Cognitive Aspects of Cognitive-Behavioral Therapy
The principal aim of cognitive therapy is to unravel the core beliefs underlying the patient's hypochondriacal thoughts. Cognitive therapists help their patients understand that an organic medical disorder is not the only reasonable explanation for highly distressing physical symptoms and that distorted patterns of cognition have problematic emotional and behavioral conse quences. In cognitive therapy, patients learn to detect and dispute their irrational beliefs about having a serious illness by discriminating these beliefs from rational alternatives (e.g., statistical probability of having the serious illness, alternative and less-threatening explanations of why they might be experiencing pain) (Salkovskis 1996). Patients need to internalize new rational beliefs by employing cognitive, emotive, and behavioral methods of challenging irrational beliefs—a process they can use throughout their lives.
Awareness of habitual patterns of cognition that reflect underlying dysfunctional cognitive structures or irrational beliefs can be achieved by teaching patients to self-monitor their health concerns and triggering symptoms on a day-to-day basis by keeping a diary of dysfunctional thoughts. Antecedent perceptions and their relationship to ongoing feelings and behaviors can then be more readily identified. Patients are encouraged to challenge their maladaptive thought patterns by listing all the "evidence" supporting their belief that they have a dreaded illness as well as all the evidence that they are not ill. Patients are also asked to examine each of their health complaints and use medical statistics to consider the likelihood that a serious illness actually exists. The patient's need for reassurance also needs to be addressed through a realization that he or she can never be reassured fully, that health risks always exist, and that the risk of serious illness is too insignificant to cause concern. Through rational restructuring methods and attributional retraining, patients can learn how to solve problems effectively and change their dichotomous reasoning, overgeneralizing, and catastrophizing (Warwick and Sal-kovskis 1989). Over time, their enhanced awareness will lead them to actively challenge their expectations of harmful health consequences (Warwick and Salkovskis 1989).
Educating patients about the merits of limiting maladaptive behavioral reinforcement can be helpful. Although repetitive reassurance seeking, body checks, and doctor visits reduce short-term anxiety, in the long term these behaviors reinforce obsessions, further convincing patients that there will be terrible health consequences if they do not perform their compulsions (Salkov-skis and Warwick 1986). A patient of ours with profound hypo-
chondriacal anxiety responded well to clomipramine therapy, to the point that she was able to use the cognitive-behavioral strategies she had learned. For example, in a demonstration of considerable insight, she called to ask us not to accept more than one call from her per week; this self-imposed limit setting worked and she felt less anxious.
Exposure. Exposure to anxiety-provoking stimuli is performed gradually and hierarchically by presenting moderately upsetting stressors, followed by several intermediate stressors and then the most distressing ones (Warwick and Salkovskis 1989). Hierarchies are targeted to expose patients to situations, places, or feelings they often avoid. Treatment sessions frequently include both actual (in vivo) exposure and imaginal exposure (Sisti 1997). In vivo exposure may involve having the patient visit hospitals, come in contact with ill patients, and elicit physical sensations (e.g., pain, dizziness, palpitations) through strenuous activity; providing medical information; and discussing illness (Warwick and Marks 1988). Someone with an AIDS phobia might be desensitized to his or her fears first by walking outside a hospital, then walking inside the hospital, followed by a visit to an AIDS ward. Patients can use imaginal or indirect exposure methods in which they imagine a doctor diagnosing them with a dreaded disease. They can rehearse this doctor-patient interaction by writing it down repeatedly, mentally reviewing the scenario, or listening to an endless loop audiotape of this frightening narration until they habituate to the fear (Sisti 1997).
The patient and therapist work together to develop a list of exposure exercises to be performed during sessions as well as exposure exercises to be done between sessions. Exposure therapy helps provide patients who are experiencing anxiety with insight into their thoughts, images, impulses, physiological symptoms, and self-reported levels of tension. After each exposure session, the therapist carefully examines the patient's specific thoughts and images for distortions, and teaches the patient necessary coping skills. The cognitive component is therefore intricately interwoven with the behavioral (Salkovskis and Warwick 1986).
Successful exposure therapy requires adequate duration, frequency, and comprehensiveness. A prolonged duration of exposure to stressors is needed to achieve a substantial reduction in the level of fear. Shorter exposures raise the risk that the patient will remain uncomfortable and fearful (Foa and Kozak 1986). The frequency of exposure is also consequential because repeated exposure to a stressor results in gradual habituation to the external stimuli, ultimately resulting in a decrease in fear. This "practice makes perfect" phenomenon emphasizes the importance of daily exposure exercises to reduce fear. Comprehensiveness of exposure is necessary to prevent relapse and achieve long-term therapeutic success. All aspects of patients' fears must be addressed, including mood, cognitive distortions, and maladaptive behaviors that enhance their health fears. The therapist may use imaginal exposure by encouraging patients to focus on physiological and behavioral reactions to their fears. In conjunction with in vivo exposure, imag-inal exposure helps expose patients to the cognitive components of their fears, thereby maximizing relapse prevention by contributing to the comprehensiveness of treatment (Sisti 1997).
Response-prevention therapy. One of the earliest reports of response-prevention therapy comes from the work of Shoma Morita, who in the 1920s developed a treatment for hypochondri-asis that consisted partly of ignoring patients' hypochondriacal complaints—a type of systematic nonreinforcement (Kitanishi 1990). Because this extinction strategy was used while patients were being cared for by family members in Dr. Morita's home, a message of acceptance and support was conveyed without reinforcing the hypochondriacal reassurance needs.
In contemporary response-prevention therapy, the therapist creates a treatment plan in which the patient is prevented from performing daily rituals. Together the therapist and patient negotiate a reduced number of times the patient is allowed to consult medical books, check his or her body for lumps and bumps, or ask doctors and family for reassurance. In outpatient treatment, it is customarily the patient's responsibility to abide by the treatment plan and abstain from ritualistic behavior. A supervisor, such as a family member or close friend, is often asked to participate in the response-prevention exercises. He or she helps monitor the time and frequency the patient engages in certain behaviors and is often instructed on how often and the manner in which reassurance should be given. Abstinence from rituals and level of supervision vary considerably among different therapies. Although the level of supervision does not seem to significantly affect patient improvement, the strictness of rules appears to affect treatment compliance. The more stringent and detailed the response-prevention instructions are for the patient, the fewer decisions the patient has to make regarding what is normal and what is ritualistic behavior, ultimately resulting in better compliance (Foa and Kozak 1985).
In a retrospective study conducted by Logsdail et al. (1991), 6 (86%) of 7 nondepressed patients whose illness phobia centered on AIDS demonstrated significant improvement after 7-10 sessions of prolonged exposure to obsessional cues and strict prevention of ritualistic behaviors. The therapist accompanied some patients during in vivo and imaginal exposures when necessary. As is the case for the treatment of OCD, the combination of exposure and response prevention is more effective at long-term follow-up than treatments that include only one of these two components. Exposure works by reducing obsessional distress, whereas response prevention aims to reduce rituals (Foa et al. 1984).
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