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. The manual calls them "illness anxiety disorder" and "somatic symptom disorder", and reserves "health anxiety" for the dimension they have in common: the fear of illness and what it drives people to do.
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, in which rest brings relief and then deconditions (sections 5 and 37).
Format. Twelve 60-minute sessions, weekly; sessions 1, 2 and 8 last 90 minutes. Two booster sessions, at one month and at three months (section 32). In severe somatic symptom disorder, the programme extends to sixteen to twenty sessions without changing its components (section 37).
Mechanism targeted. The aim is to shift 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 or limited |
| 6 |
Reassurance |
Written contract with those close to the person |
| 7 |
Bringing on the sensations |
One resembling induction done three times, prediction 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 |
Four terms from this table recur throughout the manual. The consultation rule is a written list, drawn up with the GP, of the situations that warrant calling the emergency services, consulting promptly or waiting for the scheduled appointment (sections 12 and 22). The central belief is the person's main fear, noted word for word with their degree of conviction from 0 to 100 (session 1); it is not to be confused with the general beliefs about the body and illness, which are worked on at session 9. An induction is an exercise that deliberately brings on a feared sensation (session 7). The seven-day rule applies to a symptom that the consultation rule does not cover: it is left alone, without checking, and the person consults if it is still there or has changed on the seventh day (session 10).
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
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. Depending on whether it is a fear of illness with few symptoms, distressing symptoms experienced with excessive distress, panic, obsessional intrusions or a 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, if they are 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 (section 4).
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. When the certainty is unshakeable, the content bizarre, or other psychotic features are present, refer to Delusional disorder: a therapist's manual, or request a psychiatric assessment.
Severe chronic pain, on its own, 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 either checks and consults again and again, or avoids 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, in panic, exposure quickly disconfirms the prediction, since the catastrophe announced for the next few minutes does not happen, whereas here it does so much more slowly (section 6).
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. The treatment is exposure with response prevention, described in 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. It is recognised by unshakeable certainty, by bizarre content — being infested with parasites, giving off a smell that nobody else perceives — and by 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?" The answer is noted word for word, with a conviction rating from 0 to 100.
"When would it happen?" This question separates panic from health anxiety (presentation 3).
"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?" It 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. The person repeatedly palpates, measures, inspects themselves in the mirror, searches online, questions those close to them, consults, goes to emergency departments and asks for tests. This form is exhausting, costly, and visible.
The form that avoids. The person no longer sees a doctor, does not go for screening, does not open their results, and watches no documentaries. This form is discreet, and more dangerous: it delays real diagnoses. The fear is just as strong; it produces flight instead of searching.
Alternation. Some people go from weeks of intensive checking to giving up completely, "because what's the point anyway". In both phases, the aim is to bring down an unbearable anxiety.
Somatic symptom disorder
The symptoms. They are 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: work on reassurance and exposure to illness themes carry more weight in illness anxiety disorder; activity, sleep and functioning, in somatic symptom disorder.
5. What keeps the disorder going
Nine mechanisms. Most of them have one thing in common: they bring relief in the moment and make things worse afterwards.
Catastrophic interpretation. A headache becomes a tumour, a memory lapse dementia, an ectopic beat — a premature heartbeat, felt as a skipped 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, in which one goes back over the reasons not to worry. 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 lowers this threshold too (section 10).
For persistent symptoms, rest and activity. Rest brings relief, then deconditions, that is, reduces physical fitness; 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
The circle starts from a trigger, which is given a serious interpretation. The interpretation produces anxiety, and the anxiety produces sensations; attention locks onto the body and detects more of them. Then come checking, searching, asking, which bring relief for a few hours. Then the doubt returns, stronger, and the next trigger is easier to find than the last. This is the diagram you draw in session 2, in the person's own words.
Frequently asked questions
The patient asks me directly whether I think they are ill.
Do not answer on the substance, and say why: it is not your role, and your answer would hold for an hour. Refer back to the consultation rule: if the symptom matches it, they call their doctor today; if not, you apply what was decided.
And what if they really were ill?
It is possible, and it is the reason the consultation rule exists. The programme never closes off access to medical care; it stops that access depending on fear. A symptom that changes, gets worse or does not resemble the usual episodes gets assessed, during the programme as afterwards.
Should tests be repeated before starting?
No, unless the doctor judges that a symptom warrants it. What counts is that a proportionate assessment has been carried out by a doctor who knows the person. Repeating it so as to start "with peace of mind" is one more form of reassurance.
The patient rejects the idea that this is anxiety.
Do not try to convince them. Offer the two theories and a twelve-week trial: they do not have to give up theory A, they agree to test theory B.
The patient has a real illness. Does the programme apply?
Yes, if there is a clearly disproportionate preoccupation, judged with the doctor who follows the illness. The work focuses on calibrating vigilance, not on removing it. Section 38.
What should be done with a patient who avoids all doctors?
The programme keeps its order, but the avoided medical care becomes its common thread. It is identified and dated from session 3 onwards, and the doctor says what cannot wait: that is done straight away, prepared as an exposure. The rest — appointment, screening, result to be opened — forms the session 8 hierarchy, of which it is the main exposure, and whatever has not been done is taken up again at session 10.
And functional neurological disorder?
It is diagnosed in neurology and managed in a specialised way. You check that the diagnosis has been made and explained, you refer on, and you treat what falls within your remit: the associated anxiety, depression, avoidance. Section 8.
The partner says they cannot stop themselves from answering.
The contract must be requested by the person themselves, with a form of words agreed in advance; a joint session helps a great deal. Giving in from time to time maintains the insistence, and the only exception is a warning sign.
How many sessions?
Twelve in this manual, with two booster sessions; sixteen to twenty for severe somatic symptom disorder. Shorter formats have evidence, particularly when delivered close to medical care.
The patient is doing better, then a routine test sets everything off again.
This is anticipated, and it is written on worksheet 8. Two to four targeted sessions are most often enough, provided treatment resumes early.
The GP does not reply to my letter.
Have the person take it to the consultation. A doctor approached by their own patient, with a precise and short request, replies far more often than to a letter received without context.