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Prior to beginning work on this discussion,    
· Read the Assessment Strategies sections in Chapters 5 and 6 of the course textbook.
· Read the required articles 
The Use of Behavioral Experiments to Modify Delusions and Paranoia: Clinical Guidelines and Recommendations (Links to an external site.)
 and the 
Treatment of Mental Hypochondriasis: A Case Report (Links to an external site.)
 (Combs et al., 2007; Weck, 2014).
· Read 
Cognitive Behavioral Therapy Techniques that Work (Links to an external site.)

CBT and Behavioural Experiments (Links to an external site.)
, and 
Giving a Rationale for CBT (Links to an external site.)
 (Boyes, 2012; Lebon,  2009, 2012).
Choose a specific disorder, and then conduct web research to find a person (i.e., living or not, historical, famous, and/or even fictional) who suffers from one of the conditions listed. You will then use this individual as a case study for the specifications that follow for this discussion. Choose from the following list:
· Agoraphobia
· Anorexia or Bulimia
· Generalized Anxiety Disorder
· Depression
· Panic Disorder
· Obsessive-Compulsive Disorder
· Post-Traumatic Stress Disorder
· Specific Phobias (e.g., public speaking, heights, animals, etc.)
· Substance Abuse
For your initial post of a minimum of 350 words, assume the role of a cognitive behavioral therapist who is treating the individual you have researched. Your initial post should address and focus on the following items rather than centering the activity on a detailed description of the disorder.
· Briefly describe the disorder.
· Identify the assessment strategy for diagnosing the disorder.
· Describe in detail a cognitive behavioral experiment you might use with this client to address the chosen disorder. Your experiment should include both cognitive and behavioral aspects and be measurable.
· Apply cognitive and behavioral theories to explain and justify your experiment.

The Use of Behavioral Experiments to Modify Delusions and Paranoia: Clinical Guidelines and Recommendations.

Authors:

Combs, Dennis R.1 [email protected]
Tiegreen, Joshua
Nelson, Amelia

Source:

International Journal of Behavioral Consultation & Therapy. Jan2007, Vol. 3 Issue 1, p30-37. 8p.

Document Type:

Article

Subject Terms:

*COGNITIVE therapy
*PARANOIA
*DELUSIONS
*PSYCHIATRIC treatment
*PSYCHOSES
*PSYCHOTHERAPY
*THERAPEUTICS

Author-Supplied Keywords:

Behavioral Experiments
Cognitive-Behavioral Therapy
Delusions
Paranoia
Treatment

Abstract:

Recently, there has been a renewed interested in the treatment of psychosis and it is now appears possible to modify specific symptoms of psychosis such as paranoia and delusions using methods derived from Cognitive-Behavioral Therapy. One specific technique that has received less attention is the use of behavioral experiments. In this paper, we will focus on the treatment of delusions and paranoia using behavioral experiments. To put behavioral experiments in the context of treatment, we will first provide a brief review of cognitive-behavioral treatment of psychosis. This will be followed by a discussion of the different types and goals of behavioral experiments as well as specific recommendations and guidelines for the use of experiments for delusions and paranoia. We will conclude with a case study to illustrate the use of behavioral experiments in treatment. [ABSTRACT FROM AUTHOR]

 

Copyright of International Journal of Behavioral Consultation & Therapy is the property of American Psychological Association and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder’s express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Author Affiliations:

1Department of Psychology, Lorton Hall, Room 308, University of Tulsa, 600 South College Ave., Tulsa, OK 74104

ISSN:

1555-7855

DOI:

10.1037/h0100177

Accession Number:

24910541

Psychiatr Q (2014) 85:5764
DOI 10.1007/s11126-013-9270-6
ORIGINAL PAPER
Florian Weck
Published online: 10 August 2013 Springer Science+Business Media New York 2013
Abstract Hypochondriasis is characterized by intensive fears of serious disease. Most patients with hypochondriasis worry about physical diseases like cancer, although in rare cases, patients report severe fears of mental disorders (e.g., schizophrenia), a phenomenon described in the literature as mental hypochondriasis. However, little is known about this rare subtype of hypochondriasis and experts have questioned whether mental hypochondriasis has much in common with the type of hypochondriasis in which somatic diseases are the focus of preoccupation. This paper presents, a case report of a woman with a fear of schizophrenia, which was treated with cognitive therapy. This patient fullls the DSM-IV criteria of hypochondriasis and exhibits many characteristics (e.g., selective attention, safety behavior) considered to be maintaining factors in well-established cognitive-behavioral models of hypochondriasis. Cognitive treatment strategies for hypochondriasis (e.g., attention training, behavioral experiments) also proved effective in this case of mental hypochondriasis.
Keywords Hypochondriasis Health anxiety Cognitive therapy Fear
of schizophrenia
The main characteristic of hypochondriasis is a preoccupation with fears of having, or the idea that one has a serious disease, based on a misinterpretation of bodily symptoms. Moreover, this preoccupation persists, despite appropriate medical reassurance and occurs for at least 6 months [1].
Patients with hypochondriasis seek excessive reassurance (e.g., medical consultation, searching for health information online) and safety behaviors (e.g., constant bodily self-examination, weighing themselves) which is considered a maintaining condition for the
F. Weck (&)
Department of Clinical Psychology and Psychotherapy, University of Frankfurt, Varrentrappstrasse 40-42, 60486 Frankfurt, Germanye-mail: [email protected]
Treatment of Mental Hypochondriasis: A Case Report
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disorder (e.g., [24]). Particularly the medical reassurance behavior is associated with high costs for the health care system [5].
From a cognitive perspective, hypochondriasis reveals many parallels with anxiety disorders, in particular panic disorder [6]. One familiar cognitive-behavioral model of hypochondriasis [7, 8] hypothesizes that ordinary bodily sensations or illness related information are misinterpreted in a catastrophic manner and as a sign of a serious illness. This catastrophic (mis)interpretation symptoms leads to increased physiological arousal, a focus on ones own body, as well as reassurance, and safety behavior. The physiological changes, self-focused attention as well as the reassurance and safety behaviors lead to an increased preoccupation with the persons own health status, and the irrational conviction of having a serious illness becomes more and more entrenched. The classication of oneself as seriously ill in turn produces further physiological arousal, focused attention on the body, reassurance, and safety behaviors, and so on in a vicious circle.
Cognitive-behavioral treatment strategies for hypochondriasis focus mainly on modifying dysfunctional thinking, beliefs and attitudes towards illnesses and on reducing the excessive reassurance and safety behaviors of patients [7, 9]. In several randomized trials, such treatment has proven to be effective for the treatment of hypochondriasis [10]. Moreover, cognitive-behavioral therapy has demonstrated its superiority to short-term psychodynamic therapy [11], its effectiveness in different therapy settings, like group therapy [12] or internet-based therapy [13], and it seems to be effective in routine clinical settings as well [14].
Patients with a diagnosis of hypochondriasis fear cancer, heart, or neurological diseases like multiple sclerosis most frequently (see [15]). It has been reported that, on rare occasions, patients are afraid of a mental disorder as well, referred to as mental hypochondriasis [16, 17]. This is a reasonable expectation, as some mental disorders (e.g., schizophrenia) are comparable to physical illnesses (like cancer) in terms of severity, impairment, and prognosis. Moreover, in psychiatry, all disorders, as well as hypochondriasis (see [9]), are seen as biopsychosocial. Therefore, it does not seem necessary to distinguish between mental disorders (like schizophrenia) and physical illnesses and instead, all serious diseases should be considered for the diagnosis of hypochondriasis. However, little is known about mental hypochondriasis and it has been questioned whether this subtype of hypochondriasis has anything substantial in common with the type of hypochondriasis1 in which somatic disease is the focus of preoccupation (see [17]). Moreover, it is unclear whether the successful cognitive-behavioral treatment strategies are also effective for mental hypochondriasis.
In this paper, a case report of a woman with fears of schizophrenia is presented. There is rstly a discussion of whether this case actually fullls the criteria of DSM-IV hypochondriasis. Secondly, the course and results of cognitive therapy for (somatic) hypochondriasis are reported, in order to evaluate the usefulness of this approach for mental hypochondriasis.
Case Report
Description of Patient
The main concern of the 24 year old woman (further referred to as Mrs. A.) was of having a serious mental disorder, namely schizophrenia. Moreover, she reported feeling depressed,
1 To be differentiated from mental hypochondriasis, the type of hypochondriasis in which somatic diseases are the focus and referred to in this article as (somatic) hypochondriasis.
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concentration problems, tiredness, and sometimes the experience of feeling unreal (herself) or of the outside world as feeling unreal. She suspected that some of the reported symptoms were early signs of schizophrenia and consequently developed acute health- related fears, further ruminating about the consequences of schizophrenia on her own life. She consulted a psychiatrist who reassured her she did not have schizophrenia. However, thus reassurance only had a short-term effect on her health-related anxieties.
The diagnosis of hypochondriasis was based on the Structured Clinical Interview for DSM-IV (SCID-I) [18]. Table 1 shows the DSM criteria of hypochondriasis and Mrs. A.s accompanying symptoms and behavior. She had catastrophic beliefs about schizophrenia, that it means being isolated and in a psychiatric hospital forever, unable to hear yourself think, and never seeing your family again. She mentioned that this would be a state not better than being dead. Because Mrs. A did not generally recognize that her concerns about having schizophrenia were excessive or unreasonable, the DSM qualier with poor insight can be given. Possible differential diagnoses (e.g., panic disorder, obsessive compulsive disorder) were considered as well, but neither were these diagnostic criteria fullled. Mrs. A. displayed mild depressive symptoms, but did not fulll the diagnosis of a depressive disorder. There was no evidence of a personality disorder measured with the SCID-II [19].
The hypochondriacal beliefs and fears had started 4 years ago. In the beginning, these fears concerned the existence of a heart disease and, over the past 9 months, had focused on a mental disease (schizophrenia). Mrs. A. was married, but had no children. In the past, she had worked as a receptionist and was currently a homemaker. She received no additional psychopharmacological treatment. Mrs. A. described a typical situation concerning her problems, presented in a functional model in Fig. 1. Processes which are considered important for the maintenance of (somatic) hypochondriasis (e.g., selective attention, safety behavior, cognitive processing) were also considered important in the case of Mrs.A.
Self-Report Measures
Several self-report measures were used to evaluate the outcome of the cognitive therapy. For the assessment of hypochondriacal attributes, the illness attitude scales (IAS) [20, 21] were used. The IAS entails a questionnaire consisting of 27 items which are rated on a ve-point scale ranging from 0 (no) to 4 (most of the time). The IAS are considered to be the gold standard for self-rated assessment of hypochondriacal attributes and have demonstrated high reliability, validity, and sensitivity [22]. The German version of the IAS demonstrated high psychometric properties as well [2325].
Aspects of the general psychopathology were assessed with the brief symptom inventory (BSI) [26, 27]. For the assessment of depressive symptoms, the Beck depression inventory-II (BDI-II) [28, 29] was used.
Description of the Treatment
After the diagnostic phase, Mrs. A. received cognitive therapy, which included 12 weekly sessions lasting 50 min each. At the start, Mrs. A. was informed about the clinical picture of hypochondriasis (historical background, continuum of health anxieties, risk factors). Furthermore, she was informed how common physical sensations could be produced by normal bodily processes like homeostasis (see also [9]).
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Table 1 DSM-IV-TR criteria of hypochondriasis and the according pathology of Mrs. A
Criteria of hypochondriasis (DSM-IV-TR) Pathology of Mrs. A
A. Preoccupation with fears of having, or the idea that one has, a serious disease based on the persons misinterpretation of bodily symptoms
Mrs. A. displayed excessive self-focused attention and interpreted mild and temporary experiences of derealization and depersonalization as signs of schizophrenia
B. The preoccupation persists despite appropriate medical evaluation and reassurance
After a detailed interview, a psychiatrist reassured her that there is no evidence supporting a diagnosis of schizophrenia. However, this conrmation reassured Mrs. A. only temporarily
C. The belief in Criterion A is not of delusional intensity (as in delusional disorder, somatic type) and is not restricted to a circumscribed concern about appearance (as in Body Dysmorphic Disorder)
The belief of having schizophrenia was not of delusional intensity. For example, when a member of Mrs. A.s family told her that he or she thought Mrs. A. did not have schizophrenia, she was temporarily reassured
D. The preoccupation causes clinically signicant distress or impairment in social, occupational, or other important areas of functioning
The preoccupation with schizophrenia affected her most of the day. Mrs. A. worried a lot about her mental health and, in consequence, reported concentration problems. She tended to withdraw socially, ruminated about the potential catastrophic consequences of schizophrenia for her life, and had mild depressive symptoms
E. The duration of the disturbance is at least 6 months
The fear of schizophrenia lasted for 9 months
F. The preoccupation is not better accounted for by generalized anxiety disorder, obsessive compulsive disorder, panic disorder, a major depressive episode, separation anxiety, or another somatoform disorder
The main concern was a fear of schizophrenia. There were no other intensive worries, only shorter periods of neutralizing behavior, no panic attacks, and only mild depressive symptoms, which seemed to be a consequence of her fears. Moreover, there were no separation anxieties or intensive somatic symptoms which would suggest that another Somatoform Disorder was present
A behavioral experiment was carried out to demonstrate the importance of selective attention for the perception of bodily processes. Mrs. A. was instructed to hold a book with an outstretched arm, twice for 1 min each time. In the rst run, she was asked to focus on all the sensations in her arm and in the second run (after a short break), she had to form an image of a place she likes (a nice place at the beach). She realized that she was more aware of bodily symptoms after focusing on the sensations in her arm. A discussion then followed as to what extent her selective attention on mental processes might make her aware of such processes of which people are typically unaware and to what extent her selective attention could disturb these mental processes. Attention training was conducted, with the aim of changing Mrs. A.s focus of attention from inner processes to external stimuli (see [30]). Mrs. A. was asked to focus her attention on specic sounds in and outside the room (e.g., the sound of the clock, the noise of trafc). Mrs. A. was instructed to switch between the different sounds more and more rapidly. For the next step, she was supposed to simultaneously listen to as many sounds as possible. Mrs. A. was to practice this attention training every day for at least 15 min. After the attention training, Mrs. A. experienced fewer worrying symptoms like depersonalization and realized once again that selective attention might be maintaining for her problems.
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Situation
Mrs. A. is washing the dishes. She realizes that she is distracted and is daydreaming.
Cognitive processing
“Something is wrong with my mental health”. “I have schizophrenia”. Having schizophrenia is like being dead.
Affective reactions
Intensive illness-related fears; depressive symptoms
Perceptual reactions
Selective attention to own mental processes
Behavioral reactions
Checking her own mental processes; searching for reassurance in the Internet
Consequences
Short-term: a subjective feeling of control and consequently a reduction of the fears Long-term: intensive preoccupation with her mental health, perception and disturbance of automatic mental processes via selective attention, finding further alarming information in the Internet, which was falsely interpreted as evidence of schizophrenia, curious behavior (checking her own mental processes by trying to remember her own name and address) which is an object of further worry; increased risk of interpreting normal mental processes as signs of schizophrenia
Fig. 1 Functional model of a typical situation concerning her health anxieties reported by Mrs. A
The negative consequences of reassurance (e.g., asking family members for their opinions of her mental health, searching in the Internet for descriptions of schizophrenia) and checking behavior (e.g., checking her own mental processes by remembering her own name and address) for the maintenance of her health anxieties, were all discussed (see Fig. 1). Another structured behavioral experiment (see [31]) was planned in order to demonstrate the negative consequences of reassurance behavior. Mrs. A. was instructed no longer ask to her family for reassurance. This behavioral experiment was intended to clarify whether reassurance behavior is effective in reducing health-related anxieties long-term or whether it in fact increases selective attention towards ones own health status, making oneself more and more unsure, therefore maintaining health anxieties. As a result of the behavioral experiment, the reduction of Mrs. A.s reassurance behavior further reduced her selective attention on her own mental processes and led to a reduced preoccupation with schizophrenia, thus decreasing health-related anxieties. Further behavioral experiments were planned. For example, Mrs. A. had to go on her own for a walk near the river. She had previously avoided this, because she feared that she might attempt to drown herself in the river (she believed that people with schizophrenia tend to commit suicide). However, there was no evidence of Mrs. A. really wanting to commit suicide. The behavioral experiment was further proof for Mrs. A. that she would not irrationally and that she did not suffer from schizophrenia.
Mrs. A. repeatedly had the negative image of forever being trapped on a clinic bed in a psychiatric hospital. Therefore, this image was picked up in the therapy and rescripted (see
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Fig. 2 Scores of Mrs. A. in the illness attitude scales (IAS), the general severity index of the brief symptom inventory (BSI), and the Beck depression inventory II (BDI-II) before and after treatment
[32]). Firstly, the correspondence of this image with reality was questioned and discussed with Mrs. A. Secondly, an alternative scenario was constructed. In this scenario, Mrs. A. leaves the clinic bed, because she has no symptoms of schizophrenia and goes home to her own room. Thirdly, the alternative scenario was imagined, and the associated feelings explored. Fourthly, the alternative scenario was imagined regularly and whenever the old one occurred. Consequently, the frequency and intensity of the negative image of being held in a psychiatric hospital gradually diminished.
Rational arguments for and against Mrs. A. having schizophrenia were gathered. It became obvious that the more convincing arguments were against her suffering from schizophrenia (e.g., most of the necessary symptoms did not prevail). Therefore, an alternative explanation of Mrs. A.s symptoms was considered, which included experiences from current psychotherapy (e.g., selective attention makes people excessively aware of their own mental processes). In the end, helpful strategies were recapitulated and the therapist and Mrs. A. discussed how to use them in the future for relapse prevention.
Figure 2 shows the sum scores of Mrs. A. for the IAS, BSI, and BDI-II before and after treatment. In addition to a substantial reduction of hypochondriacal fears, a reduction of the general pathology and depression was also evident.
Discussion
Mental hypochondriasis is a rarely described phenomenon and some experts have questioned whether its occurrence has much in common with (somatic) hypochondriasis, in which somatic diseases are the focus of preoccupation. In the current article, the case of Mrs. A., who had fears of schizophrenia, was presented. It could be shown that her fears of schizophrenia were so extensive that she fullled the DSM-criteria for hypochondriasis.
Maintaining factors for mental hypochondriasis (e.g., selective attention, checking and reassurance behavior) were similar to those considered in cognitive-behavioral models [7, 8]. Thus, mental hypochondriasis seems to have much in common with (somatic) hypochondriasis after all. Therefore, it does not seem necessary to distinguish between mental and somatic hypochondriasis, but that it is appropriate rather to consider and treat patients with fears of mental disorders as one manifestation of hypochondriasis. However, an interesting nding is that Mrs. A. only has a score of 42 in the IAS, even though she fullled the
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diagnostic criteria for hypochondriasis and exhibited signicant impairment (e.g., high scores in the BSI). In previous studies, a cut-off of 45 or 50 was found to be optimal for differentiating between patients with hypochondriasis and other samples [23, 25]. Measures like the IAS may be more appropriate for (somatic) hypochondriasis and underestimate the prevalence and severity of mental hypochondriasis, because of their explicit focus on somatic disorders (e.g., Do you believe that you have a physical disease but the doctors have not diagnosed it correctly?). Therefore, issues relating to measures of health anxiety and hypochondriasis should be revised and address all diseases, rather than only physical diseases.
Cognitive therapy for (somatic) hypochondriasis has also proven effective for mental hypochondriasis. This result emphasizes that maintaining factors for mental and (somatic) hypochondriasis can be addressed effectively with the same treatment strategies. Moreover, mild depressive symptoms were also reduced by the applied cognitive therapy. This result was also found for the treatment of (somatic) hypochondriasis [10].
Overall, mental and (somatic) hypochondriasis seem to have much in common after all (e.g., pathology, impairment, maintaining processes), so that there is no need for a different classication for these two hypochondriasis phenomena. Cognitive therapy seems to be appropriate for the treatment of mental hypochondriasis as well. Possibly, the prevalence and severity of mental hypochondriasis have been underestimated, because the focus of current measures is on fear of somatic disease. Further empirical research (and diagnostic instruments) should therefore not be limited to physical diseases, but extend to all serious diseases.
References
1. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th edn., Text Revision. Washington DC, American Psychiatric Association, 2000.
2. Abramowitz JS, Moore EL: An experimental analysis of hypochondriasis. Behaviour Research and Therapy 45:413424, 2007.
3. Muse K, McManus F, Leung C, Meghreblian B, Williams JMG: Cyberchondriasis: Fact or ction? A preliminary examination of the relationship between health anxiety and searching for health information on the internet. Journal of Anxiety Disorder 26:189196, 2012.
4. Olatunji BO, Etzel EN, Tomarken AJ, Ciesielski BG, Deacon B: The effects of safety behaviors on health anxiety: An experimental investigation. Behaviour Research and Therapy 49:719728, 2011.5. Fink P, Ornbol E, Christensen KS: The outcome of health anxiety in primary care. A two-year follow-up study on health care costs and self-rated health. PLoS ONE 5:e9873, 2010.
6. Salkovskis PM, Clark DM: Panic disorder and hypochondriasis. Advances in Behaviour Research and Therapy 15:2348, 1993.
7. Salkovskis PM: Somatic Problems. In: Hawton K, Salkovskis PM, Kirk J, Clark DM (Eds) Cognitive Behaviour Therapy for Psychiatric Problems: A Practical Guide. New York, Oxford University Press, pp. 235276, 1989.
8. Warwick HMC, Salkovskis PM: Hypochondriasis. Behaviour Research and Therapy 28:105117. 1990.9. Abramowitz JS, Braddock AE: Psychological Treatment of Health Anxiety and Hypochondriasis: A Biopsychosocial Approach. Washington, Hogrefe, 2008.
10. Thomson AB, Page LA: Psychotherapies for hypochondriasis. Cochrane Database Systematic Reviews 4:CD006520, 2007.
11. Srensen P, Birket-Smith M, Wattar U, Buemann I, Salkovskis P: A randomized clinical trial of cognitive behavioural therapy versus short-term psychodynamic psychotherapy versus no intervention for patients with hypochondriasis. Psychological Medicine 41:43141, 2011.
12. Hedman E, Ljtsson B, Andersson E, Rck C, Andersson G, Lindefors N: Effectiveness and cost offset analysis of group CBT for hypochondriasis delivered in a psychiatric setting: An open trial. Cognitive Behaviour Therapy 39:239250, 2010.
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13. Hedman E, Andersson G, Andersson E, Ljtsson B, Rck C, Asmundson GJ, Lindefors N: Internet-based cognitive-behavioural therapy for severe health anxiety: Randomised controlled trial. British Journal of Psychiatry 198:230236, 2011.
14. Wattar U, Sorensen P, Buemann I, Birket-Smith M, Salkovskis PM, Albertsen M, Strange S: Outcome of cognitive-behavioural treatment for health anxiety (hypochondriasis) in a routine clinical setting. Behavioural and Cognitive Psychotherapy 33:165175, 2005.
15. Visser S, Bouman TK: The treatment of hypochondriasis: Exposure plus response prevention vs cognitive therapy. Behaviour Research and Therapy 39:423442, 2001.
16. Leibbrand R, Hiller W, Fichter MM: Hypochondriasis and somatization: Two distinct aspects of somatoform disorders? Journal of Clinical Psychology 56:6372, 2000.
17. Starcevic V: Clinical Features and Diagnosis of Hypochondriasis. In: Starcevic V, Lipsitt DR (Eds). Hypochondriasis: Modern Perspectives on An Ancient Malady. Oxford, Oxford University Press, pp. 2160, 2001.
18. First MB, Spitzer RL, Gibbon M, Williams JBW: Structured Clinical Interview for DSM-IV Axis I Disorder (SCID-I). Washington DC, American Psychiatric Press, 1997.
19. First MB, Spitzer RL, Gibbon M, Williams JBW: Users Guide for the Structured Clinical Interview for DSM-IV Personality Disorders (SCID-II). Washington DC, American Psychiatric Press, 1997.
20. Kellner R: Somatization and Hypochondriasis. New York, Praeger Publishers, 1986.21. Hiller W, Rief W: Internationale Skalen fr Hypochondrie. Deutschsprachige Adaptation des Whiteley-Index (WI) und der Illness Attitude Scales (IAS) (Manual) [International Scales of Hypochondriasis]. Bern, Huber, 2004.
22. Sirri L, Grandi S, Fava GA: The illness attitude scales. Psychotherapy and Psychosomatics 77:337350, 2008.
23. Hiller W, Rief W, Fichter MM: Dimensional and categorical approaches to hypochondriasis. Psychological Medicine 32:707718, 2002.
24. Weck F, Bleichhardt G, Hiller W: The factor structure of the illness attitude scales in a German population. International Journal of Behavioral Medicine 16:164171, 2009.
25. Weck F, Bleichhardt G, Hiller W: Screening for hypochondriasis with the Illness Attitude Scales. Jouranal of Personality Assessment 92:260268, 2010.
26. Derogatis LR, Melisaratos N: The brief symptom inventory: An introductory report. Psychological Medicine 13:595605, 1983.
27. Franke GH: Brief Symptom Inventory von L. R. Derogatis (Kurzform der SCL-90-R)Deutsche Version. Manual [Short version of the SCL-90-RGerman version] Gttingen, Beltz Test GmbH, 2000.
28. Beck AT, Steer RA: Manual for the Beck Depression Inventory-2. San Antonio, Psychological Corporation, 1996.
29. Hautzinger M, Keller F, Khner C: BDI II Beck Depression-Inventar (2. Revision). Frankfurt, Harcourt Test Services, 2006.
30. Papageorgiou C, Wells A: Effects of attention training on hypochondriasis: A brief case series. Psychological Medicine 28:193200, 1998.
31. Silver A, Sanders D, Morrison N, Cowey C: Health Anxiety. In: Bennett-Levy J, Butler G, Fennell M, Hackmann A, Mueller M, Westbrook D (Eds) Oxford Guide to Behavioural Experiments in Cognitive Therapy. Oxford, Oxford University Press, 2004.
32. Hackmann A, Bennett-Levy J, Holmes EA: The Oxford Guide to Imagery in Cognitive Therapy. Oxford, Oxford University Press, pp. 8199, 2011.
Author Biography
Florian Weck PhD is a clinical psychologist and assistant professor of the Department of Clinical Psychology and Psychotherapy at the University of Frankfurt (Germany). He has been interested in health anxiety and hypochondriasis for many years and his doctoral dissertation focused on the effectiveness of a cognitive-behavioral group treatment for hypochondriasis. He published several articles and a book on health anxiety and hypochondriasis. Currently he investigates the efcacy of cognitive therapy versus exposure therapy for patients with hypochondriasis in a randomized controlled trial.
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Springer Science+Business Media New York 2014

Cognitive Behavioral Therapy Techniques That Work
Mix and match cognitive behavioral therapy techniques to fit your preferences.
Posted December 6, 2012 |  Reviewed by Devon Frye

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THE BASICS
· What Is Cognitive Behavioral Therapy?

· Find a therapist who practices CBT

Cognitive behavioral therapy techniques come in many shapes and sizes, offering a wide variety to choose from to suit your preferences.
You and your therapist can mix and match techniques depending on what you’re most interested in trying and what works for you. You can also try the following cognitive behavioral therapy techniques as self-help.
Behavioral Experiments
In cognitive behavioral therapy, behavioral experiments are designed to test thoughts. For example, you might do a behavioral experiment to test the thought, “If I criticize myself after overeating, I’ll overeat less,” vs. “If I talk to myself kindly after overeating, I’ll overeat less.”
To do this, you would try each approach on different occasions and monitor your subsequent eating habits. This would give you objective feedback about whether self-criticism or self-kindness was more effective in reducing future overeating.
This type of behavioral experiment might also help counteract a (related) thought like, “If I’m kind to myself, it’s like giving myself a free pass to overeat and I’ll lose all self-control.”
Thought Records
Like behavioral experiments, thought records are also designed to test the validity of thoughts. For example, a clinical psychology student who gets negative feedback from a supervisor might jump to the conclusion, “My supervisor thinks I’m useless.” The student could do a thought record evaluating the evidence for and against that thought.
Evidence against the thought might be things like, “My supervisor gave me positive feedback yesterday” or “My supervisor is allowing me to run assessments and give feedback to clients. If she thought I was useless, she probably wouldn’t be allowing me to do that.”
Once you’ve looked at the objective evidence for and against a thought side by side, you’ll be able to come up with more balanced thoughts to take its place. An example of a balanced thought might be, “I made a mistake; making mistakes is normal. I can learn from this. My supervisor will be impressed to see me learning from my mistakes and incorporating her feedback.”
Thought records tend to help change beliefs on a logical level, whereas behavioral experiments may be more helpful in changing beliefs on a gut or felt level—i.e., what you emotionally feel is true, regardless of the objective evidence.
Pleasant Activity Scheduling
Pleasant activity scheduling is a surprisingly effective cognitive behavioral therapy technique. It’s particularly helpful for depression.
Try this: Write the next seven days down on a piece of paper, starting with today (e.g., Thursday, Friday, Saturday). For each day, schedule one pleasant activity (anything you enjoy that’s not unhealthy) that you wouldn’t normally do. It could be as simple as reading a chapter of a novel or eating your lunch away from your desk without rushing.
An alternative version of this technique is to schedule one activity per day that gives you a sense of mastery, competence, or accomplishment. Again, choose something small that you wouldn’t usually do. Aim for something that will take you less than ten minutes. An advanced version of this technique would be to schedule three pleasant activities per day—one for the morning, one for the afternoon, and one for the evening.
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Doing activities that produce higher levels of positive emotions in your daily life will help make your thinking less negative, narrow, rigid, and self-focused.
Situation Exposure Hierarchies
Situation exposure hierarchies involve putting things you would normally avoid on a list, ordered from bad to slightly better. For example, a client with an eating disorder might make a list of “forbidden foods,” with ice cream at the top of the list and full-fat yogurt near the bottom. A client with social anxiety might put asking someone on a date at the top of her list and asking someone for directions near the bottom. The theme of the list should reflect your most pressing problem, essentially.
For each item on your list, rate how distressed you think you’d be if you did it. Use a scale from 0 to 10. For example, ice-cream = 10; full-fat yogurt = 2. Order your list from highest to lowest.
Try to have several items at each distress number so there are no big jumps. The idea is to work your way through the list, from lowest to highest. You would likely experiment with each item several times over a period of a few days until the distress you feel about being in that situation is about half of what it was the first time you tried it (e.g., you can eat full-fat yogurt with a level of distress that’s 3 out of 10 instead of 6 out of 10). Then move to the next item up the list.
Imagery Based Exposure
One version of imagery exposure involves bringing to mind a recent memory that provoked strong negative emotions. Let’s take, for instance, the earlier example of a clinical psychology student being given critical feedback by a supervisor.
In imagery exposure, the person would bring the situation of being given the feedback to mind and remember it in lots of sensory detail (e.g., the supervisor’s tone of voice, what the room looked like). They would also attempt to accurately label the emotions and thoughts they experienced during the interaction, and what their behavioral urges were (e.g., to run out of the room and cry, to get angry, etc.). In prolonged imagery exposure, the person would keep visualizing the image in detail until their level of distress reduced to about half its initial level (say from 8 out of 10 to 4 out of 10).
Imagery based exposure can help counteract rumination because it helps make intrusive painful memories less likely to trigger rumination. Because of this, it also tends to help reduce avoidance coping. When a person is less distressed by intrusive memories, they’re able to choose healthier coping actions.
Summary
This list of cognitive behavioral therapy techniques is far from exhaustive—but it will give you a good idea of the variety of techniques that are used in cognitive behavioral therapy. If you’re working with a therapist and you’ve been doing your own reading about CBT, you can let your therapist know what techniques you’re excited to try.

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