CBT for health anxiety

1. Introduction

Version followed: CBT-HA ("adapted cognitive behaviour therapy for health anxiety") as manualised by Helen Tyrer and Paul Salkovskis for the CHAMP trial (Tyrer et al. 2011 protocol; Tyrer 2013, Tackling Health Anxiety: A CBT Handbook). It is a brief version, 4–10 sessions, of the Salkovskis–Warwick cognitive-behavioural treatment of hypochondriasis (Salkovskis & Warwick 1986; Warwick & Salkovskis 1990). Where the longer specialist version differs (16 sessions over four months; Warwick et al. 1996), this is noted.

CBT-HA treats persistent, excessive worry about having or developing serious illness. This includes people who also have real medical conditions, seen in or near medical clinics (cardiology, respiratory, gastroenterology, neurology, endocrine, genitourinary). [source: Tyrer et al. 2011; Tyrer et al. 2017 HTA summary; Seivewright et al. 2008]

Core idea of change: the bodily sensations are real. Health anxiety comes from misreading normal or benign sensations, signs and medical information as evidence of serious disease. Several processes then keep the anxiety going:

body checking
reassurance seeking
attention narrowed onto the body and onto illness information
avoidance

The CHAMP materials describe the developers (Salkovskis and Warwick) as the originators of the model. [source: Tyrer et al. 2017 HTA summary; model as summarised from Warwick & Salkovskis 1989/1990 in Lees 2001]

Change comes when the client builds and tests a less threatening explanation: that the problem is fear of disease rather than disease. This is done through evidence gathering, perspective-taking techniques and by dropping checking and reassurance seeking, so that anxiety can fall without the short-term relief those behaviours bring. [source: Tyrer et al. 2011, Table 1]

Internet-delivered versions exist in the lineage. They are not covered. [uncertain]

2. Framework

Format (CHAMP version). [source: Tyrer et al. 2011; Tyrer et al. 2017 HTA summary; Seivewright et al. 2008]

Individual sessions, planned at 5–10 × 60 min. In practice the range was 4–10 sessions over 2–4 months, with a mean of about six.
Delivered in or close to the medical clinic that referred the client.
A booster session after the end of treatment is allowed.
Supported by patient booklets: three in CHAMP, one in the earlier genitourinary-clinic trial (up to seven sessions plus booklet; mean 4.3 sessions actually attended).
About half of sessions were audio-recorded. Recordings were given to patients to support progress.
Therapists in the trials were nurses, graduate research workers, trainee psychologists and other health professionals. Training was two all-day workshops plus a written handout of the essentials, then fortnightly supervision from a CBT-HA-trained practitioner.
Fidelity was rated with a health-anxiety version of the Cognitive Therapy Rating Scale (CTRS-HAV). Items are not reproduced here.
Specialist version for comparison: 16 individual sessions over four months (Warwick et al. 1996). [source: Warwick et al. 1996 abstract]

Who it is for (trial criteria, adapt clinically). [source: Tyrer et al. 2011]

Clinically significant health anxiety. CHAMP screened with the 14-item short Health Anxiety Inventory (HAI; Salkovskis et al. 2002) at a cut-off of 20 or more, then confirmed with structured interview questions for hypochondriasis.
Existing medical illness does not exclude anyone, provided it is not new and needing further investigation.
Defer CBT-HA when suspected significant pathology is still under active investigation (CBT may confuse or distress), when major illness is too severe, or when there is significant cognitive impairment.

Phases. The sources give the core elements (Tyrer et al. 2011, Table 1) and the handbook's chapter order: style, assessment, specific techniques, homework, goals, relapse prevention, troubleshooting (Tyrer 2013). They do not give a session-by-session timetable. The phase plan and session numbers below are a [synthesis] of those elements for a 6–8 session course.

Phase	Goals	Typical sessions	Move on when ([synthesis])
A. Assessment and engagement	Confirm health anxiety; check medical status with the referring team; list symptoms and interpretations; elicit worst fears; cost of health anxiety; set goals	1 (–2)	Client can name the feared illness and the main safety behaviours, and agrees to test the idea that worry, rather than disease, may be the problem
B. Formulation and alternative explanation	Shared vicious-cycle formulation; Theory A vs Theory B; pie chart and pyramid; risk evaluation	2–3	Client gives a meaningful probability to Theory B and agrees to gather evidence for it
C. Testing and dropping maintaining behaviours	Symptom–anxiety diary; cut checking and reassurance seeking; attention and avoidance work through behavioural experiments; homework each session	3–6	Lower HAI and belief ratings; checking and reassurance seeking clearly reduced; client designs own experiments
D. Relapse prevention and ending	Written blueprint; plan for new symptoms and future medical contacts; booster offer	last 1–2, plus optional booster	Client can explain their own cycle and what they will do with a new worrying sensation

Re-measure each session or every few sessions with a validated health-anxiety measure such as the HAI, which was CHAMP's primary outcome. Ask for 0–100% belief ratings in the feared illness, which is standard CBT practice. [source: Tyrer et al. 2011; belief ratings [synthesis]]

3. Guiding principles

The symptoms are real; the interpretation is the target. Never imply "it's all in your mind". Work on what the client makes of the sensations, not on whether the sensations exist. [source: model as summarised in Lees 2001; wording [synthesis]]
Do not try to prove the client is healthy. Help them test a second explanation: "fear of disease being more likely than actual disease". [source: Tyrer et al. 2011, Table 1] The Theory A / Theory B framing is associated with Salkovskis's writing; the primary texts are not drawn on. [uncertain]
Reassurance maintains the problem. Medical and personal reassurance brings short-term relief, then doubt and more seeking. The therapist does not supply reassurance either. [source: Salkovskis & Warwick 1986 and Warwick & Salkovskis 1989/1990, as summarised in Lees 2001]
Target what keeps it going: checking, reassurance seeking, attention to body and illness information, and avoidance, not the history of the fear. [source: Lees 2001 summary of Warwick & Salkovskis; Tyrer et al. 2011, Table 1]
The client generates the alternatives. In the pie chart the patient makes most of the suggestions, not the therapist. [source: Tyrer 2013, ch. 5]
Evidence over argument. Build evidence from the client's own diaries and experiments rather than debating. [source: Tyrer et al. 2011, Table 1 item 7; framing [synthesis]]
Make the cost of health anxiety explicit, because it fuels motivation to drop safety behaviours. [source: Tyrer et al. 2011, Table 1]
Work alongside medical care. Existing disease is compatible with CBT-HA. New, uninvestigated pathology is referred back, not interpreted away. [source: Tyrer et al. 2011]
Brief, structured, homework-driven and goal-led, with relapse prevention built in. [source: Tyrer 2013, chapter list]
Deliverable by trained non-specialists under regular supervision with recorded sessions, so clinicians new to CBT should arrange supervision. [source: Tyrer et al. 2017 HTA summary; Tyrer et al. 2011]
The handbook has a chapter on the "Style of therapy"; its content is not drawn on. [uncertain]

4. Intervention inventory

How this section is sourced. The CHAMP protocol lists eight "essential elements" of CBT-HA (Tyrer et al. 2011, Table 1). These are items 4.2–4.4 and 4.7–4.13 below and form the core of the version followed. Assessment, homework, goals and relapse prevention come from the handbook's chapter structure (Tyrer 2013). The pie chart steps come from the handbook's chapter 5.

The step-by-step detail for the other elements is not given in the sources. Those steps are written as [synthesis], built from standard CBT practice and from the model's maintenance processes (Warwick & Salkovskis 1989/1990, as summarised in Lees 2001). All example language is illustrative unless quoted and cited.

4.1 Screening and initial assessment

Purpose / when: Session 1. Confirm health anxiety is the main problem, check medical status, and gather the material for the formulation. [source: Tyrer 2013, ch. 4 title; Tyrer et al. 2011 for criteria]
Steps:
1. Give a validated health-anxiety measure (CHAMP used the short HAI; screening cut-off 20 or more).
2. Get consent to liaise with the referring clinician. Confirm there is no new symptom awaiting investigation. If there is, pause CBT-HA until it is resolved.
3. Take the current picture: the feared illness or illnesses; triggering sensations; what the client does when worried (checking, internet searching, consultations, asking family, avoidance); how often; and the impact on work, relationships and healthcare use.
4. Take a brief history of illness experiences (own and family), but keep the focus on the present.
5. Screen for depression, other anxiety disorders and suicidal thoughts, using standard risk assessment.
6. Give the explanation of health anxiety that the trials gave everyone at baseline: a plain account of the condition ("a simple explanation of the nature of health anxiety"). [source: Seivewright et al. 2008] Then give the booklet.
Steps 3–5 are [synthesis].
Example language (illustrative): "Your doctors have looked carefully at your body. I'd like to look carefully at the worry itself: what happens when it switches on, and what you do to cope with it."
Watch for: the client agreeing to come only to get a referral for more tests; active unexplained findings; severe depression. Working: the client describes worry episodes in detail rather than arguing for the diagnosis.

4.2 Listing all symptoms and how the client interprets them

Purpose / when: Sessions 1–2. This is the raw material for every later technique. It separates sensation from interpretation. [source: Tyrer et al. 2011, Table 1 item 1]
Steps ([synthesis]):
1. Draw two columns: what I notice and what I think it means.
2. List every current sensation, sign or medical finding the client worries about.
3. For each, write the client's interpretation in their own words, plus a 0–100% belief rating.
4. Mark which interpretation is the most frightening. That one leads into 4.3.
Example language (illustrative): "Let's write down everything your body is doing that worries you. Next to each one, put what goes through your mind when you notice it, and how much you believe that, from 0 to 100."
Watch for: symptoms the client is ashamed to mention, such as bowel, sexual or genital symptoms (privacy mattered in a genitourinary clinic). Working: the client starts to separate "I feel X" from "X means cancer".

4.3 Formulation of worst fears

Purpose / when: Sessions 1–2. Name the specific catastrophe: the disease, and what the client fears it would lead to, such as death, suffering, leaving children or being disabled. Health anxiety often hides a fear of death or of its consequences. [source: Tyrer et al. 2011, Table 1 item 2; elaboration [synthesis]]
Steps ([synthesis]):
1. Take the most frightening interpretation from 4.2.
2. Ask "and if that were true, what would happen then?" until the end-point is reached.
3. Ask for any image or "flash-forward" that comes with it, such as a hospital bed or a funeral.
4. Write the worst fear down in the client's words and rate belief and distress.
Example language (illustrative): "Say the headache really were a tumour. What is the worst part of that for you?"
Watch for: high distress, so pace it and normalise. Clients with a recent bereavement or a serious diagnosis in the family need sensitivity. Working: a clear, specific feared outcome that can later be tested and put in perspective.

4.4 Considering the price paid for health anxiety

Purpose / when: Sessions 1–2, and again whenever motivation dips. Weigh the costs of the worry and its safety behaviours to fuel change. [source: Tyrer et al. 2011, Table 1 item 5]
Steps ([synthesis]):
1. List the costs of the health anxiety itself, not of the feared illness. Cover time spent checking and searching, appointments and tests, money, effects on relationships and family, work, enjoyment, and sleep.
2. Ask what the client would do with the time and energy freed up.
3. Link the results to the goals in 4.5.
Example language (illustrative): "Whether or not anything is wrong with your heart, the worry about your heart is clearly costing you a lot. Let's add up what it takes from you each week."
Watch for: the client thinking the worry is protective ("if I stop worrying I'll miss something"). Note this belief and test it later in 4.10. Working: the client wants to change the worry rather than just get a clean scan.

4.5 Setting goals

Purpose / when: End of session 1 or session 2, reviewed throughout. [source: Tyrer 2013, ch. 7 title; content [synthesis]]
Steps ([synthesis]):
1. Translate the costs into specific, behavioural and measurable goals, such as "check breasts once a month only", "stop searching symptoms online", "go back to the gym" or "no unscheduled GP visits for a symptom that has been checked".
2. Avoid goals defined as certainty, such as "be sure I don't have cancer".
3. Rate progress at reviews.
Example language (illustrative): "'Never worry about my health' isn't something anyone has. What would you be doing differently in three months if this were much less of a problem?"
Watch for: goals that are really requests for more reassurance. Working: goals are observable and are being met step by step.

4.6 Shared formulation (the vicious cycle)

Purpose / when: Session 2. Explain how health anxiety is generated and fuelled, using the client's own material. [source: Tyrer 2013, ch. 2 title and ch. 5 summary ("how health anxiety is generated and fuelled" paraphrased); content from the Warwick & Salkovskis model as summarised in Lees 2001]
Steps:
1. Draw the cycle with a recent episode: trigger (a sensation, a news story, a friend's illness) → interpretation ("I have X") → anxiety → more sensations from anxiety itself.
2. Add the maintaining loops: body checking (which keeps attention on the body and can create soreness or new sensations), reassurance seeking and information searching, selective attention, and avoidance.
3. Show that each loop brings short-term relief but keeps the belief going.
4. Optionally add background: earlier experiences of illness and beliefs about health. Some versions of the model include longer-standing assumptions about health and doctors. [uncertain: not checked in a primary text]
Example language (illustrative): "So the tingling starts, you think 'MS', your heart races and the tingling feels stronger, you check and search, you feel better for an hour — and then it all starts again. Does that fit?"
Watch for: the client hearing "it's anxiety" as "you're imagining it". Stress that the sensations are real. Working: the client spontaneously spots the cycle in new episodes.

4.7 Two explanations: "fear of disease" versus "disease" (Theory A / Theory B)

Purpose / when: Session 2 or 3. This is the central reframe: test which explanation fits the evidence better, rather than trying to prove health. [source: Tyrer et al. 2011, Table 1 item 6: "Exploring the hypothesis of fear of disease being more likely than actual disease"] The A/B labels follow Salkovskis's published approach, which is not drawn on here. [uncertain]
Steps:
1. Write Explanation A, "I have a serious disease", and Explanation B, "I have a problem with worrying about having a serious disease".
2. Rate the belief in each, 0–100%.
3. List the evidence the client uses for A. Ask how each item would also fit B, for example "the sensation gets worse when I focus on it".
4. Agree what each explanation implies you should do. Under A, more tests and checking. Under B, reduce the behaviours that maintain worry.
5. Point out that years of acting on A, through tests and checking, have not settled the worry.
6. Propose a time-limited trial of acting as if B were true, then review. [synthesis for steps 3–6]
Example language (illustrative): "We have two possible explanations. I'm not going to try to talk you out of the first one. Can we spend the next few weeks gathering evidence on whether the second explains more of what's happening?"
Watch for: the client wanting certainty before trying. Point out that 100% certainty is not available about anyone's health. Working: belief in B rises and behaviour shifts.

4.8 Pie chart of alternative explanations

Purpose / when: Sessions 2–4, for any specific symptom with a catastrophic interpretation. It generates less threatening explanations and shows that the most serious cause is usually the least likely. [source: Tyrer 2013, ch. 5; Tyrer et al. 2011, Table 1 item 3]
Steps (paraphrased from Tyrer 2013, ch. 5):
1. Introduce it with a short invitation, e.g. "Let's make a pie chart of all possible causes" of the troubling symptom. [Tyrer 2013, ch. 5]
2. Together, list every possible cause of the symptom. The client should make most of the suggestions. Basic medical knowledge helps.
3. Group the severe, life-threatening causes under one heading, so the list does not become a catalogue of frightening diseases.
4. Fill in the pie by asking what proportion of people in the client's local area with that symptom would have each cause.
Example: in the handbook, a client with an intermittent dry throat or cough fears untreatable lung cancer. Listing the many ordinary causes of a dry cough, with lung cancer among them, shows the feared cause as the smallest slice. [source: Tyrer 2013, ch. 5]
Example language (illustrative): "Think of everyone in this town who has a dry cough today. What could be causing it for all of them?"
Watch for:
- The client adding new frightening diseases. Group them as step 3 says.
- The client insisting their own case is the exception. Bring in their own data from 4.10.
- The therapist doing the generating, which weakens the effect. [synthesis]
Working: belief in the feared cause drops after the exercise.

4.9 The pyramid

Purpose / when: The CHAMP protocol names "pie charts and pyramids" as ways of introducing alternative explanations. [source: Tyrer et al. 2011, Table 1 item 3] The pyramid's exact procedure is not given in the sources. [uncertain]
Steps ([synthesis], one plausible use consistent with its stated purpose):
1. Draw a pyramid for one symptom. The wide base is the many people with that symptom from common, benign causes. Narrower bands above are less common, treatable causes. The tiny apex is the serious disease.
2. Ask the client where most people with the symptom sit, and what route would be needed to reach the top, such as the other signs, tests and findings usually present.
3. Compare that with the client's actual findings.
Check Tyrer 2013, ch. 5, before using it as the manual intends.
Example language (illustrative): "Most people with headaches are down here at the bottom. What would have to be true for someone to be right at the top?"
Watch for: the same issues as the pie chart. Working: a shift in where the client places themselves.

4.10 Evaluating the risk of disease

Purpose / when: Sessions 3–5, when a high-probability estimate drives behaviour. Bring overestimated probability back to a realistic figure. [source: Tyrer et al. 2011, Table 1 item 4; steps [synthesis]]
Steps ([synthesis]):
1. Ask for the client's estimate (%) that they have, or will develop, the feared disease.
2. List the evidence for and against, including:
  - normal results
  - how long the symptom has lasted without progressing
  - how the symptom varies with anxiety and attention
  - age and risk factors
  - what the treating clinician said
3. Break the catastrophe into the chain of steps that would all have to be true, such as symptom → serious cause → missed by tests → untreatable. Estimate each link and note how the combined chance shrinks.
4. Re-rate the probability.
5. Do not quote precise disease statistics unless you are sure of them. Keep the source of any figures to the treating team.
Example language (illustrative): "For the worst to be true, several things all have to be true at once. Let's take them one at a time."
Watch for: the client using risk work as reassurance seeking, for example asking the therapist to confirm the numbers again and again. Let the client do the calculation once and move on. Working: lower estimates that last between sessions.

4.11 Symptom–anxiety diary

Purpose / when: From session 1–2 onward. Build evidence that symptom patterns follow anxiety, stress, attention and activity rather than disease progression. [source: Tyrer et al. 2011, Table 1 item 7 ("diary keeping")]
Steps ([synthesis]):
1. Give a simple daily record with these columns: date and time; situation; sensation; thought or interpretation (belief %); anxiety 0–10; what I did (checked, searched, asked, avoided); and anxiety afterwards and an hour later.
2. Review it every session and look for patterns:
  - symptoms appearing when stressed, tired, after illness news, or when focusing on the body
  - fading when absorbed in an activity
  - relief from checking or asking that does not last
3. Add the findings to the evidence for explanation B.
Example language (illustrative): "Let's be scientists about this for a week. Every time you notice the sensation, jot down what was going on and what you did."
Watch for: the diary turning into more body monitoring. Limit it to brief entries at set times if needed. Working: the client sees links between symptoms and anxiety that they did not expect.

4.12 Reducing bodily checking

Purpose / when: Sessions 3–6. Checking keeps attention on the body and stops anxiety settling. Repeated prodding or examining can itself cause soreness, swelling or new sensations. [source: Tyrer et al. 2011, Table 1 item 8; mechanism from Warwick & Salkovskis as summarised in Lees 2001]
Steps ([synthesis]):
1. List every form of checking: palpating lumps, pulse or blood pressure checks, examining moles or stools, swallowing tests, mirror inspection, and repeated thermometer use.
2. Estimate how often each happens, from the diary.
3. Run a short behavioural experiment. If the client checks a spot by pressing it, ask what happens when they press it repeatedly. With consent, a few presses in session typically produce tenderness. Discuss what daily prodding might be doing.
4. Agree a plan to drop checking, either at once or stepwise. For checks with medical value, such as monthly breast self-examination or a prescribed glucose check, agree a once-only, time-limited version at the recommended frequency, ideally confirmed by the treating clinician.
5. Predict the effect first ("If I don't check, anxiety will..."). Rate the urge and anxiety over the following hours and days, then compare with the prediction.
Example language (illustrative): "Checking feels like it keeps you safe. What does the diary say happens to the worry an hour after you check?"
Watch for:
- Covert or partial checking, such as glancing or brushing a hand over the area.
- Medically required monitoring: never ask the client to stop something their doctor has prescribed.
Working: urges peak and then fall over days, and sensations become less noticeable.

4.13 Reducing reassurance seeking (doctors, family, internet, therapist)

Purpose / when: Sessions 3–6. Reassurance gives short-lived relief, then doubt, new questions and more seeking, so the belief is never tested. [source: Salkovskis & Warwick 1986 and Warwick & Salkovskis 1989/1990, as summarised in Lees 2001; Tyrer et al. 2011, Table 1 item 8]
Steps ([synthesis] unless marked):
1. Map all the sources of reassurance: GP and specialist visits, A&E, private tests, partner and family, friends, internet symptom searches, health forums and the media.
2. Run a reassurance experiment. When the urge to seek reassurance arises, the client rates anxiety before seeking, straight after, and after a few hours. Plot the curve: a short dip, then a return, often with new doubts.
3. Make a reduction plan, for example:
  - no symptom searches
  - delete health apps that prompt checking
  - no repeat questions to the partner
4. With the client's consent, agree with family members a kind, non-reassuring reply that they give consistently. The family member acknowledges the worry and redirects to the plan. They do not argue about the symptom.
5. Agree with the GP or treating clinician a planned contact arrangement for new or changed symptoms, rather than visits driven by anxiety. That clinician decides what needs medical review. [synthesis; trials delivered CBT-HA within medical clinics, Tyrer et al. 2011]
6. Notice when the therapist is being asked for reassurance, and reflect it back rather than answering.
Example language (illustrative):
- To the client: "If I told you you were fine, how long would that last?"
- For a partner: "I can see you're worried. We agreed I wouldn't answer health questions — let's go for that walk."
Watch for:
- Reassurance seeking that moves elsewhere, for example from Google to friends.
- The family feeling unkind. Explain the rationale to them.
- Genuinely new red-flag symptoms, which must still go to a doctor. Agree in advance with the client and doctor what counts as new.
Working: fewer unscheduled consultations and searches, and the anxiety curve flattens without reassurance.

4.14 Attention-focusing experiment (selective attention)

Purpose / when: Sessions 2–4. Demonstrate that attention to the body amplifies sensations, and that scanning for illness information makes illness seem everywhere. [source: role of selective attention in the model, Warwick & Salkovskis 1989/1990 as summarised in Lees 2001; experiment format [synthesis] / [uncertain] whether in Tyrer 2013]
Steps ([synthesis]):
1. Ask the client to focus on a neutral body area, such as the soles of the feet or the tongue in the mouth, for about a minute. Ask them to describe the sensations: tingling, pressure, warmth.
2. Ask whether those sensations were there before they focused.
3. Repeat with the feared area, and then with attention deliberately placed outside the body (describing the room in detail). Compare intensity ratings across the three.
4. For homework, have the client notice symptom intensity when absorbed in an activity versus when idle and scanning.
5. Parallel point: after a diagnosis features in the news, people notice it everywhere.
Example language (illustrative): "Notice your feet in your shoes for a moment. What do you feel? Was that there a minute ago?"
Watch for: turning the exercise into a distraction strategy used as a safety behaviour ("I must keep my mind off my chest"). The point is understanding, not avoidance. Working: the client links symptom intensity to attention.

4.15 Dropping avoidance (graded exposure to avoided health cues)

Purpose / when: Sessions 4–7, for clients who avoid illness-related cues. Examples:
- hospitals, doctors or test results (some health-anxious people avoid rather than seek care)
- illness words, TV programmes or obituaries
- exercise because of heart fears
- making a will
- talking about death
Avoidance is listed among the model's maintaining behaviours. [source: Warwick & Salkovskis 1989/1990 as summarised in Lees 2001] The exposure procedure is [synthesis] from standard CBT and is not confirmed in the CHAMP materials. [uncertain]
Steps ([synthesis]):
1. List the avoided situations and rate the anxiety each would cause. Build a graded hierarchy.
2. Before any physical-exertion task (for example, someone with cardiac fears resuming exercise), get the treating clinician's confirmation that it is medically safe for this client. Never set exertion against medical advice.
3. Get informed consent. Explain that anxiety will rise and then usually fall. The client chooses the pace and can stop.
4. Exposure must be done without safety behaviours (no pulse-checking during the walk, no reassurance call afterwards). Stay long enough, or repeat often enough, for the prediction to be tested.
5. Rate the prediction before the task and the outcome after it. Repeat between sessions.
Contraindications and cautions ([synthesis]):
- Defer if a new symptom is under investigation.
- Defer if acute medical instability or a recent cardiac event is unassessed.
- Be cautious with active suicidal ideation or severe depression: assess and treat those first.
- Recent bereavement needs a slower pace for death-related material.
Example language (illustrative): "You've been avoiding the cancer ward corridor for years. What do you predict will happen if you walk down it and stay for ten minutes?"
Watch for: hidden safety behaviours, and escape before the prediction has been tested. Working: the predicted catastrophe does not occur, anxiety falls with repetition, and the client widens their range of activities.

4.16 Booklets and session recordings (bibliotherapy)

Purpose / when: Throughout. They consolidate learning between sessions and suit brief formats.
- CHAMP handed out three patient booklets during treatment. [source: Tyrer et al. 2011]
- The genitourinary-clinic trial used one booklet, which patients reported using to recognise abnormal health perceptions. [source: Seivewright et al. 2008]
- Recordings of sessions were given to patients to support progress. [source: Tyrer et al. 2011]
- Booklet contents are not drawn on. [uncertain]
Steps ([synthesis]):
1. Give the explanatory booklet at session 1 or 2.
2. Assign specific pages as homework.
3. Ask what the client recognised in themselves.
4. If recording, get written consent. Agree where the recording will be stored, and offer it for re-listening.
Example language (illustrative): "When you read it, mark anything that sounds like you."
Watch for: re-reading or re-listening used as reassurance, and privacy worries about recordings. In the genitourinary trial two patients declined taping for confidentiality reasons. [source: Seivewright et al. 2008] Working: the client uses the material to catch and label health-anxious thinking.

4.17 Homework: setting and evaluation

Purpose / when: Every session. This is where the evidence is built. [source: Tyrer 2013, ch. 6 title; steps [synthesis]]
Steps ([synthesis]):
1. End each session with one or two specific tasks that come from that session's work: a diary, an experiment, a reduction target or reading.
2. Write each task down with when and how.
3. Ask the client to predict obstacles.
4. Start the next session by reviewing the homework. Ask what was learned and how it fits explanation A versus B.
Example language (illustrative): "What's one thing you could try this week that would tell us more about whether this is worry or illness?"
Watch for: tasks done but carried out with safety behaviours, and tasks not done at all (see section 5). Working: homework is completed and generates surprises.

4.18 Relapse prevention, ending and booster

Purpose / when: Final 1–2 sessions. A booster may be offered after the course. [source: Tyrer 2013, ch. 8 title; booster from Tyrer et al. 2017 HTA summary; Seivewright et al. 2008 offered booster sessions when improvement was insufficient]
Steps ([synthesis]):
1. Write a blueprint with the client. It covers:
  - their cycle
  - what helped
  - early warning signs, such as starting to search or check again, or a friend's diagnosis
  - a plan for new sensations: notice, label "health worry", apply the alternative explanations, delay acting, and use the agreed medical-contact route if it meets the agreed red-flag criteria
2. Plan for high-risk times: health news, birthdays at the age a parent died, routine screening invitations.
3. Taper sessions if possible.
4. Book or offer a booster.
Example language (illustrative): "Health worries will visit again — everyone gets symptoms. What will you do the next time a new one turns up?"
Watch for: fear of ending, which can show as a last-minute new symptom. Treat it as a chance to practise the plan. Working: the client applies the steps independently between the final sessions.

4.19 Liaison with the medical team

Purpose / when: Before starting, and as needed. CBT-HA was designed for delivery within medical clinics, alongside usual care, for people who often have real disease. [source: Tyrer et al. 2011; Tyrer et al. 2017 HTA summary] The liaison steps are [synthesis].
Steps ([synthesis]):
1. With consent, confirm the current medical status with the referrer and that no investigations are pending.
2. Ask the referrer to support the plan: consistent, non-escalating responses, and a scheduled review rather than repeated tests unless clinically indicated.
3. Agree which symptoms warrant medical review.
4. Share the formulation briefly. Keep the medical decisions with the doctor.
Example language (illustrative, to a GP): "We're working on reducing checking and repeat consultations. It would help if new symptoms were reviewed at a planned appointment rather than urgently, unless you have clinical concerns."
Watch for: splitting between clinicians, and clinicians ordering tests to settle anxiety. Working: fewer unplanned contacts and a consistent message.

5. Handling problems

The handbook has a "Troubleshooting" chapter (Tyrer 2013, ch. 9), but it is not drawn on. [uncertain] Unless a source is given, the responses below are [synthesis] from the model and standard CBT practice.

Client insists on more tests before engaging.
- Do not argue for or against tests.
- Ask what previous tests achieved and for how long, and use the reassurance curve (4.13).
- Offer the time-limited trial of explanation B (4.7) without requiring the client to give up A.
- Check medically indicated tests with the doctor, not in therapy. [synthesis]
"You think it's all in my head" (rupture risk).
- Acknowledge the miscommunication.
- Restate that the sensations are real and that the work concerns the worry and its costs.
- Return to the client's own goals. [synthesis]
Seeking reassurance from the therapist.
- Name it gently and link it to the formulation.
- Ask what the client predicts would happen to the worry if you answered.
- Agree a session rule together. [synthesis]
New symptom or genuine medical finding during therapy.
- Stop interpreting it.
- Direct the client to the agreed medical route and pause the techniques related to that symptom until it has been assessed.
- Afterwards, review how the client coped.
- CHAMP excluded people whose new pathology needed investigation. [source: Tyrer et al. 2011]
Coexisting real disease (e.g., heart disease, diabetes).
- Distinguish appropriate self-care, as advised by the clinician, from excess checking and worry.
- Use the pie chart and risk work with medically accurate inputs from the treating team.
- Health anxiety in people with real disease was the CHAMP target population. [source: Tyrer et al. 2011]
Non-adherence to dropping checking or reassurance seeking.
- Grade the reduction: fewer checks, delayed checks, then no checks.
- Revisit the costs (4.4).
- Look for a belief that worrying is protective, and test that belief.
- Involve family with consent. [synthesis]
Homework not done.
- Explore the barriers: fear, practical problems, or the task feeling irrelevant.
- Do a small version in session.
- Simplify the diary. [synthesis]
Overwhelm or panic during worst-fear or exposure work.
- Slow down, ground the client, and reduce the step size.
- Treat the panic sensations as more data for explanation B.
- Do not end the session at peak distress without a plan. [synthesis]
Fear of death at the core.
- Address the meaning directly: what the client fears about dying or about the people left behind.
- Consider values work on living well despite uncertainty.
- Grief related to an illness death in the family may need its own focus. [synthesis]
Low or erratic attendance.
- Trial attendance varied widely: in the genitourinary trial the range was 0 to 13 sessions. [source: Seivewright et al. 2008]
- Front-load the core elements (4.2–4.8, 4.13), give booklets early, and offer a booster rather than an open-ended course. [synthesis]
Depression, hopelessness or suicidal thoughts.
- Use standard risk assessment and safety planning, including lethal-means counselling (safe storage or removal) where relevant.
- Treat significant depression alongside CBT-HA or first.
- CHAMP excluded clients in current psychiatric care. [source: Tyrer et al. 2011; rest synthesis]
Internet and media triggers (health news, celebrity illness, online forums).
- Treat them as reassurance seeking or exposure cues.
- Plan responses in relapse prevention. [synthesis]
Privacy concerns about recording or clinic attendance.
- Respect a decision not to record.
- Offer a venue choice. [source: Seivewright et al. 2008 for declined taping; response synthesis]
Therapist inexperience.
- The trials used nurses and graduates with brief training. Fortnightly supervision and recorded-session review are part of the model.
- Arrange both if you are new to CBT-HA. [source: Tyrer et al. 2011; Tyrer et al. 2017 HTA summary]

Sources

Sources:

Further reading (not drawn on) [uncertain where relied on]:

Salkovskis PM, Warwick HMC (1986). Morbid preoccupations, health anxiety and reassurance: a cognitive-behavioural approach to hypochondriasis. Behaviour Research and Therapy 24:597–602.
Warwick HMC, Salkovskis PM (1990). Hypochondriasis. Behaviour Research and Therapy 28:105–117.
Salkovskis PM, Warwick HMC, Deale AC (2003). Cognitive-behavioral treatment for severe and persistent health anxiety (hypochondriasis). Brief Treatment and Crisis Intervention 3:353–367.
Salkovskis PM, Rimes KA, Warwick HMC, Clark DM (2002). The Health Anxiety Inventory. Psychological Medicine 32:843–853.
Tyrer P, et al. (2014). Clinical and cost-effectiveness of CBT for health anxiety in medical patients (CHAMP). Lancet 383:219–225.
Tyrer H (2013). Tackling Health Anxiety: A CBT Handbook. RCPsych Publications. Only the chapter 5 preview and the contents list were read.
ISRCTN14565822 trial record and the full HTA report (PMC5601246) are not drawn on.

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