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	Running head: CBT for health anxiety
Article type: Case report


COGNITIVE-BEHAVIORAL THERAPY FOR HEALTH ANXIETY DISORDER: A CASE REPORT OF A JAPANESE MALE SUFFERING THE AFTEREFFECTS OF APOPLEXY AND ATTEMPTED SUICIDE

Mayuko Okita1)3), Osamu Kobori2), Tetsuya Shiraishi3)4), Masaomi Iyo3)

Chiba Aoba Municipal Hospital, Chiba, Japan 
Centre for Forensic Mental Health, Chiba University, Japan
Department of Psychiatry, Graduate School of Medicine, Chiba University, Japan
Research Center for Child Mental Development, Graduate School of Medicine, Chiba University, Japan

*Correspondence concerning this article should be addressed to Mayuko Okita, Department of Psychiatry, Chiba University Graduate School of Medicine. 1-8-1 Inohana, Chuouku, Chiba, Japan. Email: okitam@chiba-u.jp Tel: +81-HYPERLINK "tel:310-794-9756"43-226-2297

Word count: 4865
Abstract
Health anxiety, also known as hypochondriasis, is classifiable as an anxiety disorder. We present a case report on the effects of a brief cognitive-behavioral therapy (CBT) on health anxiety in order to demonstrate the successful implementation of techniques proposed by cognitive-behavioral models of health anxiety. The client was a Japanese male suffering from slight paralysis in his limbs and the left recurrent nerve. The case formulation suggested that he was misinterpreting his health condition, which made him more anxious and fostered a range of safety-seeking behaviors, including reassurance seeking. The intervention involved attention training and preventing reassurance seeking and the provision thereof. In addition, �mastery and pleasure ratings� were used to improve the patient�s mood and increase his engagement in activities other than preoccupation with his health condition. These techniques enabled the client to stop his reassurance seeking behavior and rumination about his symptoms. The present study demonstrated the effectiveness of CBT in reducing health anxiety relating to actual medical conditions.

Keywords: health anxiety; hypochondriasis; aphasia; reassurance seeking behavior; single case experimental study; cognitive behavioral therapy. 

Introduction
Hypochondriasis can be categorized as an anxiety disorder (termed �health anxiety�) because it has much in common with both obsessive-compulsive disorder (OCD) and panic disorder. According to the cognitive behavioral model [e.g., 1] of health anxiety, individuals who experience severe and persistent symptoms of the disorder have a relatively enduring tendency to misinterpret bodily symptoms, bodily variations, medical information, and any other health-related information as evidence that they currently have, or are at risk of developing, a serious physical illness. 
Some uncontrolled case series have shown promising results of behavioral treatment of hypochondriasis. Salkovskis and Warwick [1] reported two cases of hypochondriasis that were successfully treated with cognitive-behavioral therapy (CBT) using a single-case experimental design with alternating treatments. Furthermore, Warwick and colleagues [2] reported successful results while using CBT to treat 32 patients with severe health anxiety. Health anxiety and disease conviction dramatically decreased, along with comorbid depression. More recently, Sorensen and colleagues [3] carried out a randomized controlled clinical trial on 76 patients who had been diagnosed with health anxiety. These authors compared the effects of CBT with those of short-term psychodynamic therapy (STSPT). They subsequently found that the CBT group showed greater improvements than the waiting-list control group on all measures. In addition, this group showed greater improvements than the SSPT group on a measure of the main outcome variable (i.e., health anxiety) and a measure of depression; more specifically, CBT patients� scores on the Health Anxiety Inventory declined from 28.8 in the pre-treatment condition to 15.2 post-treatment. Hedman and colleagues [4] compared the effects of providing an Internet-based protocol, mostly based on CBT, with those undergoing attention training on health anxiety. At the end of the treatment, 67% of CBT participants could no longer be considered to have health anxiety. 
Looper and Kirmaye reported that, although cases that meet the criteria of hypochondriasis are rare within a given community [5], lower levels of health anxiety are extremely common among individuals with actual physical ailments, or in some instances, individuals have reasons to regard their longer-term health status as ambiguous. 
Health anxiety and reassurance seekingSafety-seeking behavior is an important and undesirable feature of health anxiety, just as it is in other anxiety disorders. Safety-seeking behaviors might maintain health anxiety by preventing the acquisition of information that completely disconfirms the inaccurate threat beliefs through a misattribution of safety [6, 7], or by diverting attentional resources away from disconfirming information [8, 9]. Health anxiety sufferers often attempt to cope with their anxiety by carrying out safety-seeking behaviors, including avoidance (of hospitals, specialist clinics, sick people, blood, the mentally ill, and so forth), repeated medical consultations and tests, self-checking (of their bodies, memory, or vision), compulsive requests for reassurance, and repeated searches for reassuring information on websites. �Those safety-seeking behaviors interrupt their habituation to distress and modifications to maladaptive cognitions; individuals with health anxiety may conclude that they feel safe just because they tried hard to prevent harm by engaging in range of safety-seeking behaviors.� Evidence indicates that safety-seeking behavior can reinforce maladaptive behavior and interfere with the progress made through therapy [10]. Olatunji and colleagues [11] demonstrated through their well-conceived experiment that engaging in hygienic safety-seeking behaviors exacerbated the bodily �symptoms� experienced by health anxiety sufferers, also increasing participants� scores on measures of health anxiety. Safety-seeking behavior could also interfere with treatment techniques, such as CBT. The behavior could disrupt or undermine the effects of exposure exercises, and interfere with the required disconfirmations of maladaptive cognitions. Thus, in the longer term, safety-seeking behavior is partly responsible for maintaining health anxiety. 
Seeking reassurance is regarded as a type of safety-seeking behavior; researchers have suggested that it is a fundamental mechanism in the development and maintenance of severe and persistent health anxiety. Among individuals with health anxiety, requests for reassurance tend to focus on health status (e.g., �Do I have a disease�?; �Is this spot cancerous�?). In such contexts, it has been shown that the excessive tendency to seek reassurance contributes towards unnecessary health costs (e.g., increased and unnecessary medical consultations by those experiencing health anxiety [1]) and the long-term exacerbation of compulsive behavior (e.g., increased demand for additional reassurance; [1, 12]). 
Previously, few case studies have focused on reassurance seeking among health anxietyHA patients with actual somatic problems [13-15]. We hypothesized that preventing people from seeking reassurance or being provided with reassurance by others, along with active cognitive restructuring, would be effective in reducing persistent health anxiety. In this paper, we present a case study showing the successful treatment of an individual with health anxiety using CBT. The client was suffering from the aftereffects of apoplexy and attempted suicide; however, his health anxiety was not entirely due to his poor physical health.

Case summary 
The client was a 57-year-old inpatient Japanese male. At the time of the study, he was an aircraft engineer who was working at an airport in Japan. Four months prior to therapy, the client had a stroke in a vessel in the area of his anterior cerebral artery. This induced psychotic symptoms, such as delusions involving the belief that everyone he saw wanted to kill him. These symptoms drove him to attempt suicide by cutting his arms with a kitchen knife, which ruptured the nerves and vessels in his wrist, and caused severe bleeding and brain injury due to the loss of oxygen. After this incident, the client was admitted to the hospital where, incidentally, the first author works. At this point, the client was suffering from slight paralysis in his limbs and the left recurrent laryngeal nerve, which controls the vocal cords. He began to feel depressed, hopeless, and that he had lost too much. Despite improvements in his ability to perform everyday tasks, he began to fear becoming aphasic or permanently bedridden. He gradually became demoralized, eventually to the point where he was unable to attend rehabilitation. The client subsequently began seeking reassurance. His first reported episode of reassurance seeking was when he was sitting in a wheelchair, unable to stop himself from thinking that his nasal voice might be a sign that his paralysis was spreading. Furthermore, when someone asked him to repeat something that he had said, he worried that his words were difficult to hear. He, then, tried to elicit reassurance from the hospital staff by asking them if he spoke well or if his voice was audible. Reassurance seeking increased, particularly when the client noticed his nasal-sounding voice or someone asked him to repeat what he had said. Although he underwent a course of SSRIs, his fear of becoming aphasic and permanently bedridden did not significantly alter, despite his improving physical condition.

Case assessment
The patient was diagnosed with hypochondriasis by an experienced psychiatrist using the Structured Clinical Interview for Axis I Disorders (SCID-I). He had no other comorbid Axis I and II disorders. The previous medication regime had been fluvoxamine 150 mg/day and clonazepam 1.5 mg/day (although it could not improve his health anxiety), which remained constant throughout the CBT treatment. We decided to continue administering this medication, although the arousal-dampening effects of the benzodiazepine could interfere with the adequate activation of the fear structure. When we tried to reduce the benzodiazepine before introducing those treatments, the patient�s condition worsened. Therefore, we continued the medication after weighing its advantages and disadvantages [16].
 
Treatment
The therapist was the first author (MO), who was a sixth-year, postgraduate Japanese medical doctor then. CBT was identified as an appropriate form of treatment, which was regularly supervised by the second author (OK), a consulting clinical psychologist. The therapy course consisted of 10 weekly sessions, with each session consisting of 60 minutes of individual therapy. This course was selected to ensure that the therapy ended before the patient could be discharged from the hospital. The therapy was conducted both inside and outside the session room, and between-session homework was collaboratively designed by the patient and the therapist. The homework comprised a continuous trial of mastery and pleasure ratings, or attention training, all undertaken by the patient. Furthermore, the nurses in the ward understood the details of the treatment and collaborated with the authors to treat the client. 

Case Formulation
The client became anxious when he felt bodily changes, such as stuttering, or some form of speech impediment, firmness in his fingers, or any numbness in his body. Although he was reassured that his impediment was not progressive, he was afraid of becoming aphasic or permanently bedridden, which made him pay more attention to his body. 
He engaged in various activities to supposedly prevent himself from becoming aphasic or permanently bedridden, such as pronouncing �Ahhhhh� repeatedly, asking staff members questions for reassurance, walking for long periods (in order to become �fit�), and repeatedly stretching his limbs and fingers. He also felt regretful and hopeless, due to the actual loss of functioning in his limbs. 
The case formulation was collaboratively developed by the patient and the therapist. Typical triggers included being asked to repeat what he had said and noticing his nasal voice; these led him to catastrophize for example, �My body is losing function,� �I am going to be permanently bedridden and aphasic because my brain function is getting worse.� These thoughts made him feel anxious and pay more attention to inner sensations, thus motivating his safety-seeking behaviors, which in turn maintained his beliefs of functional decline. In addition, selective attention to his body allowed him to detect such triggers more frequently.
As this vicious circle continued, the patient became more convinced that he would eventually lose mobility and the ability to do things on his own, and eventually become permanently bedridden. He began to rest in bed more than necessary and stopped attending rehabilitation. As a result, he became less active and was more likely to feel fatigued; these deprived him of a sense of mastery and pleasure.

Mastery and pleasure ratings
The client reported losing all hope regarding the future because of the paralysis resulting from his suicide attempt. In addition, he was preoccupied with his symptoms almost all day, which made him more depressed and inactive. Thus, we customized �mastery and pleasure ratings� to help improve his mood and activity levels. Using the customized technique enabled him to stop ruminating about his disabilities; he also started noticing improvements and actively sought what made him feel more comfortable. He was surprised that he could change his mood and activities by trying to understand the steps he needed to take toward progress or what made him feel better. Gradually, he managed to resume rehabilitation, even if he felt unwell during the sessions, and finally started walking by more often. Eventually, he regained his hope for the future. 
Additionally, the client was asked to write down a problem list and solve each problem with the help of others, since his health anxiety seemed to be concurrent with anxiety about real problems (e.g., work, family, money).

Belief modification
A series of interventions were employed to modify his beliefs. First, in collaboration with the client, the therapist compared his (the client�s) beliefs with less threatening, alternative explanations. For instance, his main problem was extreme worry about his health condition, which made him pay closer attention to his bodily sensations and engage in other counterproductive behaviors that maintained this belief. The evidence nullifying the validity of this worry was that, in retrospect, he continued to recover and his physical functioning kept improving. 
Attention training was introduced in order to demonstrate to the client the way in which his increased self-focused attention affected his bodily sensations, thoughts, and anxiety. Once he learned how to shift his attention, he came to believe that it was natural for him to have a nasal voice, which was due to his stroke and slight paralysis. 
Behavioral experiments were conducted to reveal to the client that the more intensely he sought reassurance, the more anxious he became. We used the term �behavioral experiment� in the hope that this expression would stimulate his curiosity and interest when he felt anxious, as opposed to simply reminding him that anxiety would slowly subside if he does not seek reassurance. Thus, what we were referring to was tantamount to, �Let us test what happens if you seek reassurance and if you refrain from seeking reassurance.� In addition, he learned that while the absence of reassurance made him more anxious in the short-term, his anxiety slowly subsided in the long-term. Furthermore, he discovered through discussion with the therapist that people sometimes ask others to repeat what they have said for clarification, even if the latter do not have any problems with pronunciation. The client was encouraged to remind himself of the counterproductive effects of reassurance seeking, and replicate the behavioral experiment whenever he started to feel anxious. 
The nursing staff was asked to help prevent his reassurance seeking. The frequency with which he sought reassurance from nurses was not routinely assessed. However, his requests for reassurance included, �Can you understand what I�m saying? I feel that my condition has worsened and that I can�t speak anymore,� every time nurses went to his room for vital check-ups. Moreover, when he felt anxious about his health state, he called his nurses approximately every 30 minutes. Although we did not explicitly ask whether he had stopped �self-checking� when he was on his own, such as saying �Ahh� repeatedly, he stopped the reassurance seeking behaviors described above. In order to help prevent his tendency to seek reassurance, we shared the case formulation with the nursing staff and educated them on the counterproductive effects of providing reassurance. First, when he became anxious and tried to seek reassurance from the staff, they expressed reluctance to provide reassurance and reminded him of the discussion with the therapist. Second, when he engaged in self-checking, they asked him to stop it, reminding him of how counterproductive it would be in alleviating his anxiety. Finally, once he had managed to stop reassurance seeking, they asked him to tell them what he was going to write down for his mastery and pleasure records so that he could re-focus his attention on what he could do. During response prevention, he discovered that his anxiety subsided when he did not engage in any safety-seeking behaviors, including reassurance seeking. This helped him understand that he overestimated the threats and provided him with the opportunity to develop more accurate beliefs, such as �My speech is normal, even if I feel anxious, because this staff member understood what I said, and it does not worsen my condition.�
Thus, response prevention not only led to habituation, but also helped him understand that he overestimated the threat; he subsequently developed beliefs that were more accurate.

Results 
The Short Health Anxiety Inventory (SHAI) was developed specifically to assess health anxiety [17], and has been shown to have satisfactory psychometric properties [15, 18, 19]. The inventory has two main factors, namely, �probability of illness� and �severity of illness� [21, 19]. Furthermore, it can be used to assess therapeutic improvement (Clark et al., 1998; Sorensen et al., 2011). Given the broad perspective of health anxiety mentioned here, the SHAI would benefit from the inclusion of items pertaining to fears of developing a serious mental illness, items that assess a generalized fear of a variety of health risks, and those that address circumscribed, idiosyncratic fears of a particular illness. In addition, we administered the Obsessive Compulsive Inventory (OCI) [21] because previous studies have shown a relationship between health anxiety and OCD. Over the course of the intervention, SHAI ratings gradually decreased from 31 during session one to only 9 during session ten. In addition, the OCI ratings gradually decreased from 25 during session one to only 3 during session ten. Both sets of scores remained low at the 1-month and 6-month follow-up intervals (Figure 1). 

Insert Figure 1 about here

Over the ten sessions, the client�s score on the Beck Anxiety Inventory (BAI) [23] decreased from 14 to 3, and his score on the Beck Depression Inventory (BDI) [24] decreased from 15 to 3; these scores remained low at the 1-month and 6-month follow-up intervals (Figure 2).

Insert Figure 2 about here

Through the sessions described above and the between-sessions homework, the client learned to recognize anxiety as his main problem; thus, the intensity and persistence of his anxiety lessened. Upon learning that he could move, walk, and speak without his symptoms worsening, he began to enjoy his social life more. This subsequently increased his motivation to participate in the experiments. He could engage in other activities, such as watching TV and reading the newspaper, which made him feel more comfortable and relaxed. Gradually, the therapy and behavioral experiments enabled him to reduce the frequency with which he had been missing rehabilitation sessions, reassurance seeking behavior, and pessimistic statements about the future. Since the therapy improved his sense of mastery, pleasure, and self-esteem, he began to think about what to do after his discharge.
Ten-minute follow-up sessions were held once a month, and the therapist scored HAI at 1-month, 3-month and 6-month intervals. The follow-up sessions confirmed that the client�s health anxiety had not recurred. Furthermore, the client had expanded his range of activities and subsequently enjoyed his social life a lot more. His walking and speaking abilities improved and, eventually, he was able to work at a welfare institution without suffering from anxiety. 

Discussion
According to the self-report measures that we administered, the therapy was effective in reducing the client�s health anxiety, general depressed mood, and general anxiety. The OCI rating also decreased during therapy; this might reflect similarities between health anxiety and certain presentations of OCD with reference to preoccupation with health and disease, and the repetitive and pervasive nature of this preoccupation [18], [25]. Our results suggest that the therapy helped alleviate the patient�s fear of the progression of his paralysis, being permanently bedridden, and his concerns regarding being an inconvenience to his family. This section presents an outline of the manner in which the CBT was employed, before detailing the limitations of this research and suggesting future areas of study.
Patients who have both health anxiety and actual somatic problems tend to have vivid images of worsening conditions, particularly because their actual somatic symptoms (despite the low risk of being aggravated) and regular hospital visits remind them of their anxiety and heightens their awareness of their own health status. These images and anxiety maintain their catastrophic cognition and subsequent vicious circle. 
In the case of health anxiety, patients� fears tend to be ego-syntonic, which means that reassurance seeking easily facilitates their mobility (e.g., visiting hospitals) because their fears were linked to their state of health. The hospital staff might have felt obliged to provide reassurance, or provided it in order to encourage the patient to continue his rehabilitation. Understanding that his main problem was anxiety was helpful to him, coupled with the knowledge that his anxiety was subject to change, depending on his behaviors. The mastery and pleasure ratings helped him improve his depressive mood and activities, as well as decrease his preoccupation with his disabilities. This technique restored his motivation to pursue rehabilitation. 
Attention training was effective in decreasing the frequency with which the client attended to his malfunctions. However, this process of shifting attention should be gradually reduced because attention training could become a safety-seeking behavior if employed only to alleviate surplus anxiety. In this instance, attention training enabled the patient to understand the link between attention and anxiety, and the fact that his condition was stable. Decreases in the frequency of anxiety made the patient more active, and in turn, engaging in enjoyable activities decreased his preoccupation with anxiety. This positive interaction seemed to facilitate the patient�s acceptance of the psychosocial model of health anxiety.
Furthermore, behavioral experiments led him to realize that reassurance seeking was counterproductive to his health and anxiety. We decided to use behavioral experiments, as this sort of hypothesis testing would be more acceptable and enjoyable for the client, rather than exposure and response prevention. In addition, the idea of behavioral experiments could make him more curious and interested when he felt anxious, as opposed to simply reminding him that anxiety would slowly subside if he does not seek reassurance. For example, he may think, �Let�s test what happens if I seek or refrain from seeking reassurance.� 
We carefully monitored the patient�s reassurance seeking after being discharged. Generally, in Japan, almost all citizens are covered by the national health insurance and can go to any hospital or clinic without reference letters. This makes it easy for them to go �doctor-shopping.� This suggests that reassurance seeking may have cultural variations. Japan has a universal public pension insurance system that covers all citizens�70% of outpatient and inpatient treatment costs are covered by the national insurance, while the remaining 30% is covered by the citizens. Thus, the assessment and treatment of health anxiety should focus on the ways in which individuals spend their money on healthcare costs, along with other types of reassurance seeking behaviors, such as repeated medical consultations and examinations, self-checking, strict diets, and repeated searches for medical information on the Internet. This would be particularly important in Japan, where people are highly health-conscious and quite willing to purchase health products.
The present study has certain limitations, and several considerations should be taken into account for future research. First, because baseline data were not available, it was not entirely clear whether the observed improvement was entirely due to the CBT. Although the administration of medication was stable throughout the course of the therapy, we cannot discount the possibility that improvement could have been because of the medication. At the same time, we deciphered the possible effectiveness of CBT for cases that cannot be expected to improve substantially because of medication only. In addition, it is unclear as to how long the effectiveness of the therapy will continue. In future research, we should have longer follow-up periods with patients in order to confirm the long-term effects of the therapy, as well as its applicability to other people with health anxiety. In conclusion, the present study demonstrated that CBT was effective in reducing persistent health anxiety regarding actual medical conditions, and illustrated the manner in which individuals could be prevented from engaging in reassurance seeking behavior, or being provided with reassurance by others.
Lastly, the concept of hypochondriasis has been incorporated into illness anxiety disorders and somatic symptom disorders in the DSM-V. Starcevic (2013) explained that since 75% of hypochondriasis patients are excessively concerned and preoccupied with their somatic symptoms, their condition would be referred to as a �somatic symptom disorder.� In addition, 25% of hypochondriasis patients may have only a few somatic symptoms or none, with their main presenting feature being anxiety and preoccupation with having or acquiring a serious illness condition; this would be referred to as an �illness anxiety disorder� [26]. The distinction between these two conditions, as opposed to their being broadly conceptualized as hypochondriasis, could be helpful and hold important implications for treatment. Further research in this regard would be expected to facilitate greater diagnostic precision and more carefully tailored therapeutic approaches, as well as improve the outcomes of psychological treatments, such as CBT. 
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Figure Captions

Figure 1. Health Anxiety Inventory and Obsessive-Compulsive Inventory scores


Figure 2. Beck Anxiety Inventory and Beck Depression Inventory scores












PAGE  22
A case report of health anxiety



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