This programme is a treatment manual written for mental health professionals. It assumes clinical training, experience of behavioural experiments and of conducting exposure, a working relationship with the doctors who look after the person, and a supervision framework. It replaces neither your clinical judgement nor your professional responsibility, and it replaces no medical assessment: the therapist never gives an opinion on the nature of a symptom. Diagnostic criteria are reformulated in our own words and never reproduced: refer to the original manuals for the wording itself. It is not written for the people concerned, who will find a guide written for them in The fear of being ill: health anxiety. In the face of a symptom that looks serious or a suicide risk, your country's emergency services come before anything written here.
1. The programme at a glance
Indication. Illness anxiety disorder and somatic symptom disorder in adults: the persistent fear of having or contracting a serious illness, with few or no symptoms; and distressing bodily symptoms accompanied by disproportionate thoughts, feelings and behaviours. The two presentations often overlap, and the programme treats the mechanisms they share.
Reference model. The cognitive behavioural model of health anxiety (Salkovskis and Warwick, 1986; Warwick and Salkovskis, 1990): ordinary sensations, signs or pieces of information are interpreted as proof of a serious illness, and four processes keep that interpretation going — physiological arousal, selective attention to the body, safety-seeking behaviours, and mood. For persistent symptoms, the programme adds what is known about symptom perception — the role of interpretations, expectations and attention (Rief and Broadbent, 2007) — and about the vicious circle of avoiding activity.
Format. Twelve 60-minute sessions, weekly; sessions 1, 2 and 8 last 90 minutes. Two booster sessions, at one month and at three months. In severe somatic symptom disorder, the programme extends to sixteen or twenty sessions without changing its components (section 37).
Mechanism targeted. Shifting the question. As long as the question is "am I ill?", no answer holds, because medicine does not deliver certainty. The programme replaces it with another one, which can be tested: "what best explains what is happening to me — an illness that has not been found, or a fear of illness that produces sensations, monitoring and checking?"
| Session |
Focus |
Session output |
| 1 |
Assess and triage |
Triage done, medical care inventoried, baseline measures |
| 2 |
The formulation and the two theories |
The circle written down, two theories set out |
| 3 |
The GP and the consultation rule |
Rule drafted, letter written |
| 4 |
Monitoring means finding |
Two experiments done, checking inventoried |
| 5 |
Checking and online searching |
Ceilings set, searching stopped |
| 6 |
Reassurance |
Written contract with those close to the person |
| 7 |
Bringing on the sensations |
Three inductions, predictions tested |
| 8 |
The words, images and places of illness |
Hierarchy written, scenario read |
| 9 |
Beliefs |
Central belief re-rated |
| 10 |
Living without certainty |
Seven-day rule applied, avoided care resumed |
| 11 |
Taking back |
Three dated resumptions |
| 12 |
Review, relapse, maintenance |
Written plan, measures repeated |
What the person takes away. Nine printable worksheets, listed in section 42: my record, my vicious circle and my two theories, my consultation rule, my checking and my searching, my experiments, what I avoid and what I take back, what I believe, my plan for what comes next, and the corner for those close to you.
What distinguishes this programme from the other manuals on this site. Three things. The consultation rule written with the general practitioner (GP), which protects both against serial tests and against the risk of missing a real illness. The treatment of reassurance as a maintaining behaviour in its own right — including the reassurance you are tempted to give. And the explicit distinction between what this programme treats and what it refers on, in particular functional neurological disorder.
2. Before you begin
Who this programme is for
This text is written for psychologists, psychiatrists, psychotherapists and doctors trained in cognitive behavioural therapy. It assumes that you accept three things: never saying that a symptom is benign, because that is not your role; not reassuring, even though the request will come back at every session; and working with the GP rather than alongside them.
It is written neither for the people concerned nor for those close to them: read by someone with health anxiety, a text that lists warning signs and differential diagnoses becomes one more checking tool. The guide The fear of being ill: health anxiety was written for them, and it is consistent with this manual.
The four preliminary decisions
Where does the medical assessment stand, and who is in charge of it? Section 11. It is not up to you to carry it out; it is up to you to know that it has been done, that it is proportionate, and that a lead doctor is responsible for it.
Which presentation is it? Section 3. Fear of an illness with few symptoms, distressing symptoms experienced with excessive distress, panic, obsessional intrusions, delusional conviction: the approach is not the same.
Is there depression or suicide risk? Both are common, especially when pain has lasted for years. They are asked about explicitly and, when severe, treated first. Sections 10 and 13.
Does the person consult too much, or avoid? Both forms exist, sometimes alternate, and steer the work on medical care in opposite directions.
What this programme does not treat
An organic illness. It never decides that there is none: the medical question belongs to doctors. It treats the fear, the monitoring and the distress, and it organises access to care without closing it off.
Functional neurological disorder, as the main focus. The diagnosis is neurological and the management specialised. Section 8.
A delusional conviction. Unshakeable certainty, bizarre content, other psychotic features: Delusional disorder: a therapist's manual, or a psychiatric assessment.
On its own, severe chronic pain, with heavy use of painkillers: the programme's principles apply, in liaison with a specialist pain service.
Factitious disorder or malingering, which involve the intentional production of symptoms.
How to use it
Read the whole text before the first session, in particular sections 6, 11, 12, 34 and 37: the model, working with the GP, the warning signs, reducing reassurance, and the adaptations for persistent symptoms. Each session is described using the same framework: the aim, the steps, what you say, the common errors, and the criterion for moving on.
Three warnings specific to this presenting problem.
The person often arrives hurt by medical care. They have heard "there's nothing wrong with you", "it's stress", "it's all in your head", and they expect the same from you. Treatment begins by not saying it to them.
You will be asked to reassure. "Do you think it's serious?" will come up at every session. Answering keeps the disorder going, and giving an opinion on a symptom lies outside your role: the two reasons converge.
And the opposite risk exists. People with health anxiety also fall ill, and the "anxious" label can lead to an illness being missed. The consultation rule from session 3 protects you as much as the person.
3. Five presentations not to confuse
Five people can say "I'm afraid I have something serious" and call for five different approaches. Triage takes fifteen minutes at the first session, and it decides the rest.
1. Illness anxiety disorder
What you observe. A persistent preoccupation with having, or developing, a serious illness, with few or no symptoms: an ordinary sensation, a mole, a lymph node, a memory lapse, a piece of news heard somewhere is enough. The person is easily alarmed, and there is either repeated checking and consulting, or the avoidance of anything to do with medicine.
The deciding question. "If you could be guaranteed that this sensation is harmless, would it still bother you?" If the answer is no, it is the meaning that causes the suffering.
What this implies. The programme described here, in its main form.
2. Somatic symptom disorder
What you observe. One or more real and distressing bodily symptoms — pain, fatigue, digestive problems, dizziness, palpitations — with distress, worry and a place in the person's life that are out of proportion.
The deciding question. "What makes you suffer most: the sensation, or what you fear it means?" When the answer is "both", it is often this one.
What this implies. The same programme, with the adaptations in section 37: the criterion of success becomes functioning.
3. Panic disorder
What you observe. Sudden surges of anxiety, peaking within a few minutes, with intense sensations.
The deciding question. "When would the catastrophe happen?" In the next few minutes, it is panic. In months or years, it is health anxiety. This difference explains why exposure quickly demonstrates what it needs to in panic, and much more slowly here.
What this implies. The attacks are treated first, with Panic disorder and agoraphobia: a therapist's manual; then the health preoccupation, if it persists.
4. Obsessive-compulsive disorder with a health theme
What you observe. Intrusions experienced as absurd, often about contamination or transmission to others, followed by precise rituals and an overwhelming sense of responsibility.
The deciding question. "If you fell ill on your own, with no risk to anyone else, would it be as terrible?"
What this implies. Exposure with response prevention: Treating obsessive-compulsive disorder in adults: a therapist's manual.
5. A proportionate reaction to a real illness, or an illness not yet recognised
What points the way. The worry follows a symptom that is new or changing, it subsides when information arrives, and it is not kept going by repeated checking.
What this implies. A medical opinion, not therapy. And, if the worry becomes disproportionate in relation to a real illness, work that calibrates vigilance instead of removing it. Section 38.
The three other things to have ruled out
Depression, which produces pain, fatigue and ideas of illness. In older people, a conviction of being ill tinged with fatalism or guilt should prompt a search for severe depression.
A delusional conviction. Unshakeable certainty, bizarre content — being infested with parasites, giving off a smell that nobody else perceives —, a total absence of doubt.
Factitious disorder, rare, never to be presumed, and not to be confused with somatic symptom disorder, in which nothing is intentional.
The four triage questions
"What are you afraid it might be?" Noted word for word, with a conviction rating from 0 to 100.
"When would it happen?" Separates panic from health anxiety.
"If the best specialist told you it was not that, what would you think?" The person with health anxiety most often answers that they would be relieved for a few days, then would wonder whether the specialist had missed something. The person with a delusional conviction answers that the specialist is wrong, without any doubt.
"And when it takes hold of you, what do you do?" Separates the form that checks and consults from the form that avoids, and picks up rituals.
4. The two presentations, in detail
Illness anxiety disorder
The themes. Cancers, neurological diseases — multiple sclerosis, amyotrophic lateral sclerosis, brain tumour —, heart attack, stroke, serious infections, dementia in older people: serious, widely publicised illnesses whose described first signs resemble sensations that everyone experiences.
The feared illness moves. A normal test calms the fear of a digestive cancer, and the fear of multiple sclerosis takes its place. The content changes, the mechanism does not, and it is the mechanism that is treated.
The form that consults. Palpating, measuring, the mirror, online searches, questions to those close to them, multiple consultations, emergency departments, requests for tests. Exhausting, costly, and visible.
The form that avoids. No doctor, no screening, no result opened, no documentary watched. Discreet, and more dangerous: it delays real diagnoses. The fear is just as strong; it produces flight instead of searching.
Alternation. Weeks of intensive checking, then giving up completely "because what's the point anyway". In both cases, the aim is to bring down an unbearable anxiety.
Somatic symptom disorder
The symptoms. Real, often multiple: pain in the back, joints, head or abdomen, fatigue, digestive problems, palpitations, dizziness. They can accompany a recognised illness; what counts is the disproportionate response they give rise to — persistent thoughts about their seriousness, high anxiety, and a life organised around them: monitoring, resting, looking for a cause, consulting, giving up activities.
What is not enough to make the diagnosis. A recognised functional syndrome — irritable bowel syndrome, fibromyalgia, tension-type headache — is not in itself somatic symptom disorder. Many people who have one cope with it proportionately. The diagnosis rests on the excessive psychological response, not on the origin of the symptom.
The overlap
The classifications decide on the basis of whether or not significant symptoms are present; in practice, the two presentations share the same maintaining mechanisms, and this programme treats them together. What changes is the weight given to each component: reassurance and exposure to illness themes in illness anxiety disorder; activity, sleep and functioning in somatic symptom disorder.
5. What keeps the disorder going
Eight mechanisms, which have one thing in common: each brings relief in the moment and makes things worse afterwards.
Catastrophic interpretation. A headache becomes a tumour, a memory lapse dementia, an ectopic beat heart disease. The interpretation produces anxiety, and the anxiety produces sensations — tension, palpitations, digestive upset — that seem to confirm it.
Selective attention to the body. The more one monitors a part of the body, the more sensations one perceives there. This is not imagination, it is detection: the body constantly produces signals that we filter out, and attention lifts the filter. Added to this is a tendency, described under the name of somatosensory amplification, to experience these sensations as more intense and more worrying.
Checking. Palpating, pressing, looking, measuring, testing one's strength or memory. One always ends up finding something, because the body is irregular; one irritates what one palpates; and one confirms to the brain that monitoring is necessary.
Reassurance. From those close to the person, doctors, pharmacists, forums, the therapist, and from oneself through mental reviews. It genuinely brings relief, briefly, and it prevents the person from learning to tolerate doubt. In people with high health anxiety, the calming effect of a normal test wears off quickly (Lucock et al., 1997); Salkovskis and Warwick (1986) had described this paradox from the very beginning of the model.
Online searching. For any ordinary symptom, the benign explanation and the rare disease appear side by side; anxious attention goes to the latter, and the next search starts from there. This escalation has been described under the name of cyberchondria (Starcevic and Berle, 2013). Chatbots can play the same role.
Avoidance, or excessive use of medical care. On one side, the avoidance of words, hospitals, exertion, screening and results, which prevents the person from discovering that the situation is bearable and, when it concerns medical care, creates the very risk it fears. On the other, multiple consultations, emergency visits and repeated tests: each normal test brings relief for a few days, reinforces the need for the next one, and exposes the person to incidental findings that rekindle the worry.
Arousal, mood and sleep. Anxiety maintains the sensations; depression lowers the threshold for pain and fatigue and darkens interpretations; poor sleep does the rest.
For persistent symptoms, rest and activity. Rest brings relief, then deconditions; on better days, the person does too much, and the next day confirms that activity is dangerous. This circle of overdoing it and collapsing is dealt with separately (section 37).
And the healthcare system itself. "We haven't found anything" is heard as "we haven't found it yet". Contradictory opinions, tests ordered to reassure, missing explanations: it is nobody's fault, and that is why the programme works with the GP.
The complete circle
A trigger. A serious interpretation. Anxiety, which produces sensations. Attention that locks onto the body and detects more. Checking, searching, asking, which bring relief for a few hours. Doubt that returns, stronger. And a new trigger, easier to find than the last. This is the diagram you draw in session 2, in the person's own words.