaxation techniques, global stress reduction, and reducing cardiac risk factors to bolster her ability to cope with her illness.
Journaling is a critical component of CBT in treating somatization disorders. Regular journaling by the patient can reveal dysfunctional beliefs that may be driving his or her health anxieties, such as those listed in Table 1. We find it useful to assign patients to answer five questions about one symptom experience each day (Table 2). This self-monitoring provides material to work on with the patient during each session.
Cognitive restructuring. During therapy sessions, we ask patients to suggest alternate explanations for the symptoms recorded in their journals. We then ask them to determine which explanations are more feasible.
For example, if Mrs. M develops palpitations during emotionally charged arguments, we would ask her to develop explanations other than, “I was having a heart attack.” Reality testing includes rhetorical questions such as, “Would you be alive today if you were having a heart attack every time you had palpitations?” Automatic thoughts are successively identified and then tested aloud with the patient:
- “Has every unexplained symptom led to the discovery of a serious illness?”
- “Does every instance of hurt equal harm?”
Eventually, patterns of automatic thoughts emerge, and these reveal the underlying dysfunctional beliefs.
Dysfunctional beliefs are maintained when patients selectively attend to and amplify somatic sensations. Behavioral experiments during sessions can demonstrate to the patient in vivo the process by which they misattribute illness to physical symptoms. For example, overbreathing with a patient during a session may elicit light-headedness, paresthesias, or tachycardia, which can then be linked to overbreathing rather than a chronic or catastrophic illness.