manual for group cognitive behavioural therapy for
TRANSCRIPT
1
Manual for Group Cognitive Behavioural Therapy for Patients with severe Health Anxiety
by Mathias Skjernov, MD, Psychiatrist and Specialist in Psychotherapy,
Clinic for Liaison in Koege, Denmark, latest revision 15.03.2014
2
Contents
An overall guidance to the manual and treatment for therapists and patients............................ 5 Meeting 1 - Introduction.................................................................................................................... 9
Presentation of therapists and patients ........................................................................................... 10 Frames for the course of the group therapy ................................................................................... 11
Case summary ................................................................................................................................ 17 Grade your current condition and your trust in change ................................................................. 20 The life line .................................................................................................................................... 21 Week schedule (symptoms) ........................................................................................................... 22 On goals, values, expectations, motivation an commitment to treatment and change .................. 23
Goals and values ............................................................................................................................ 24 Exercise about expectation and motivation ................................................................................... 26
Involvement of relatives in the treatment ...................................................................................... 27 Health Anxiety in general .............................................................................................................. 28 Concurrent mental disorders .......................................................................................................... 33 Stress, anxiety and strain in general ............................................................................................... 34
Bodily reactions to stress and anxiety ............................................................................................ 35 Emotional reactions to stress and anxiety ...................................................................................... 36
Cognitive reactions to stress and anxiety ....................................................................................... 36 Various types of anxiety symptoms and symptoms of other ongoing psychiatric disorders ......... 37 Cognitive Behavioural Therapy (CBT) in general ......................................................................... 38
Over all aims for cognitive behaviour therapy ............................................................................... 39
About homework assignments ....................................................................................................... 40
The cognitive model for Health Anxiety ....................................................................................... 43 The 5 main elements ...................................................................................................................... 43
Cognitive Model of Health Anxiety (figure) ................................................................................. 44 The vicious circle of anxiety .......................................................................................................... 45 Exercise in Persistent selective attention and the Vicious circle of anxiety .................................. 46
Exercise in assessment of health threat using the Anxiety Threat Fraction ................................... 47
Homework assignments for Meeting 2 .......................................................................................... 48
Meeting 2 – Stress management ..................................................................................................... 49 Stress management ......................................................................................................................... 50 Examples of known strains (stressors and triggers) ....................................................................... 51
Exercise in Deep Breathing ............................................................................................................ 52 Week schedule (triggers and how to handle) ................................................................................. 53 Troubleshooting ............................................................................................................................. 54
Scheduling ...................................................................................................................................... 55 List of ideas of positive activities .................................................................................................. 56 List of ideas for your individual positive activities ........................................................................ 61 About lifestyle factors .................................................................................................................... 62 Sleep ............................................................................................................................................... 63
The vicious circle of insomnia ....................................................................................................... 64 Causes for sleep disturbances ........................................................................................................ 65 Advice on good Sleep hygiene....................................................................................................... 66 Weekly recording of sleep pattern ................................................................................................. 67
Network (your relation with others) ............................................................................................... 69 Homework assignments for Meeting 3 .......................................................................................... 70
3
Meeting 3 – Stress management continued .................................................................................... 71 Exercise in Progressive relaxation – a deep form of relaxation ..................................................... 72 Week schedule (feelings) ............................................................................................................... 74 Exercise in Assertion and Common communication ..................................................................... 75 List of ideas for your common positive activities .......................................................................... 77 Homework assignments for Meeting 4 .......................................................................................... 78
Meeting 4 – General management of negative automatic thoughts and worries ....................... 79 Different ways of managing negative automatic thoughts and worries ......................................... 80 Simple thought management .......................................................................................................... 80 Advanced handling of thoughts ..................................................................................................... 80 Basis for the cognitive restructuring technique .............................................................................. 81
List of common types of cognitive misinterpretations ................................................................... 84 List of the 4 basic emotions (incl. examples of specific feelings) ................................................. 85 Plan for types of cognitive distortion ............................................................................................. 86
Basic Model ................................................................................................................................... 87 Simple management of negative thoughts and worries using 2 simple techniques ....................... 88 Thoughts on a Leaf ........................................................................................................................ 88 Room for Thought .......................................................................................................................... 88
Homework assignment for Meeting 5 ............................................................................................ 89
Meeting 5 – Management of negative automatic thoughts using cognitive restructuring ........ 90 Positive Diary (for improved positive thinking) ............................................................................ 91 Guidance to Cognitive restructuring .............................................................................................. 92 Challenging questions for cognitive restructuring ......................................................................... 93
The Basic Model ............................................................................................................................ 94
Basic Model for alternative thoughts and behaviour ..................................................................... 95 Thought form for cognitive restructuring ...................................................................................... 96 Homework assignment for Meeting 6 ............................................................................................ 97
Meeting 6 – Managing schemata with restructuring, cards and behaviour experiments ......... 98 Deep layer of thinking (registration) .............................................................................................. 99 Typical inappropriate thought patterns at Health Anxiety ........................................................... 100
Restructuring of inappropriate underlying presumptions, life rules, attitudes and core assumptions
(schemata) .................................................................................................................................... 101 Managing negative automatic thoughts and schemata using Memory cards for alternative
thoughts, presumptions, life rules, attitudes and core assumptions as well as behaviour
experiments .................................................................................................................................. 103
Positive Diary (for improved self-esteem) ................................................................................... 104 Homework assignment for Meeting 7 .......................................................................................... 105
Meeting 7 – Cognitive restructuring continued .......................................................................... 106 Homework assignment for Meeting 8 .......................................................................................... 107
Meeting 8 – Safety behaviour and avoidance behaviour. Managing safety behaviour using
response prevention ....................................................................................................................... 108 Safety behaviour and Avoidance behaviour at Health Anxiety ................................................... 109 Managing safety behaviour using response prevention. Managing avoidance behaviour using
exposure ....................................................................................................................................... 109 Week schedule ............................................................................................................................. 111 Managing safety behaviour with response prevention ................................................................. 112 Ranked list of your Safety behaviour ........................................................................................... 113
Homework assignment for Meeting 9 .......................................................................................... 114
4
Meeting 9 – The coping of avoidance behaviour through exposure .......................................... 115 Managing avoidance behaviour through exposure ...................................................................... 116 Ranked list of your Avoidance Behaviour ................................................................................... 118 Exercise with interoceptive exposure .......................................................................................... 119 Exercise of imaginary exposure ................................................................................................... 120 Homework assignment for Meeting 10 ........................................................................................ 121
Meeting 10 – Managing avoidance behaviour by exposure, continued .................................... 122 Exercise in situational exposure ................................................................................................... 123 Homework assignment for Meeting 11 ........................................................................................ 124
Meeting 11 – Relapse prevention .................................................................................................. 125 Relapse prevention (questions for your future plan) .................................................................... 126
Individual Plan for Relapse Prevention ....................................................................................... 129 List of exercises and managing techniques .................................................................................. 130 Homework assignment for Meeting 12 ........................................................................................ 131
Meeting 12 - Conclusion ................................................................................................................ 132 Homework assignment for the Booster Meeting ......................................................................... 133
Booster Meeting – 3 months follow-up ......................................................................................... 134 Individual Plan for Relapse Prevention (adapted) ....................................................................... 135
Applied literature ........................................................................................................................... 136
Appendix ......................................................................................................................................... 137 Basic Model (encl. 1) ................................................................................................................... 137 Basic Model for alternative thoughts and behaviour (encl. 2) ..................................................... 138 Thought form for cognitive restructuring (encl. 3) ...................................................................... 139
Week schedule (encl. 4) ............................................................................................................... 140
Recording of your Homework activity (encl. 5) .......................................................................... 141 Overall evaluation of the group therapy session (encl. 6) ............................................................ 142 Outcome Rating Scale (ORS) (encl. 7) ........................................................................................ 143
Group Session Rating Scale (GSRS v.3.0) (encl. 8) .................................................................... 144
5
An overall guidance to the manual and treatment for therapists and
patients
Distributed and applied material
At Meeting 1 the patients are given a file consisting the entire treatment manual including various
extra enclosures of the Basic Model (8), Basic Model for Alternative Thoughts/behaviour (6), Plan
of Thoughts (3), ORS (13) and GSRS (13), a notebook to be used as Positive Diary, and a
cardboard sheet to be used for memory cards. Besides the manual and enclosures, the therapists
possess PowerPoint presentations of the theory to be used at the Meetings, including a chart to
record attendance as well as the HAI questionnaire, which is used as a primary measure to assess
the treatment effect. The HAI is given at the beginning of treatment, at midway, at the end of
treatment, and at the Booster Meeting (HAI = Health Anxiety Inventory; measures the degree of
Health Anxiety). The HAI consists of 18 items; each item has 4 possible answers, which are scored
0-3. HAI is assessed after the first 14 items (HAI-14, max total score = 42) or after all the items
HAI-18 where the max total score is 54. A total HAI-18 score > 22 is above the normal rate for the
degree of Health Anxiety. Alone, the HAI-score cannot be used to diagnose Health Anxiety.
At the end of the manual are enclosed sheets, which are frequently used by the patients for written
homework assignments. Should the individual patient require further sheets the patient is advised to
copy the sheets or write his own based on the sheets. Also enclosed is the written information from
Region Sjælland concerning the so-called KRAM recommendations (recommendations concerning
diet [kost](K), smoking [rygning](R), alcohol [alcohol](A) and exercise [motion](M) (appendix 5)
and the questionnaires ORS and GSRS, which are distributed at each Meeting. Finally, a sheet on
which the patient register homework activity/attendance (appendix 6) and a final assessment sheet
(appendix 7), both given at Meeting 12. The effect and satisfaction questionnaires ORS and GSRS
are visual analogue scales and each questionnaire consists of 4-point graded items on which the
patient puts his graded mark regarding the individual item. The therapists score the placement of the
mark at an equivalent number on a 10-point scale, after which the combined effect questionnaire
can be graded on a 0-40 score. The therapists are recommended to use a projector for the
PowerPoint presentations and a whiteboard or flip over at the meetings, e.g. for joint written
cognitive restructuring. For documentation, the co-therapist may copy the essence of the contents of
the board into the individual patient’s case summary, which then may be lent to the patient.
Alternatively, the co-therapist may take a snapshot of the contents of the board and send the picture
to the patient.
Timetable and contents of the manual, patient and therapists’ preparation and time
management
The full contents of the course of the group therapy is described in short at the beginning of the
manual, and the contents and topics of the individual meeting are briefly discussed.
The full contents and timetable of the individual meeting are described on the first page of each
meeting. The therapists are advised to go over the topics in the order mentioned on the front page of
each meeting, as it is also the order of the material in the manual. The average duration of each
group exercise is shown together with the headline of the exercise. However, it is up to the
therapists to manage the time so that the ordinary agenda is observed and the individual topics are
gone over in a well-balanced manner. Special emphasis should be on carrying out the group
exercises as well as guidance and going over the home assignments as the patients may find it easier
to learn the theoretical background material through the manual. Then, at the following meeting, it
is possible to ask questions regarding the theory.
6
PowerPoint presentations concerning the new topics of the individual meeting are included in the
therapists’ manual. The PowerPoint presentations for the background sections also demand
preparation from the therapists.
There is no special manual for the therapists, as full openness between therapists and patients
regarding the treatment is wanted.
On the last page of each meeting, the recommended patient homework for the next meeting is
described in detail and in the order in which it should be prioritized by the patients. It is
recommended that the patients do their homework 30-60 minutes a day during the course of the
group therapy. Furthermore, the patients are recommended to do one assignment thoroughly as
described, rather than parts of several assignments. Homework should be seen as suggestions for
self-coaching. The patient should continuously on his own and together with the therapist assess
which exercises have the most positive effect, and continue to do these as self-coaching. The
exercises the patient does not manage to do during the course of group therapy, may be practiced
after the end of the course, e.g. in the period before the Booster Meeting. At the Booster Meeting,
the patient may be supervised in these exercises as well.
At the end of the manual is a list of relevant definitions as well as a list of literature used in the
manual, which the therapists are recommended to look further into. There is also a list of
recommended literature for the patients such as various self-help books.
Demands on the therapists
As a minimum, it is implied that the main therapist is trained and has experience in conducting
cognitive behaviour therapy for patients with Health Anxiety as well as experience in group therapy
to ensure an effective treatment. The co-therapist should be trained in cognitive behaviour therapy
at the least. Before the beginning of the course both therapists should have acquainted themselves
with the contents of the manual, the PowerPoint presentations for each meeting, and the HAI
questionnaire, and it is also recommended, that they have decided responsibilities and division of
labour regarding the course of treatment. Furthermore, we recommend that the therapists have
familiarized themselves with the patients’ histories before beginning of treatment. It is vital
however, that the therapists remember to keep the therapist-patient confidentiality regarding the
individual patient during sessions. The time and date for the relatives’ meeting (a weekday at 16-18
hrs) is scheduled before Meeting 1.
Recommended division of responsibility and work for the therapists
The main therapist is generally responsible for the treatment, i.e. that all the topics of each meeting
are carried out, and that the meetings’ fixed agenda is respected, e.g. including socializing of the
model and training in new managing techniques, review of relevant home assignments and therapy.
It is also the responsibility of the main therapist, that patients with specific acute problems and
therapeutic needs are followed outside the group therapy, e.g. by phone calls if considered
necessary. If a patient fails to attend a meeting (and did not cancel) or shows lack of participation or
commitment during a meeting (e.g., a low GSRS score), the patient should receive a phone call in
order to motivate him to participate in the group and avoid dropout. The patients’ contact person
can also handle these extra contacts. We recommend that one of the therapists is the contact for all
group participants. A note in the patients’ chart should be made in connection with these extra
treatment contacts. As the main therapist is generally responsible for the time management of each
meeting, this also demands a good deal of preparation and efficient time management during the
meeting.
The co-therapist is responsible for the patients’ interaction during group sessions to be as
constructive as possible and conducted in a manner of mutual respect. It is also responsibility of the
7
co-therapists that the more formal duties concerning group therapy are performed, i.e., that the HAI
questionnaires are handed out, completed and returned at the start of Meetings 1, 7, 12 and 13. That
the ORS and GSRS questionnaires are handed out, completed and returned at each meeting
(remember to fill out name and date on all questionnaires). During the break, the HAI
questionnaires are scored and the results are given to the patients immediately after as well as
entered in the case summaries. The therapists as guidelines in the treatment use the ORS and GSRS;
consequently, the score usually is not shared with the patients. At the beginning of each meeting,
the patients’ attendance is registered (the attendance sheet is enclosed in the therapists’ material as a
computer file). In addition, the patients are asked to record their homework activity since the
previous meeting (the past week) on enclosure #6 at the end of their manual (for Meeting 2 to 13).
The co-therapist’s duty during the meetings is continuously to register essential information from
the patient in his case summary. Each patient has his own case summary sheet in his manual under
Meeting 1; a copy is added to the case file before Meeting 1 by the co-therapist. The information is
shared with the patient during or between meetings, e.g., the patient borrows the case summary and
at home transfers the information to his own case summary in order for the essential information to
be the same. It is the duty of the co-therapist that as a minimum an individual note is put in each
patient’s case file at the beginning as well as the end of each group course (i.e., after Meetings 1, 12
and the Booster Meeting.
A Standard Note should be made in each patient’s case file after each Meeting (Meeting #,
attendance, cancellation, absence). A secretary from the attendance sheet alone may type the
standard notes.
The Start Note should at least include information of the treatment indication and a short description
of the general treatment (e.g., ”Group CBT for patients with Health Anxiety, duration of treatment 3
hrs a week for 12 weeks + 1 Booster Meeting 12 weeks after end of treatment, group size 7 patients
and 2 therapists), names of the therapists and the division and distribution of the work between
them (main and co-therapist) as well as the patient’s starting HAI score”).
The End Note should at least include the final HAI score, the development in HAI since primary
HAI score, patient attendance activity (number of meetings the patient attended/12 meetings), the
subjective homework activity per week as an average for the course of 11 weeks (5 degrees: 0 = 0
hrs/week, 1 = 0-1 hr/week, 2 = 1-3 hrs/week, 3 = >3-6 hrs/week, 4 = > 6 hrs/week as well as a
conclusion regarding the treatment effect. At the end of the manual is enclosure #6, which the
patient should use for registration of his own weekly homework activity. At Meeting 12 enclosure
#6 is returned and enclosed in the patient’s case file with his name written on it, and at the Booster
Meeting the patient registers his homework activity on the enclosure, which is handed over and
returned. On enclosure #6, the therapist also make a note of the patient’s attendance activity after
Meetings 12 and 13.
The case note after the Booster Meeting as a minimum should include the follow-up HAI score, the
patient’s subjective average homework activity per week since Meeting 12 as well as possible
conclusion on the total treatment effect. The conclusion on treatment effect, however, is assessed
together with the patient at the final therapist appointment.
After the Booster Meeting, the patient should receive an individual final consultation with the
evaluating treating health care professional. At this consultation, the following items should be
discussed: the overall treatment, treatment effect, the patient’s possible continued needs and wishes
for further professional treatment and other possibilities, e.g. referral to another treatment facility
for another ongoing psychiatric disorder. After the final consultation a case note as well as a
discharge summary is prepared and sent to the referring doctor and the patient’s GP as a
confirmation of the discharge of treatment.
8
In addition, the case file should contain enclosures as well as a copy of the patient’s individual
cognitive disease model and Case Summary. The individual patient’s sheets and scores regarding
HAI, ORS and GSRS with correct name and date are continuously enclosed in the patient’s case
file. We recommend the instructors have three separate plastic folders for 1) HAI; 2) ORS and
GSRS and 3) the Case Summary, Disease Model and the sheet for Homework Activity/Attendance.
Other communication with the patient, contact person and the doctor responsible for
treatment
The patient has full access to his own case file through the internet via www.sundhed.dk (the
official portal for the public Danish Healthcare Services) – the so-called “e-journal”. At the
preliminary consultation, the patient should receive written information regarding the e-journal,
contact person arrangement and patients’ rights. At this point or at the start of the group therapy
course, the patient should be assigned a contact, whom the patient may contact when needed during
the course of treatment. The contact may be the evaluating doctor and one of the group therapists.
The medically responsible doctor is typically the doctor, who has performed the preliminary
medical examination. He is also responsible for relevant written communication with the patient’s
referring doctor and GP, who are both initially informed in writing of the result of the preliminary
consultation, the agreed treatment and at the end of treatment of the results and possibly
recommended follow-up (discharge summary) for the purpose of coordinated common treatment.
Furthermore, approximately at the time of commencement of treatment (Meeting 1) the patient
receives a written treatment schedule that requires the patient’s consent to treatment, which is then
registered.
9
Meeting 1 - Introduction
Content and Timetable
13.00 – 14.30 Hrs
Distributing and presentation of material (manual, diary, cardboard for memory cards)
Presentation of therapists and patients (short and alternately starting with the therapists)
Frame and Content of the course of the group therapy (overall from Meeting headlines)
Measures of Effect and Satisfaction (Preliminary HAI is completed and written in the Case
summary, ORS)
Case summary (remember a copy for the case file) (Treatment plan from the case file is distributed,
consent)
Current condition and trust in change
Lifeline and Week schedule (medical history in relation to life events, symptoms and possible
triggers)
Values, aims, subsidiary aims (Aims ladder), expectations, motivation and commitment to change
Expectations and motivation for treatment. Exercise (15 minutes)
15-minutes break
14.45 - 16.15 Hrs
Motivation for involvement of relatives in the treatment (support, care and assistance, support
group). Date and time for Relatives’ meeting is distributed.
Health Anxiety in general and other concurrent psychiatric disorders
General information on stress, anxiety and psychological strain
General information on Cognitive Behaviour Therapy (KAT) and Homework
The cognitive model for Health Anxiety
The vicious circle of anxiety
Persistent selective attention/the vicious circle of anxiety and Hazard fraction. Exercises (20
minutes)
10
Homework: Week schedule (symptoms, grading). Life aims and quality of life, Main aims and
subsidiary aims for the treatment (aims ladder) .Current condition and trust in change. Lifeline.
Rounding off (GSRS, questions, summary, feedback)
Presentation of therapists and patients (Short, alternate, starting with the therapists, and possibly nametags)
Therapists:
Patients:
11
Frames for the course of the group therapy
Overall frames for the group:
1. Group treatment involving 7 patients and 2 therapists per group
2. Each meeting has a duration of 2 x 90 minutes + 15 minutes break
3. In total 12 + 1 meetings, once a week on a fixed weekday and period at the Clinic for
Liaison Psychiatry. The course lasts 11 weeks after which a Booster Meeting follow-up is
offered approx. 12 weeks after Meeting 12. The patients are convened by letter to Meeting
1. Time and date of the Booster Meeting is planned at Meeting 12 at the latest. The course of
treatment at the clinic is ended by an individual outpatient visit (typically conducted by the
evaluating treating doctor) after the Booster Meeting.
4. Confidentiality. The therapists are subject to the usual professional secrecy. The patients are
also expected to keep the confidentiality regarding the group therapy, e.g. regarding the
names of other patients and what is said during therapy. What the patient may tell his or her
relatives regarding their own comments during treatment is usually okay (to be decided in
the group).
Overall frames for patients (participation requirements):
1. Main diagnosis: severe Health Anxiety (F45.2, hypochondriacal disorder [ICD-10])
2. Age: 18-65 years
3. Initial WI-7 score > 21.4 (questionnaire regarding the degree of Health Anxiety given at
primary psychiatric assessment)
4. Understands, reads and speaks Danish fluently
5. Motivated for and agrees to participate on a regular basis in the course of group therapy’s 12
+ 1 meetings and conduct homework 30-60 minutes daily throughout the course of the
therapy
6. A maximum of absence from 5 Meetings (cancellations/failure to show up) during the
course of the group therapy (13 Meetings)
Other ongoing treatment
Unless there are special circumstances, patients, who are undergoing medical treatment for a
psychiatric disorder should not start or change their medical treatment during the course of the
group therapy. Changes in medication should only be done after consultation with the doctor. We
recommend that the medical treatment is monitored by the doctor at least every two months, and
that any questions that may arise are asked by the doctor in charge of this treatment, as the group
therapy sessions are not meant for this. If you have a need for further advice or help, please contact
you contact person at the Clinic for Liaison Psychiatry (see below). Other ongoing
psychotherapeutic treatment is discouraged as it may have an adverse effect on the course of the
group therapy, which demands a high level of commitment from the patient.
Ongoing treatment for a physical disorder or of another physical or social nature, e.g. physiotherapy
or social rehabilitation can be necessary and relevant, but should be coordinated with the treating
doctor at the Clinic for Liaison Psychiatry at an individual consult.
12
Your contact person
All patients at the Clinic for Liaison Psychiatry have a contact person. Please contact you contact
person, e.g. through the secretary if you need special advice or help which cannot wait until next
group meeting or if the problem cannot be dealt with in the group.
The therapists
The therapists are trained in Cognitive Behaviour Therapy (CBT). To be able to use the treatment
manual effectively it is vital that the main therapist is experienced in treatment with CBT for
patients with Health Anxiety as well as treatment with CBT in a group setting. The therapists can be
doctors, psychologists, psychomotor therapists or nurses. The main therapist manages the overall
treatment. The co-therapist overall manages and administers the group, e.g. makes sure that there is
a safe environment and a good interaction between the patients; is in charge of the questionnaires
and possible written documentation of in the course of the therapy (e.g., takes a snapshot of the
whiteboard to be distributed, special case file documentation as a minimum at the beginning and
end of course of therapy). Interns who are students in one of the abovementioned fields may on
occasion participate, e.g. as co-therapist or as an observer. It is the therapists’ responsibility to offer
the best possible treatment.
Therapist supervision
The therapists are continuously supervised during the course of the group therapy by an external
supervisor, which is why the therapy may be video recorded. Video recordings are confidential and
apply to the rules of professional secrecy, and only shown to the supervisor and then deleted.
Fixed agenda for each meeting
In session 1, items 1-3 are usually gone over, in session 2 typically items 4-7. The therapists are
responsible for keeping the time and that it is distributed evenly among the patients. In item 2 the
patients are asked how they have been in general since the previous meeting. A possible
deterioration may have to be treated individually after the group meeting. In item 6 the patients are
asked to sum up the topics and most important points of the meeting for the purpose of improved
memory. The group is also asked to evaluate the contents and therapy of the meeting both orally
and in writing (GSRS).
1. ORS questionnaire is filled out, patient attendance and homework activity is registered
(approx. 2 min)
2. How the group has been since last meeting and summery of previous meeting (approx. 8
min.)
3. Review of relevant home assignments (approx. 80 min.)
4. New theory, techniques and exercise (approx. 75 min.)
5. New home assignments (approx. 8 min)
6. Filling in GSRS questionnaire (approx. 2 min)
7. Questions, Summery and Evaluation (approx. 5 min.)
Cancellation due to illness or other failure to attend
In case of illness please call the secretary at 47 32 83 30 during working hours. At failure to attend
without cancellation the patient will be contacted by one the group therapists. Long-term absence is
inappropriate in terms of the individual patient’s treatment and the group collaboration and the
patient may be dismissed early from the therapy in this case.
13
The overall aims of the therapy To reduce Health Anxiety, bodily symptoms, stress, anxiety and depressive symptoms
To improve life quality and ability to function
To prevent recurrence
To reduce the need for doctor’s appointments and examinations in the health care system
Assessment of effect and satisfaction with treatment
The effect and satisfaction with treatment is continuously assessed during the course of the group
therapy using short questionnaires given to the patients at each meeting (visual analogue scales). At
the beginning of each meeting, the effect questionnaire Outcome Rating Scale (ORS) is completed,
and before the end of each meeting, the satisfaction questionnaire Group Session Rating Scale
(GSRS) completed. It takes approx. 2 min. to complete these questionnaires. The questionnaires are
there to ensure that you as a patient can give your honest feedback to the therapists regarding the
therapy. They are also there to ensure a continuous effect of the therapy in each patient, so that the
treatment can be individually adjusted at lack of efficacy, and the total treatment effect of the
patient can be better assessed both by the patient and therapist as well as used as a means of
treatment quality assurance. The main aim for the treatment effect is measured by the questionnaire
HAI (Health Anxiety Inventory), which measures the degree of Health Anxiety. This questionnaire
is distributed by the therapists and filled in by the patients (together with the ORS) at the beginning
of meetings 1, 7, 12 and at the Booster Meeting. The score for the HAI questionnaire is noted in the
Case summary afterwards.
Realistic expectations for the course of treatment
Every beginning is difficult. When you suffer from Health Anxiety, which is a combined functional
and anxiety disorder, your condition naturally incorporates a lot of anxiety and concern, and
therefore also typically concerning this new group therapy, you are about to participate in. It takes
time to get to know the therapists and the other group members and thereby to trust and feel safe in
the group. Furthermore, you will be confronted daily during the therapeutic work with your disorder
and that of the members of the group, and at the same time, you have to learn new techniques for
better handling your disorder. Some people will therefore experience a slight deterioration of their
condition in the first few weeks of the group therapy. Nevertheless, hold your head up high because
most of the patients will have a good result from the group therapy.
Contents of the group therapy course (gone over from the items in the table of contents)
The overall chosen treatment items and managing techniques in this group therapy course have been
found to have effect on patients suffering from Health Anxiety in scientific studies. Some
techniques may prove to be especially effective for some patients, but not for others, it is an
individual matter. It usually takes approx. 2-3 weeks to learn a technique and practice it sufficiently
to assess if the technique works for you, which means that diligence and persistence is how to reach
you goal. After 2-3 weeks of daily practicing the individual techniques, however, you should be
able to assess if the technique has any positive effect on you, possibly guided by one the therapists,
and then chose if you want to continue using the technique as one of you daily homework
assignments and self-treatment.
Our recommendations regarding your participation:
We recommend that you participate actively in the treatment at the meetings
Meeting attendance is only a part of your treatment
14
It is an important and necessary part of the treatment, that you practice your homework
assignments 30-60 min. a day between meetings, e.g. register effect, train managing
techniques and new behaviour experiments
You have the right and obligation to refuse to talk about issues you do not want to tell the
group or if there are specific homework assignments, you do not want to perform.
You depend on the group and it depends on you, so we recommend that you participate
regularly, responsibly and respectfully towards group members. During the course and
afterwards the group acts as your external support group and network regarding support and
prevention of relapse in the future.
The effect of your treatment depends on your participation and commitment at the meetings
and while performing the home assignments. Attend the meetings and be active, try to be
open, take responsibility for your treatment and your life, do your best and you will go far
15
Outcome Rating Scale (ORS)
Name ________________________Age (Yrs):____ Sex: M / F
Session # ____ Date: ________________________
Who is filling out this form? Please check one: Self_______ Other_______
If other, what is your relationship to this person? ____________________________
Looking back over the last week, including today, help us understand how you have been feeling
by rating how well you have been doing in the following areas of your life, where marks to the
left represent low levels and marks to the right indicate high levels. If you are filling out this form
for another person, please fill out according to how you think he or she is doing.
ATTENTION CLINICIAN: TO INSURE SCORING ACCURACY PRINT OUT THE
MEASURE TO INSURE THE ITEM LINES AR 10 CM IN LENGTH. ALTER THE FORM
UNTIL THE LINES PRINT THE CORRECT LENGTH. THEN ERASE THIS MESSAGE:
Individually (Personal well-being)
I----------------------------------------------------------------------I
Interpersonally (Family, close relationships)
I----------------------------------------------------------------------I
Socially (Work, school, friendships)
I----------------------------------------------------------------------I
Overall (General sense of well-being)
I----------------------------------------------------------------------I
Institute for the Study of Therapeutic Change
_______________________________________
www.talkingcure.com
© 2000, Scott D. Miller and Barry L. Duncan
16
Group Session Rating Scale (GSRS v.3.0)
Please rate today’s group by placing a mark on the line nearest to the description that best
fits your experience.
Relationship
I----------------------------------------------------------------------I
Goals and Topics
I----------------------------------------------------------------------I
Approach or Method
I----------------------------------------------------------------------I
Overall
I----------------------------------------------------------------------I
Institute for the Study of Therapeutic Change
_______________________________________
www.talkingcure.com
© 2000, Lynn D. Johnson, Scott D. Miller and Barry L. Duncan
Name ________________________Age (Yrs):____
ID# _________________________ Sex: M / F
Session # ____ Date: ________________________
I felt heard, understood and
respected.
I did not feel heard, understood and
respected.
We worked on and talked about what I wanted to work on
and talk about.
We did not work on or talk about what I wanted to work on
and talk about.
Overall, today’s group was right for
me.
There was something missing in today’s
session.
The leader’s approach is a good
fit for me.
The leader’s approach
is not a good fit for me.
17
Case summary
Name and date of birth:
Date:
1. Diagnoses:
2. Measures of effectiveness during course of treatment
(questionnaires):
a. Beginning: date: HAI:
b. Mid (Meeting 7): date: HAI:
c. End (Meeting 12): date: HAI:
d. Follow-up: date: HAI:
Attendance (x/13): Homework activity (during/after):
3. Symptoms at onset, current condition and level of functioning:
4. Development profile:
a. History (e.g., inheritance, upbringing, environment, education, work, physical and
psychological problems, treatments):
b. Relations (e.g., parents, siblings, partner, friends, acquaintances, authorities, colleagues,
physicians):
c. Traumatising life events (e.g., illness, death, assaults, divorce, harassment, work)
18
5. The cognitive profile:
a. Typical critical situations (+ triggers):
b. Typical negative automatic thoughts
c. Underlying assumptions, life rules and attitudes:
d. Core assumptions:
6. Dysfunctional behaviour. Safety and avoidance behaviour:
a) Dysfunctional stress management:
b) Safety behaviour (bodily checking, seek reassurance, safety signals):
c) Avoidance behaviour:
7. Overall understanding of the developing and cognitive profile (see
your individual cognitive illness model):
19
8. Expectations, motivation, values and common goals for treatment:
a. My expectations:
b. My motivation:
c. My life goals:
d. My life values:
e. Common main aims:
f. Common subsidiary aims:
9. The appropriate and desired cognitive profile and behaviour:
a) Alternative core assumptions:
b) Alternative presumptions, life rules and attitudes:
c) Alternative thoughts:
d) Alternative behaviour, strategies and actions (behaviour experiments):
20
Grade your current condition and your trust in change
The condition How do you rate your current condition as a whole? (mark with an X)
What would you like to achieve? (mark with an circle)
What would make you satisfied? (mark with asterix)
0 10
Trust in change How much do you trust, that you will achieve the goals, which will satisfy you? (Mark with an X)
What makes you make your mark there and not at 10?
How can we help you to go from there to 10?
What could prevent you from reaching your goals?
0 10
Your answers:
Completely
disabled Completely
well
No
trust Completely
sure
21
The life line Introduction
Write in the figure:
At the top, you write the year you were born.
To the left of the line you write your symptoms in the order of occurrence. It is important when the
symptoms started.
When you have written down your symptoms og the year and your age of the onset, you write in
short which stressful life events or factors took place at the time of occurrence, i.e. biological,
psychological or social factors and:
20
Symptoms Age, Year Biological, Psychological, Social factors
22
Week schedule (symptoms)
Registration of your symptoms and their degree. If you have many symptoms, chose
the most important (max 5) and register them continuously.
Please register 4 times daily every day of the week the symptoms that have bothered you and how troublesome the individual symptoms have been during the day on a scale from 0-10.:
0 1 2 3 4 5 6 7 8 9 10
day
date:
day
date:
day
date:
day
date:
day
date:
day
date:
day
date:
Morning
Afternoon
Evening
Night
Worst degree of the
symptom, e.g., anxiety,
bodily symptoms, cognitive
and general symptoms
No symptoms, e.g.,
anxiety, bodily
symptoms, cognitive and
general symptoms
23
On goals, values, expectations, motivation an commitment to treatment and
change
The main goal for psychotherapy is a reduction of the disorder through change in the patient and the
in patients’ habits. In cognitive behaviour therapy you seek to change your thoughts and behaviour
through which your feelings and bodily sensations also changes. The change in the patient may
afterwards affect others and the surrounding world in a positive manner. It is however not the aim
of psychotherapy to change others or the outside world.
For you to effectively change yourself, we need to describe your individual goals and subsidiary
goals from the prompt SMART, which derives from the initials of the factors:
Specifics, Measurable, Acceptable, Realistic and Time-limited.
The more subsidiary aims your main goal can be dived into, the easier it is for you to reach your
main goal. Small steps are the road to success. Your possible partial goals become easier to describe
as the group therapy progresses. Your goals are concurred with the therapists regarding SMART, so
that we agree and share the course and goals for your therapy.
People navigate advantageously in life as in this treatment from both life goals and life values.
Based on the view that the development and the process in itself or where you are in your life
should be at least as important as reaching a certain life goal or treatment goal. It should also be
possible to flexibly change these goals as the development and life moves forward. Therefore, it is
not only important for you during treatment to be aware of your goals and partial goals, but also of
your life values, that can give your development direction and meaning. Life values can be divided
into internal and external life values. Typical internal life values are rest, joy, humour, laughter,
presence, nurture, humility, chastity, courage, interest, commitment, perseverance, patience, energy,
willpower, kindness, goodness, generosity, stability, loyalty, curiosity, knowledge, experience,
understanding, tolerance, wisdom, solidarity, togetherness, interaction, autonomy, vigour,
acceptance, expression, creativity and change.
Typical external life values are food, housing, car, clothes, other material things, education, work,
hobbies, leisure activities, entertainment (e.g., music, sports), travelling, children, family and
friends.
It is also important for you to accept, that not all in life can be changed. For instance it is impossible
for you to change your inheritance and past, you cannot get new parents, you cannot awaken the
dead, what is done is done, and in the end illness and death cannot be avoided. There are there some
things in your life that you will have to learn to live with and make do with what you have.
You have to get the most out of life while you are alive and not let yourself be inhibited, e.g. by
inappropriate anxiety.
You will have to choose your main and partial goals from the circumstances of your life, which you
believe, can be changed or improved through the treatment. Next, change demands that you are
motivated, willing and committed to the treatment. Psychotherapy can help you understand and
handle your life better and reach some of your desired goals. We concur your overall goals for the
therapy at the next meeting, and you can then adopt them into your Case summary, item 7. It is
important that we are in agreement of our expectations regarding treatment, so that possible
unrealistic expectations can be corrected and misunderstandings avoided. We do this at Meeting 1.
24
Goals and values
Introduction:
Describe and register your goals and values in life below as well as your main goals and possibly
your subsidiary goals for the treatment
My goals in life:
My life values:
My goals for the treatment: (Main goals and possibly subsidiary goals)
25
Ladder of Goals
Introduction 1. On the top step write your main goals for the treatment
2. On the bottom step write the subsidiary goals that you give yourself for the next meeting
3. On the following steps continuously write the subsidiary goals that you give yourself at the
meetings.
Remember the goals must be SMART (specific, measurable, acceptable, realistic, time limited).
26
Exercise about expectation and motivation (Duration: 15 minutes)
Instruction:
Describe and register your expectations and motivation regarding treatment below (3 min), then
describe them to your neighbour and your neighbour will describe his to you (5 min.), last but not
least you present your neighbours expectations and motivation to the group (1 min per patient).
Your overall motivation can e.g. be set on a 10 scale (0-10).
My expectations regarding the treatment:
E.g., which, why?
My motivation regarding treatment: E.g., why, how, how much in general (0-10)?
27
Involvement of relatives in the treatment Possibility of a separate meeting for relatives
We attempt to involve caring, supportive and helpful relatives (spouse, lover, family and friends) in
the treatment as resource people, as they increase the effect of the treatment in the patient. During
the course of the group therapy, a separate after hours meeting only for relatives is held on a
weekday from 16-18 hrs. The date for this meeting is scheduled by the therapists before Meeting 1.
At Meeting 1 the patients write down the names and addresses of the relatives they want invited to
the relatives meeting and the therapist send them an invitation. It is our hope that the relatives and
friends will support the treatment in both attitude and action by giving the patient the appropriate
care, support and help. During the course of the group therapy, the patients are also taught
appropriate involvement of relatives in the treatment, but the relatives must respect that it is the
decision of the adult patient how much they want their relatives involved in the treatment.
A short introduction concerning the content and effect of the group therapy
At the relatives’ meeting, the therapists will explain the same general knowledge of Health Anxiety,
CBT and the group therapy course as the patients received at Meeting 1. The relatives will have the
possibility of asking the therapists questions regarding Health Anxiety and the treatment. It will not
be possible to discuss the individual patients’ medical history at the relatives’ meeting as the
therapist are required to honour the patient doctor confidentiality, and the relatives are asked to keep
their relatives history to themselves. The course of the group therapy consists of 12 weekly meeting
of approx. 3 hrs each and a Booster Meeting approx. 12 weeks after Meeting 12, and the
participants are 2 therapists (e.g. psychologists and doctors) and 7 patients. The patient receives a
written manual to the course of treatment. The relatives receive parts of the manuals’ written
material regarding Meeting 1.
Possibility of establishing a Support group
At the end of the course, a permanent support group is formed for interested patients and those
interested resourceful relatives, which the patients agree can participate in the group. For more
information of the involvement of relatives in psychiatric care, please note the campaign ”Netværk,
vi er alle pårørende” [Network, we are all relatives]. We are all connected in networks and affect
each other both positively and negatively, and therefore appropriate care, support and help for
patients and each other is helping the relatives themselves and the entire network surrounding the
patient and in the end our society.
How a relative can motivate a patient for treatment
Much of the treatment takes place outside the group sessions as daily homework assignments
exercising managing techniques, written work and the use of memory cards and behaviour
experiments in which the relatives can join in with support and help with an advantage. The
relatives are asked to keep motivating the patients for participation in the group sessions and do the
daily homework assignments between meetings. Studies show the effect of the treatment in the
patient also depends on his or her commitment and activity in the treatment both at attendance at
sessions and regarding homework (duration: 30-60 min daily). It is painful and difficult to be a
patient. Furthermore doing psychotherapy is a lot of hard work, especially at the beginning of the
course, where it is important that the patient gets a good start on the homework. The patient may
sometimes experience deterioration of his condition, especially at the beginning of the course,
because at this point, the patient also works on feeling safe within the group and the treatment, and
new managing techniques must be learned before they will work therapeutically and lessen the
suffering. It is therefore vital that the relatives are especially caring, supporting and helpful at the
beginning of the course. The expressions “a good start is half the battle” and ”persistence is the
way to success” suit this form of group therapy well.
28
Health Anxiety in general
Background
Below is given a short description of the disorder Health Anxiety through the newly suggested
diagnostic criteria, as well as the current diagnostic criteria from the two psychiatric classification
systems ICD-10 (International Classification of Diseases (WHO)), in which the condition is called
hypochondriacal disorder and DSM-IV (Diagnostic and Statistical Manual of Mental Disorders
(USA), in which the condition is called hypochondriasis.
The name Health Anxiety covers both the symptom in itself, which among other things appears in
other psychiatric disorders such as panic disorder and depression, and the primary disorder
described in the newly suggested diagnostic criteria. The name has been suggested as an alternative
to the former names hypochondriacal disorder and hypochondriasis, which over time have come to
include negative prejudices, so-called stigmatization of imaginary illness, the ridiculous and
difficult character, and the worrying and constantly recurrent patient.
The name hypochondriasis is Greek and means ”under the rib cartilage”, og dates all the way back
to approx. 500 B.C. from antique Greece and the father of medical science Hippocrates.
Hypochondriasis is often described as the male equivalent to female Hysteria, and designates the
symptom of stomach aches (under the ribs) and simultaneous fear of serious physical disease.
Hysteria was removed as a diagnosis in mid-20th century and was replaced by somatoform and
dissociative disorders. In the somatic (psychical) fields of medicine, corresponding symptoms are
called functional illnesses and disorders, which describe a disturbed bodily function.
The diagnostic criteria
The psychiatric disorder and diagnostic entity Health Anxiety is characterized by an ongoing fear
and circling thoughts of suffering from or developing a serious physical condition. Furthermore, the
patient has somatoform or functional symptoms, which are bodily symptoms, which cannot be fully
explained by physical causes. The patient cannot be reassured or only briefly by medical
examinations and assurances and further medical examinations are often demanded. The symptoms
have been persistent for at least 6 months and may be characterized by excessive preoccupation of
personal bodily functions and medical knowledge as well as a high level of entrainment concerning
medial issues (suggestivity and auto-suggestivity) and preoccupation with infection, disease and
medical treatment. The disorder reduces the patient’s life quality and/or level of function.
ICD-10 criteria (the present diagnostic criteria in Denmark (WHO)):
A. 1. At least 6 months of fear for an severe named somatic disorder or
2. Preoccupation with an alleged deformity
B. Preoccupation with fear and the symptoms are unpleasant or affects every day functions and
lead to examinations and treatment.
C. The patient cannot (or only passing) accept reassurance that there is no physical explanation
for the condition.
D. The symptoms do not only appear in connection with other psychiatric disorder (psychoses,
affective disorder)
29
General Symptomology
When suffering from Health Anxiety, the typical physical symptoms and their interpretation are
occasional chest pain or irregular heartbeat, which are interpreted as serious heart disease,
occasional headaches, which are interpreted as brain cancer, occasional stomach ache, interpreted as
cancer in the gastrointestinal system, swollen lymph nodes and fatigue, interpreted as spreading
cancer, and occasional numbness of arms and legs as well as muscle spasms, which are interpreted
as the onset of scleroses. General discomforts such as stress symptoms of occasional discomfort,
agitation, dizziness, nausea, visual disturbance etc. (see below) are also experienced.
Apart from fear of disease, worries and anxiety, other emotional disturbances such as frequent
mood swings, increased sadness and irritability are seen. The thoughts are unpleasant and involves
disease either the actual appearance of a severe and disabling or lethal disease or the fear of
attracting a severe disease or death. General symptoms are seen as in general physical and
psychological strain and chronic stress, e.g. fatigue, loss of interest, disturbances in appetite and
sleep as well as cognitive disturbances, e.g. reduced ability to concentrate, attention, overview and
memory, often reduced short-term concentration. The condition is sometimes worsened in a way
that develops other ongoing psychiatric disorder such as another anxiety disorder, a functional
disorder or depression (see below).
Occurrence of Health Anxiety, other functional disorders and functional symptoms
Studies have shown that 1-2% of the population suffers from Health Anxiety, up to 10% are
patients with new health problems in general practice and up to 20% of the population is patients
with new health problems in hospitals. The number is equally distributed between men and women.
Somatoform and functional disorders generally appear in about 25% of patients with new health
problems in general practice. Generally, four times more women than men suffer from other
somatoform disorders than Health Anxiety such as somatization and functional disorders such as
fibromyalgia, chronic fatigue, irritable bowel syndrome, whiplash and functional convulsions. The
onset of Health Anxiety appears at all ages, but mostly in the twenties.
One study has shown that at least 80% of all human beings suffer from at least one disturbing
symptom within a period of 14 days. About 40% of these people feel that the symptom or sensation
is very disturbing. At 3 year, follow up a well-defined physical disease was the cause of the
symptoms in only 10-15% of the cases. This means that in 85-90% of all symptom cases there
appears to be functional symptoms, where the symptoms are not caused by a well-defined physical
disease (or other psychiatric disorder). The most common functional symptoms are back pain,
headache, chest pains, fatigue, dizziness, stomach pain, nausea and numbness of arms and legs.
Studies have shown that less than 1% of patients referred to specialized treatment at the Clinic for
Liaison Psychiatry afterwards turn out to have a physical disease that can explain the disorder.
Therefore, it is very seldom that physicians miss physical symptoms in patients with Health
Anxiety. It is much more common that physicians miss psychiatric disorders such as Health
Anxiety, which long unacknowledged and untreated can be just as disabling for the patient as
having a severe physical disease.
Occurrence of other concurrent mental disorders
Approx. 50% of patients with Health Anxiety at the same time suffer from another mental
disorders. The most common disorders are depressive disorders (25-50%), anxiety disorders (25-
50%) (Generalised Anxiety Disorder, Panic Anxiety, OCD), personality disorders better named as
vulnerable personality (25-50%), other somatoform disorders/functional disorders (10-20%) and
substance abuse (5-10%).
30
Causes of disease
A functional disorder is generally believed to be an underlying chronic physical and psychological
stress disorder. The basis and causal relationship at functional disorder and Health Anxiety is only
partly clarified, but is believed to be multifactorial, which means that physical, psychological, social
and cultural factors and strain over time and through interaction with the health care system are
believed to play a part. This holistic view of the health, illness and disorder of each individual is
called the Bio-Psycho-Social Illness model. Each individual patient therefore has their own
individual factors as causes for their condition of Health Anxiety and basic chronic physical and
psychological stress. Generally, the explanatory model Vulnerability-Stress-Model is used at
psychiatric disorders and especially at functional disorders in which a disorder appears due to
overload of the inherited and developed vulnerability in the individual person. The causing factors
to functional disorders are divided into predisposing factors, so-called vulnerability factors that
appeared before onset of the disorder, triggering factors, which can be related directly to the onset
of disease and maintaining factors, which result in the continuation of the disorder and possibly in
time the deterioration of the disorder.
Investigations have shown that general predisposing factors for Health Anxiety are particularly
stressful life events during childhood such as exposure to physical and sexual abuse or illness and
death in the family. Other stressful life events could be divorce of the parents and exposure to
harassment at school. Other general predisposing factors could be the patient’s personal injury or
illness both physical and psychological (e.g. disease phobia, mortal fear, depression) during
childhood as well as increased personality related vulnerability e.g. traits of an excessively high
degree of anxiety, perfectionism and tendency to control things as well as low self-esteem. In all
probability, there is also a hereditary factor with an increased incidence of anxiety disorder in the
family. The parent relationship during childhood also seems to be a predisposing factor for learning
and is typically described with an over-protective mother and an unempathic and a failing father as
well as a large degree of isolation or conflict and the expression of negative feelings at home or
socially in general. Decreased personal resources in terms of decreased interests, abilities, skills,
knowledge and social skills and so on are both factors of vulnerability and maintenance in the given
situation and condition.
General triggering factors for Health Anxiety are often the patient’s own short term physical illness
or illness and death of relatives, media attention to serious illness or stressful life events such work
related stress, divorce, moving, birth or other bio-psycho-social stress mentioned under maintenance
factors.
Maintenance factors are underlying the bio-psycho-social strains, which are leading to the current
stress, i.e. physical and psychological overload that can be equivalent to the predisposing and
triggering factors. Ordinary maintenance psychosocial strains are e.g. reduced economic
circumstances, housing and network, work related problems and overload, interpersonal problems,
reduced social status and ongoing social and legal feuds. In terms of biological stress, there are
issues such as physical impairment and illness as well as an unhealthy life style regarding diet,
smoking, alcohol and exercise.
In Health Anxiety investigations have found typical maintenance factors to be intellect (cognitive),
emotion, body and behaviour, which are targeted in the cognitive behaviour therapy and in the
individual cognitive model for Health Anxiety. Regarding intellect (cognitivity), constantly
occurring thoughts of worry with coercion (obsessive ruminations) and catastrophic thoughts of
having or getting a serious physical illness. Inappropriate underlying assumptions, attitudes and
rules of life as well as core-assumptions regarding oneself, others or outside world have also been
found. Increased selective attention to bodily sensations and information regarding heath and in
31
addition to den increased attention also an increased memory for such worrying information is
found. Furthermore, a linkage between the cognitive, emotional and body-wise in which a somatic
sensory reinforcement takes place (the vicious circle of Anxiety at Health Anxiety), where regular
bodily symptoms are misinterpreted as a serious illness, and this creates an increased anxiety
response of tension and anxiety, which increases the selective attention to bodily sensations and
thereby strengthens them, and the vicious circle spins.
If this goes on for a longer period and is intensified by individual inner and external
biopsychosocial factors and stress, it is possible to develop Health Anxiety and possibly other
ongoing psychiatric illnesses such as depression or other kinds of anxiety later on. It is found that
the same kind of sustaining behaviour is found in Health Anxiety as in other anxiety illnesses, i.e.
safety behaviour and avoidance behaviour.
Safety behaviour at Health Anxiety, e.g., is constantly scanning and monitoring your body for
threatening bodily sensations, often physically checking your body for an assumed illness, seeking
knowledge and assurance on the internet, doctors and relatives regarding your health worries. This
immediately soothes the fear, but in the end it maintains the behaviour and the inappropriate focus
on body and illness and thereby Health Anxiety.
Avoidance behaviour at Health Anxiety, e.g., is to avoid circumstances and situations, which
directly worsens the condition such as avoiding hospitals, sick people and health stories in the
media, social and physical activity, which may trigger or worsen the bodily symptoms, and attempt
to push mentally push away the worries. It can initially hold down the fear but in the end the
misinterpretation is not challenged, and is thereby kept and brings an inhibited lifestyle and
suffering with it. The reduced activity and exercise leads to poor shape, which the patient then
misinterprets as signs of a serious illness. Some Health Anxiety patients avoid to be examined by
doctors and so the Health Anxiety stays unconfirmed.
Social disturbances are often seen in the relationship with people in general, relatives, doctors and
other staff, because some people plays the sick role and this way obtains advantages such as
increased attention and protection. The patient’s social relations are often characterized by negative
feelings and thoughts, in which relatives are accused of not being good enough, the doctor is
accused of not listening and understanding the patient and of being incompetent, and the patient
often visits another doctor instead. A general avoidance of social activities and a tendency of social
isolation is often seen, because such occasions often results end anxiety symptoms or the patient
believes himself to function badly and hides himself and his condition possibly for fear of
stigmatization. This kind of social avoidance or conflict between people is overall called
interpersonal problems.
Often psychological helps is dismissed because the patient believes the condition is caused by a
serious physical illness (concept of disease), and the patient is often afraid that a serious illness is
overlooked. Accepting the condition as psychological is also by the patient seen as a mistake, a
personal defeat and a failure to his social relations, and at the same time he tries to handle a
condition, which at the same time is handled in a handled in a condition that already holds a feeling
of personal fiasco and defeat, fault, shame and reduced self-esteem.
A general stigmatization is also socially and culturally experienced and a resistance against mental
illness and the mentally ill, probably because mental illness is more complicated and multifactorial
in its origin, and therefore more difficult to understand than physical illness. Mental illness creates
fear of the unknown and uncontrollable mental illness, and mental illness is thought to be self-
inflicted. The hypochondriac is called the imaginary invalid, which also means that the patient is
not thought to suffer from something in the body, and the bodily symptoms are thereby not
acknowledged as real, the symptoms are imaginary and thereby possibly simulated. If the doctors or
32
surroundings do not see the condition as chronic and not treatable it creates a feeling of impotence,
and rejection from both the doctor, patient and the surroundings often creates a conflict.
Previously, doctors saw functional illnesses as an expression of personality disturbance in the
patient because of the fruitless interaction often played. Investigations show that the incidence of
personality disturbances in Health Anxiety patients is not greater than in patients with other mental
illnesses, in general ca. 2-3 times higher than in the general population, in which the rate of
personality disturbances is 10-15%. Personality disturbances such as Health Anxiety were formerly
seen as incurable. The development with research and psychotherapy within the past 20 years have
changed this prognosis considerably, however it is still necessary to create knowledge and introduce
it to both doctors and the general public. Vulnerable personality structure is a better and more
useful name for personality disorder.
A reduced ability to register, understand and express your feelings and needs spontaneously,
honestly and naturally is called alexithymia, and is found in functional disorders and in Health
Anxiety.
In psychodynamic terms, somatization (the mechanism for functional symptoms) is described as an
immature neurotic defence mechanism like repression as a defence against unsolved
unconscientious intrapsychic conflicts. However, this theory lacks an empiric base and
psychodynamic psychotherapy has not shown good results in treating patients with Health Anxiety.
The general biological basis for functional illnesses:
Increasing documentation that biological changes also occur because of functional illnesses is seen.
Ongoing biopsychosocial stress creates the physical and psychological stress condition in which,
i.e. brain scans, blood samples and pain stimulation tests have shown sickly changes.
Hypersensitivity towards stimuli, reduced filter function in the brain so that less irrelevant nerve
signals from the body to the brain are taken away and finally an overproduction of symptoms are
the result. Hormonally the disturbances resembles what is seen in other stress, anxiety and
depressive disorders, i.e., a dysregulated HPA axis (Hypothalamus-Pituitary-Adrenal Axis) with an
increased level of cortisol (a stress hormone from the cortex of the adrenals) and a neurological
imbalance in the neurotransmitter systems (e.g., the sympathic nervous system, noradrenalin,
sertraline) creating a hypersensitive adrenalin response (acute fear, ”flight-fright-fight-response”).
Studies show that the central nervous system is plastic and the biological changes here can be
reversible, and therefore often can be normalised by effective treatment.
Course, prognosis and treatment effect Untreated, the course of Health Anxiety is often chronic with changing symptoms and sporadic
deterioration. Studies have shown that psychotherapy using short-term specialised cognitive
behavioural therapy (CBT) developed within the past 20 years can cure 25-50% of the patients. The
vast majority of patients (>75%) report a reduction of symptoms through this treatment. However,
some patients will need more long-term psychotherapy i.e. further treatment after this group
treatment, i.e. those with an underlying vulnerable personality (previously known as personality
disorders) or other concurrent mental disorders, e.g. OCD. Studies also show that treatment with
SSRI, the so-called ”happy pills” may have a positive effect on patients with Health Anxiety or
other concurrent mental disorders such as anxiety or depressive disorders. However, there may be
side-effects to the medication. In general therefore specialized cognitive behaviour therapy is
recommended as first choice for Health Anxiety if the patient is eligible and motivated for cognitive
behaviour therapy, as this treatment also requires doing homework between meetings. Here
specialized means that the treatment program is developed for treating patients with Health Anxiety
and is conducted by therapists, who have a special knowledge of treating patients suffering from
33
Health Anxiety. It is only during the past 10 years (2003) that Liaison Psychiatric Clinics in
Denmark offer specialized treatment of functional disorders. At this moment there are 3 Liaison
Psychiatric Clinics in Denmark situated in Køge, Copenhagen and Aarhus.
Short-term psychotherapy means 10-20 meetings of 1-3 hours duration most often once a week and
is conducted individually or in a group. Group therapy has advantages compared to individual
therapy because of a written manual securing a structured treatment, positive group dynamic,
increased social activity and at the same time the creation of a permanent support group. Studies
have shown that the prognoses for improvement and cure of Health Anxiety through psychotherapy
is worsened from a high degree of symptoms, the degree of distorted illness perception, the
occurrence of other concurrent mental disorders, the duration of untreated Health Anxiety, the
degree of functional impairment and the consumption of health care products. However, as
increased research, development of improved treatment programmes and increased dissemination
and knowledge of Health Anxiety for doctors and the general public, the prognosis improves in
general.
Concurrent mental disorders (All the illnesses should overlap)
Substance
Abuse
Generalized Anxiety
Disorder
Panic Disorder
OCD
Health Anxiety
Other Somatoform
Disorders
Depression
Vulnerable Personality
Structure
34
Stress, anxiety and strain in general
Background
Physical and psychological strain results in stress. Stress disorders can be acute in onset after a
catastrophic strain (acute stress disorder) or appear in a chronic manner at adjustment disorders
(commonly known as stress) or as posttraumatic stress disorder (PTSD, delayed reaction to
exposure to a disaster). Stress is not denoted as a disorder, however, long-term stress is a well-
known risk factor for developing both physical illness such as diabetes and atherosclerosis as well
as psychological disorders such as functional disorders, anxiety disorders and depression. On a
continuum with anxiety as a generic term stress is a discreet degree of anxiety. At a higher degree
of anxiety the number and degree of symptoms below increases.
On the following pages, the symptoms of both acute and chronic stress and anxiety (functional
disorder) are listed and divided into bodily, emotional and cognitive reactions. Since other anxiety
disorders and depression often appear coinciding with Health Anxiety, some main traits of these
disorders are mentioned afterwards. E.g., it is important that the patient can identify the symptoms
of a panic attack, i.e. several acute anxiety symptoms simultaneously. To begin with, the patient
often interprets panic attacks as a possibly serious heart condition because the anxiety attack
appears suddenly and without a conscious subject and reason to trigger the anxiety. In phobias, it is
the other way around where e.g. enclosed areas or spiders are the subject to the fear and trigger the
symptoms of anxiety. Depression often occurs due to a long-term stress or anxiety disorder. These
disorders include a complex continuum of symptoms, and it takes a professional clinical assessment
to determine whether a certain psychological disorder and illness is present. As a patient, you have
undergone a thorough clinical evaluation for both physical illnesses and psychological disorders at
the preliminary medical examination.
The physical and psychological are interconnected
As our physique and psyche are interconnected, a possible physical illness is a physical distress,
which often also results in a psychological overload and thereby in stress, which is a condition of
physical and psychological overload. On the other hand, a psychological overload such as
continued unfounded fear of a physical illness (Health Anxiety) often also results in a physical
overload and thereby in stress. Whether or not you have a physical illness, you certainly have a
basic chronic stress disorder as your condition has lasted more than 6 months. Therefore, you may
profit from learning more about stress management which is the topic for Meeting 2 and 3.
35
Bodily reactions to stress and anxiety
Heart and
circulation
Warm or cold sweat
Tremor or tingling sensations
Dry mouth
Rapid or irregular heart beats
Dyspepsia
Redness or flushing
Chest tightness
Breathlessness without exertion
Air hunger with fast and deep breathing
Choking
Stomach and
intestine
Decreased appetite
Loose stools
Stomach pain
Bloating, sensation of tightness or heaviness
Diarrhoea
Eructation or regurgitation
Constipation
Nausea or malaise
Vomiting
Burning sensation in the chest or at the top of the
stomach
Difficulty swallowing Arm og leg pain
Muscle and joint pain
36
Muscles and
joints (pain)
Sensation of paralyses or weakness
Back pain
Moving pain
Uncomfortable sensation of numbness or tingling
General
discomfort
Memory difficulties
Tension headache
Dizziness
Concentration impaired
Fatigue after physical exertion
Fatigue after psychological exertion
Sleep disturbance
Emotional reactions to stress and anxiety Depressive reaction Depression
Tearfulness
Tendency to keep to oneself
Loss of interest and ability to feel joy
Feeling of guilt and shame
Reduced self-confidence
Hopelessness regarding the future
Thoughts of suicide and death
Nervous reaction Tendency to worry
Restlessness and inner turmoil
Fatigue
Sensitivity to noise
Irritability
Tension and feeling under pressure
Muscle tension
Tension pain (e.g. headache, back pain)
Tendency to startle
Nervousness
Cognitive reactions to stress and anxiety
Concentration and ability to think
Difficulty concentrating
Difficulty in thinking clearly and making decisions
Loss of interest
Loss of energy
Poor memory
Overwhelmed by every day task
Feeling of unreality
Fear of becoming insane
Fear of losing self-control
Fear of dying
37
Various types of anxiety symptoms and symptoms of other ongoing psychiatric
disorders
Symptoms of acute anxiety:
Rapid heartbeat, sweating, tremor, dryness of mouth, difficulty breathing, choking sensation, chest
tightness, nausea, upset stomach, dizziness, feelings of unreality, fear of losing self-control, fear of
dying, shivering, flushing, numbness.
A panic attack includes several of the abovementioned symptoms, which occur suddenly and
unpredictably. At the condition panic attack a minimum of 4 panic attacks have occurred within
the past 4 weeks.
Chronic anxiety symptoms:
Persistent tendency to worry, anxiety, nervousness, tension, muscle tension or pain, restlessness,
difficulty in relaxing, psychological tension, difficulty in swallowing, tendency of startling,
difficulty in concentrating, irritability, difficulty falling asleep.
At the condition generalised anxiety disorder a constant tension, anxiety and tendency to worry
over every day events and problems appears as well as several of the symptoms mentioned under
acute and chronic anxiety symptoms, and they have been present for at least the past 6 months.
Obsessive thoughts and actions:
Obsessive thoughts are felt personal thoughts, which involuntarily repeatedly appear, and as they
have a negative anxious content, they are attempted to be dismissed, but to no avail. The discomfort
connected with the obsessive thoughts can be minimal especially if the compulsions proceed
unobstructed. The compulsions are repeated uniform actions which are conducted because of the
obsessive thoughts and which transiently soothes the anxiety. The obsessive thoughts may be
almost unconscious. The obsessive thoughts may contain fear of infection, disruption, attack or
disaster regarding the patient himself or his relatives. The compulsion may occur in thoughts by a
special system and counting or physically by excessive hand washing, checking for shut doors and
if the hot plates are on, making order and cleaning the house etc.
In the condition obsessive-compulsive disorder (OCD) excessive obsessive thoughts or/and
actions occur which lead to suffering and/or function impairment.
Depressive symptoms:
Depression, reduced desire or interest, reduced energy or increased fatigability, decreased self-
confidence or self-esteem, self-blame or guilt, thoughts of death or suicide, difficulty in thinking or
concentration, agitation or inhibition, sleep disturbance, appetite or weight changes.
In the condition depression, most of the depressive symptoms occur and have been present for at
least 2 weeks.
Note: Remember that diagnosing psychiatric disorders is a complex matter and demands a
clinical assessment built on professional knowledge, experience, clinical investigation and
objectivity.
38
Cognitive Behavioural Therapy (CBT) in general
Background
The word ”cognitive” means thoughts and recognition. Cognitive behaviour therapy has been
developed since the 1960s based on learning and behaviour psychology. The focus of the CBT is
primarily the patient’s thoughts and behaviour for the purpose of increasing recognition and
understanding of the interconnection of thoughts and behaviour and the negative feelings and bodily
sensations of the disorder also in relation to the surroundings/situation and time (time
development. To change the negative feelings and bodily sensations of the disorder and to increase
the patient’s ability to function we work with testing and learning new and more appropriate ways
of thinking and acting. Important factors of cognitive behaviour therapy and treatment in a group
setting are, that CBT is:
1. An active cooperation between a therapist, you and the group (and your relatives)
2. A structured treatment with an agenda for each meeting
3. A treatment in which we together identify and register areas of your daily life and your life in
general which are troublesome and inappropriate for you.
4. A treatment in which together we test techniques that can help you manage your symptoms and
malaise.
5. A treatment in which together we make a list of all your problems and together try to find
realistic solutions to your problems.
6. A treatment in which you develop short term aims (subsidiary aims) for what you want to
achieve with the treatment concerning: (1) physical activities, (2) employment/education, (3)
social activities, (4) recreational activities, (5) other aims and values
7. A treatment in which we use various teaching methods i.e. we use a white board, overheads,
PowerPoints, you have a folder containing the manual and paper, you participate in group
exercises and do homework.
8. An investigating and exploring treatment in which you learn to ask yourself exploring questions,
that will broaden your understanding of your difficult situations, and you will learn that there are
many different answers and ways to think and manage in your specific situations.
9. A creative treatment in which together we find more appropriate ways for you to think and act in
difficult situations and in the future in general
10. A treatment in which you exercise new ways of thinking and acting through active participation
in group meetings and exercises as well as homework and behaviour experiments where you can
seek help and support from your relatives and network with an advantage.
11. A time limited treatment
39
12. Here is a group treatment where you meet fellow sufferers and together you work to create
secure and positive group dynamics in which everybody help and support each other in the
sometimes demanding therapeutic and self-evolving process.
13. Here is a group treatment in which social skills can be trained and improved naturally during
the group meetings
14. Here is a group, which forms the foundation for a possible lasting support group and network,
possibly also involving relatives, who can support and help you in your future life when
necessary.
Over all aims for cognitive behaviour therapy
1. In CBT you learn to investigate the connection between your symptoms and bodily nuisances,
thoughts, feelings and actions in various difficult situations
2. In CBT you learn new ways of thinking about your symptoms, discomforts, disorder and life
3. In CBT you learn new ways of acting in difficult situations
4. In CBT you learn new managing techniques to improve the way you handle your symptoms and
discomforts
5. In CBT you learn how you can maintain what you have learned i.e. your managing techniques
and new ways of thinking and acting, so that you can keep reducing your symptoms and
discomforts, handle relapses and generally improve your ability to function and life quality.
Basically, you are training to become your own therapist.
40
About homework assignments
A very important part of cognitive behaviour therapy (CBT) is doing homework. CBT is an active
cooperation between a therapist and you and in this case also the other members of the group, and
since we can only meet a few hours a week and there therefore are several days between meetings,
it is important to spend the time outside the meetings on testing the various exercises at home. It
requires an effort from all of us between meetings to do exercises and prepare ourselves for the
meeting, if together we are to work towards your main aim of getting better. At the next meeting,
we will start with going through the homework assignments and this way you will receive help to
continue your training and therapy. Typically, we will not have time to go through all your
homework, so our focus will be on what best helps you and the group in your continued training.
Typically, this is done by focusing on those homework assignments that caused the most distress as
well as those that were the most effective and caused the most improvement.
The purpose of the homework assignments
From investigations, we know that the more actively you take part in the therapy both by
participating in the group therapy and by doing the homework, the better your treatment outcome
will be. Therefore, do not do the homework assignments for the sake of the therapists’ or the other
group members. Do them, make the exercises continuously and use the managing techniques
because they make you feel better.
Homework assignment content It is a condition for doing the homework assignments that you participate in the meetings during
which the assignments are gone through and then read the manual regarding the individual meeting
thoroughly. If you have not participated in the meeting, you should still read the manual for the
meeting and try to do the homework as they are gone through at the next meeting. The assignments
(last page of each meeting) consist of performing and training the exercises at home, which we have
gone through or exercised at the therapy session. The assignments can be written assignments and
exercises, performance of managing techniques and performing behaviour experiments. At the
beginning, it is important when you train, that you write down your work (registration) as it will
help your memory and the structuring of your ongoing therapeutic work. Typically, several
homework assignments are given at each meeting. Obviously, we recommend that you try to do all
of the homework assignments for the next meeting. However, if you do not have time to do all the
suggested homework assignments for the next meeting, you should do the assignment in accordance
with the prioritized order. You may choose to do only certain homework assignments, should you
or the therapist assess that this is more relevant for you. Not all homework assignments will have an
effect on your individual disorder and condition, as patients with Health Anxiety are different from
each other and each have their individual problems and challenges as well as a different degree of
their disorder. Furthermore, patients also have a different degree of resources and energy to do the
homework assignments. That is why several homework assignments are given per meeting so that
everybody’s needs are met. Typically it is better to do an assignment thoroughly as described rather
than doing several assignments superficially and insufficient. You should train the individual
assignment daily for a few weeks before you can assess e.g. together with the therapists if it has
helped you. You should continue to do the exercises that work for you as long as they help you and
also after the end of the group therapy. The homework assignments should be seen as suggestions to
new managing techniques, and we suggest that you try and exercise them over a few weeks, so that
you can assess if the technique has help you and will help you in the future.
41
Get a good start with the homework assignments We start with a little bit about what habits are. The purpose of having habits is that once actions or
thoughts have become habits we spend less energy on acting or think the thought, which is now a
habit (e.g. when you are learning how to ride a bike, you spend a lot of energy trying to learn it, but
once you have learned the technique and it has become a habit, you no longer give a second
thought, and the body rides the bike automatically, i.e. you spend less energy). We all have habits,
which we consider appropriate (e.g., biking, walking up a staircase, driving a car). In addition other
habits that we think inappropriate (e.g., smoking, eating candy, drinking coffee, lying down for
many hours of the day, worrying persistently).
It is difficult for all of us to change ourselves and our habits and the training may seem like hard
work, but it takes small steps and persistence to create changes and improvement. Often it takes
several weeks of training a technique before it becomes a habit and improvement occurs. The earlier
you start doing the homework assignments the quicker you experience improvement.
At the beginning of the therapy, some patients may experience deterioration in their condition,
because it can be a strain to get to know a new group of people, to be confronted by your personal
problems and challenges and at the same time expose your problems to the group. We suggest that
you do not answer more questions in the group than you are comfortable with. If participation in the
group or doing the homework feels difficult, it is often an expression of you having difficulty in
managing these situations, which is why you will benefit from training these kinds of situations and
homework. Your challenges within your disorder, in the group and with the homework interact and
eventually it will improve your condition if you continue to train at managing these things better.
The recommended extent of homework assignments
We recommend that you devote 30-60 minutes every day to your homework during this 12-week
course. If you plan to do the assignments on a fixed time of day every day, e.g. in the afternoon
from 5-6 p.m., it will be to your advantage. Generally, it is recommended that you train the
assignments as much as possible without overburdening yourself. We are aware that you also still
have your daily chores and that is important, that you do them. Daring to do the homework a little is
however better than to avoid doing them completely. It is also better to do the individual exercise
sufficiently than doing many different exercises insufficiently. Please do the homework assignments
in the prioritized order (maybe your own order) as well as you can and as much as your time allows.
Nobody can expect more from you, neither yourself nor others. During the course of the group
therapy, you will learn to become and be your own therapist. When the course of the group therapy
is over, however, there are probably still assignments and exercises that you did not practice
sufficiently for them to have become learned techniques, whose effect you can assess properly. It
would therefore do you good to practice these exercises every now and then. Life changes and good
times turn into bad times and vice versa, and therefore it is always a good idea to continue
practicing the techniques that work for you to prevent relapse and to stay healthy. The future plan
for your continued training after the end of the group therapy course we plan together during the
second last and last meetings (Meetings 11 and 12), when we design your Individual Plan to
Prevent Relapse.
Motivation for continued training
It is your life the treatment is all about and basically you are doing most of the work. Now you have
the chance to get help and guidance from professional therapists. You may already be receiving
help from your relatives. Throughout the course of treatment, you can better your function, your
quality of life and network, but you have to be willing and to work hard at the change. You have to
believe that practice makes perfect and that perfection is created through hard work rather than just
42
talent. You have to believe that small steps and endurance is the road to recovery. You have to
believe in yourself and that faith can move mountains. You must try to have confidence in the
treatment, the therapists, the other group members and your relatives, you have to believe that
everybody want what is best for everybody. Patiently stay open and confront yourself and keep
training and practicing. In time, you will find that some of the homework assignments, exercises
and learned techniques actually help and work for you. Your hope of life improvement and your
desire to continue training and using the techniques increases, and eventually your former learned
unhealthy habits replaced by the new learned healthy habits. Then your love for yourself, for others
and for the world around you increases, which is our driving force in life.
Subjective registration of your homework activity
At the start of each group meeting, you are asked by the therapists to fill in your overall homework
activity for the previous week (per week) in enclosure no six (at the back of the manual). The
enclosure is returned to the therapists at the end of Meeting 12 along with your conclusive
evaluation of the course of the group therapy as we know that the effect of your treatment is
especially depend on your attendance and your homework activity, which is why we register this for
the purpose of treatment quality assurance. Please remember that we encourage you to commit
yourself to the treatment for your own sake and not for that of the therapists or the health care
system.
43
The cognitive model for Health Anxiety
The 5 main elements
1a. Persistent selective attention
A persistent selective attention to bodily symptoms causes other information, which does not fit
with clinical picture to be neglected and the bodily symptoms are then reinforced.
1b. Catastrophic thoughts and concerns
Misinterpretation of bodily symptoms leads to a persistent physical illness perception with
catastrophic thoughts and obsessive ruminations. Persistent anxiety leads to cognitive disturbances
such as reduced attention, general overview, flexibility, creativity and memory, which again may
lead to e.g. persistence regarding misinterpretation. In sudden severe anxiety, (panic attack) feelings
of unreality may also occur i.e. a global misinterpretation of reality. The deep level of thinking
(schemata) maintains catastrophic thoughts and concerns.
2. Emotional discomfort (and increased sensitivity)
The fear of catastrophe i.e. the disease, the disability, the loss and death often leads to other
negative feelings e.g. increased sadness and anger (irritability), which again reinforces the anxiety.
A generally changed sensitivity, stress and pain threshold occur.
3. Bodily tension
Bodily symptoms at persistent anxiety are e.g. tension, muscle tension and twitching, pain,
restlessness, sleep deprivation, fatigue, coldness, dizziness and nausea. Bodily symptoms at sudden
onset of anxiety can be shaking, rapid heartbeat, hyperventilation (quick breaths), sweating, dryness
of mouth, choking, numbness of arms and legs as well as dizziness. Fainting appears very rarely
(vasovagal reflex). Dissociative symptoms such as movement disturbance including paralyses and
cramps are also rarely seen (trauma related).
4. Safety and avoidance behaviour
These are behaviours and actions, which immediately curb the anxiety, but in the end if used
regularly maintain and possibly strengthens the fear. Safety behaviour is divided into checking
behaviour, assurance seeking behaviour and safety signals. Checking behaviour means e.g.
constantly checking your body, function and performance. Assurance seeking behaviour means e.g.
constantly seeking information regarding diseases on the internet, frequent visits to the doctor and
frequently talking to your family about diseases. Safety behaviour is e.g. bringing a mobile phone to
activities so you can call for help if necessary. Taking these security measures an excessive focus
on danger and symptoms is maintained, gathered information about the condition is often
misinterpreted and interpersonal problems occur and are maintained.
Avoidance behaviour means avoiding things, which immediately trigger and increases anxiety. E.g.
avoiding physical activity, sick people and news of disease, avoid social activity and some people
even avoid going to the doctor. If avoidance continue the assumption of illness and danger is not
tested and disproved, and fear of what was avoided increases too.
44
Cognitive Model of Health Anxiety (figure)
(Extracts from the Vulnerability-Stress-Model and the Bio-Psycho-Social Disease Model. At the pre-examination, you will receive
your individual cognitive model Time
Predisposing factors: Heredity (e.g., functional disorders, anxiety and depression)
Upbringing (e.g., parental problems and failure, divorce, bullying and relocation)
Life events (e.g., abuse in childhood, close relatives’ sickness and death)
Environment (e.g., economic reduction, housing, car)
Social (e.g., reduced network, interpersonal conflicts, reduced education/work)
Physical (earlier and (current) injuries and diseases)
Mentally (earlier and (current) mental disorders)
Personality vulnerability (e.g., anxious/compulsive personality structure)
Schemata (I am not good enough, I am week, things must be perfect, you can’t trust
anybody, you must be in control, the world is dangerous)
Trigger factors (e.g., mild sickness, others’ disease or
death, medical histories in the media,
getting fired, new baby)
Maintenance factors: (+internal and external stressors)
Thoughts (e.g., constant selective attention, worries, thoughts of
disaster, negative thoughts, cognitive reactions)
Body symptoms Behaviour (see earlier list of bodily reactions) (safety- and avoidance)
Emotions (e.g., anxiety, sadness, anger, anxiety disorder and depression, emotional
reactions)
45
The vicious circle of anxiety
Body symptom/sensation
Increased selective attention
Concerns of disaster
Increased tension and anxiety
(Bodily arousal)
Anxiety (Emotional arousal)
46
Exercise in Persistent selective attention and the Vicious circle of anxiety (Duration: 10 min.)
Instruction
The therapist instructs the group in persistent selective attention, e.g. on the right thumb.
Keep looking at your right thumb and feel the finger (describe the finger in detail). Then introduce a
catastrophic thought regarding the finger (bacteria, infection and gangrene of the finger, amputation
necessary, as a consequence you can never hold something in your hand, play an instrument or
racket sports) (3 min.).
Discussion
Now discuss the exercise in the group. Your and the groups reflections on the exercise:
(observations before, during and after, and why do you think? What can be learned from the
exercise?) Note your own and the groups’ reflections below:
47
Exercise in assessment of health threat using the Anxiety Threat Fraction (Duration: 10 min.)
Instruction
Use the threat fraction below to calculate and register your assessment of the degree of your current
health related threat, i.e. your current worst health related threat. All numbers must be 0-100. How
likely do you think it is that your health threat happens? How terrible would it be, if your health
threat happens? How well do you think you can cope if the threat comes true? How likely do you
think it is that you will be saved, treated and cured should your health threat happen? (You may use
a patient as example)
Degree of threat = Possibility x Awfulness/Ability to cope + Salvation (Help)
(All numbers must be indicated between 0-100)
Calculate your Threat degree =
Discussion
Now discuss the exercise in the group. Your own and the groups’ reflexions regarding the exercise:
Are there any similarities between you? What is overrated and underrated? What can we learn from
the exercise? Register your and the groups’ reflexions below:
48
Homework assignments for Meeting 2
1. Identify your current symptoms and register on the Week schedule your current symptoms and
their severity 4 times a day, every day during the week. Grade the severity of each individual
symptom on a 10 scale on which 0 means no symptom present and 10 means the symptom is
present in the most severe degree.
2. Describe your life goals and life values as well as your main aims and possibly subsidiary aims
for the treatment (start the Aims ladder)
3. Grade your current condition and your trust in the possibility for change
4. On the Lifeline describe the former and current symptoms of your condition and their possible
time relation to your significant physical, psychological and social circumstances and strains
(predisposing, trigger and maintaining factors)
49
Meeting 2 – Stress management
Content and Timetable
13.00-14.30 Hrs
Since last meeting (ORS, Homework activity)
Review of homework: Possible questions for distributed material to Meeting 1. Current condition
and trust in change. Values, main aims and subsidiary aims, aims are assented and made common
for the group (all patients are reviewed in short regarding all of the above (max 5 minutes per
patient). Case history (Lifeline and Week recording incl. symptoms and grade) (max 7 minutes per
patient). Essential information is written in the Case summary. List for relatives’ contact
information is distributed regarding invitation to Relatives’ meeting. Informed consent regarding
treatment schedule is obtained. Possible primary HAI is entered in the Case summary.
15-minutes break
14.45-16.15 Hrs
Stress management
Deep breathing (Relaxation exercise with focus and silence). Exercise 10 minutes.
Week recording (symptoms + grade, triggers, ways of managing)
Troubleshooting
Time planning
Positive activities (individual)
Lifestyle factors (diet, smoking, alcohol, exercise, sleep and network)
Homework: Deep breathing. Week recording (trigger, handling). Individual positive activities (List
of ideas) and their implementation. Troubleshooting (also for Homework). Time planning. Relevant
changes of Lifestyle factors.
Rounding off (GSRS, questions, summary, evaluation)
50
Stress management
Background
The physical and psychological factors of a human being are interconnected and a possible physical
illness will therefore be a physical overload, which also leads to psychological strain and possibly
also to psychological overload, which then leads to stress, which as you know is a condition
combining physical and psychological overload. On the other hand, psychological overload such as
unfounded fear of a physical disease (Health Anxiety) also leads to physical overload (bodily stress
symptoms) and thereby to a stress condition. Therefore, whether you also have an overlooked
physical disorder, which doctors have rendered unlikely, you certainly have a basic chronic stress
disorder, because your condition has lasted for more than 6 months. Moreover, you will certainly
benefit from learning how to manage stress, if you do not already master and use these techniques.
It can be just as disabling to have a psychological disorder such as Health Anxiety as it is to have a
physical disease, and therefore it is just as vital to be evaluated and treated for a condition of Health
Anxiety as quickly and well as possible. Typically, a physical disease does not evolve in such a
manner and speed that this 12-week group therapy focused on psychological treatment will be
problematic, should you really have an overlooked physical disease. Therefore, there are no good
reasons why you should not invest all of your energy in the course of the group therapy and
experience at first hand that this therapy will probably help you too.
Simple stress management
There are many different ways to deal with stress. How to deal with your specific stress naturally
depends on what it is that specifically and overall overloads you, and how you already deal with
your strain. Sometimes these strains are dealt with in less appropriate ways, which is why it is
important to identify and record you present ways of managing and change the inappropriate ways.
Your former and current strain, both what stresses you and how they do it, can be more or less
known to you. At the first doctors’ appointment you and the doctor made your individual cognitive
disorder model, and you found some of your major strains both in your past and present. During the
course of the group therapy, you will often become aware of more biopsychosocial factors, that
have put a strain on you in the past or especially, that specifically strain you right now and the
specific situation in which your condition deteriorates, as well as how you coped with these strains
previously and presently. Perhaps you sometimes deal with your condition in a less appropriate
manner, and perhaps you can learn from other peoples’ positive experiences with stress
management and learn to cope with your strains in a more effective manner through the chosen
techniques of this course. The focus areas and techniques your will learn at Meetings 2 and 3 are the
same traditional and simple methods of stress management, that you are probably already
acquainted with and you probably already use some of the techniques in a good way. The rest of the
group therapy course will focus on more advanced methods of stress management and anxiety
treatment. We recommend that you train the simple stress management techniques for minimum 4
weeks, because sometimes the simple methods actually have a better effect than the more advanced
ones, also when it comes to treating Health Anxiety. Simple stress management techniques mean
that the techniques often are simple to understand, train, learn and use without therapeutic
assistance.
Strain with stressors, triggers, and their impact
The first step for better stress management is to become more aware of your current strain, both
overall strain but also strain in the individual situation. These strains are also generally called
stressors. Triggering strain in the individual situation are called triggers. Triggers can be both
51
external, i.e., coming from the surroundings, or internal i.e., disturbing thoughts, feelings or bodily
sensations. In the homework assignment ”Week recording” for next week you are asked to record
and thereby become more aware of the current triggers of your symptoms and uncomfortable
situations. Below is a list of more common biological, psychological and social strains.
Examples of known strains (stressors and triggers)
Biological stressors and triggers
Physical illness, injuries, reduced bodily function, appearance, side effects from medication or other
treatments, obesity, malnutrition, poor shape and condition, sexual problems, lack of sleep, bodily
symptoms and sensations.
Psychological stressors and triggers
In this particular case, a psychiatric disorder primarily is a dysfunction of emotions and consists of
increased anxiety, sadness or anger, and loneliness, low self-esteem, concerns regarding anything in
particular health, the meaninglessness of life, doubt and choices of life, frustration because of lack
of understanding, reduced understanding and insight in oneself and others regarding thoughts,
feelings, body and behaviour, reduced understanding of being ill, reduced ability to express oneself,
reduced ability to make contact with other people, reduced social skills, shyness regarding conflict
or frequent conflicts with other people due to increased conflict creation or reduced conflict
management, lack of fulfilment of own needs, unsolved problems, the feeling of having to little
time etc.
Social stressors and triggers
Network: reduced number of or support and contact to family, friends, acquaintances, no lover, no
children, death in the family, conflicts, harassment, isolation, social rejection, divorce, too many
social engagements and work.
Work og education: Too many demands (outer or inner), reduced predictability, reduced control,
over or under qualification, reduced opinion, reduced social support, conflicts, reduced security,
reduced feedback, bad working environment, unemployment.
Home: poor housing conditions, poor shopping possibilities, lack of accessibility aids (e.g. lift),
problems with car and parking, problems with childcare and shopping.
Economics: poor economy, badly managed economy (budgeting).
Spare time: Lack of interests and activities.
Environment: Judicial or social cases, noise, smell, pollution, climate, traffic, crime, discrimination,
unsafe area.
Four overall ways for simple stress management
1. Reduce or modify the stressor (e.g., record, Troubleshooting and time planning)
2. Make yourself strong (e.g., positive individual and common activities)
3. Train and use techniques for better management of stress (e.g. relaxation techniques,
assertion)
4. Reduce or eliminate improper stress management (e.g., over activity, inactivity, overeating,
abuse, reduced sleep, self-destruction)
52
Exercise in Deep Breathing (Duration: 10 minutes)
Background
The technique ”Deep Breathing” is used as a basic element in many meditation exercises. The
technique focuses on breathing and makes the breathing deep, even, slow and calm by means of
which the breathing has a calming effect. The technique must be learned and can be used as general
relaxation and an exercise in attention to learn how to focus on other things than e.g. annoying
bodily sensations, concerns and anxiety. It can also be used against rapid breathing, superficial
breathing or difficulty breathing, which can be symptoms of acute or chronic stress and anxiety,
which again can be experienced in general, in particularly stressful situations or sudden onset
without any clear reason at a panic attack. In this situation, the technique can be used as a coping
strategy. The quick superficial breathing (hyperventilation), which is often present at a panic attack,
often, brings with it the following symptoms: chest tightness, choking, dizziness and sensory
disturbances.
Instruction and Guidance
The technique is initially trained sitting or lying down. Make yourself comfortable in as chair and
put your feet firmly on the floor. Be comfortable with a straight back and your arms resting in your
lab or on your thighs. You may also choose to lie down. You may choose to close your eyes or
focus on a certain point during the exercise. Take some slow, regular deep breaths. Take a deep
breath while you count to (it takes about 3 seconds), then breath out, again you may count to 5 (it
takes about 3 seconds). Then you hold your breath and when it comes naturally, you take another
deep breath. The best way to breathe is through your nose. During the exercise let your breathing
find its own natural rhythm, but keep focusing on your breath. Instead of counting to 5 you can
focus your attention on your breath by noticing how you slowly breathe in air through your nose,
down into your lungs to the chest and stomach, which rises, the little break between breathing in
and breathing out, how the air then flows out through your nose during your slow exhale, and the
stomach and chest lowers, then you rest for a few seconds until you inhale again. Exercise taking 10
deep breaths in a row (duration approx. 10 minutes). The take a break and repeat the exercise or
repeat the exercise later in the day and in other situations (see below).
Train the technique “Deep Breathing” all in all approx. 10 minutes a day for 1-2 weeks, then start
training and using the technique outside your home and in increasingly stressful situations for about
10 minutes a day the following weeks. Once you’re are familiar with the technique you can try to
use it as a coping strategy in the prelude to or during a panic attack if you experience this kind of
attack, and then preferably use the technique lying down as this exercise often is used to master this
kind of acute anxiety. Eventually as a habit, you will start breathing more deeply, which in the end
will give you a feeling of relaxation and wellbeing in your everyday life.
Discussion (record your and the group’s reflexions):
53
Week schedule (triggers and how to handle)
Registration of your symptoms, their degree and the trigger that caused the
aggravation and the way you coped with your symptoms in these critical situations. If
you have many symptoms, chose the most important (max 5) and register them
continuously.
Please register 4 times daily every day of the week the symptoms that have bothered you and how troublesome the individual symptoms have been during the day on a scale from 0-10.:
0 1 2 3 4 5 6 7 8 9 10
Enter keywords about your situation when you experienced the symptoms. E.g., alone, in the
bus, at work, sports, with girl-/boyfriend, child, at in-laws. Could it be external og internal
strain or stress that triggered the aggravation? (Internal triggers could be negative thinking
or bodily symptoms). Register how you coped in the situation.
day
date:
day
date:
day
date:
day
date:
day
date:
day
date:
day
date:
Morning
Afternoon
Evening
Night
Worst degree of the
symptom, e.g., anxiety,
bodily symptoms, cognitive
and general symptoms
No symptoms, e.g.,
anxiety, bodily
symptoms, cognitive and
general symptoms
54
Troubleshooting
Guidance
There are solutions to many of your daily problems (e.g., unpaid bills, reduced contact to or conflict
with a friend, undone chores, too many assignments at work, boredom). These 10 steps can help
you solve your problems better. Make a list of current problems which you think could be solved,
and use the 10 steps to solve each problem. Try to solve one problem at a time. Be patient and
satisfied with the fact that you are trying and training to become better at Troubleshooting even
though the problem may not be solved right away. Reward yourself for the effort, e.g. by
encouraging yourself and positive activities. For each step you overcome the more free, you will
become
Your current problem list:
1.
2.
3.
4.
5.
The 10 steps to Troubleshooting:
1. Choose a problem and describe it
2. What is your specific and realistic aim for solving the problem?
3. What are your resources for solving the problem?
4. Mention a lot of different solutions to the problem (Brainstorming)
5. Attempts to improve your solutions?
6. Estimate which solution is the best for you (pros and cons to each solution)
7. Divide your aim into subsidiary goals, make a plan for the Troubleshooting and commit
yourself to working your way through the plan on a daily basis (Time planning)
8. Identify possible obstructions (thoughts, feelings, body, behaviour, external factors) and
find solutions to remove the obstacles and remove them
9. Assess minimum once a week where you are in the process (Time planning)
10. Go through the result. Acknowledge your effort. Estimate how the problem can be solved
better next time.
55
Scheduling
Guidance
Time planning can be clever if you often feel that you are late for appointments, which you often
have to hurry, that you are not very efficient in your work and that your list of chores only piles up.
Your time planning can improve most advantageously if you work on the following 3 areas:
Prioritizing, Scheduling and Completion from the following list:
1. Make a list of this weeks’ chores
2. Prioritize these chores in order after importance
3. Assess the duration of the solving of each chore
4. Make time in your schedule, so that you will know when you have to do each chore
5. If you cannot make all the chores on the list, try to delegate some of them, streamline the
Troubleshooting, reduce the standard of the solving, delete less important chores or reduce
the number of interruptions when you do the chores (e.g. turn off the phone and internet)
6. Identify possible hurdles in order to get the chores done and remove the hurdles. Try
motivating yourself by saying “you will feel better once the chores have been done”, ”just
do it”, and reward yourself, when the chore is done. Get started by giving the chore 5
minutes. Many people continue doing the chore once they have started. Do you have
thoughts that prevent you from doing the chore? It could be that you think the chore is too
hard, that is has to be done perfectly, that you are too tired to do it now or that you are not
good enough to get it done. Estimate if these thoughts really are realistic. The difficulty is of
the chore is often overestimated and your own abilities underestimated. You will have more
energy once you get the chores done. ”Better late than never” and ”half a loaf is better than
none at all”.
List of this week’s chores in prioritized order (then put them realistically in your schedule):
1. ___________________, duration: _______, enter the time for the chore in your schedule
2. ___________________, duration:________, enter the time for the chore in your schedule
3. ___________________, duration: _______, enter the time for the chore in your schedule
4. ___________________, duration:________, enter the time for the chore in your schedule
5. ___________________, duration: _______, enter the time for the chore in your schedule
6. ___________________, duration:________, enter the time for the chore in your schedule
7. ___________________, duration: _______, enter the time for the chore in your schedule
8. ___________________, duration:________, enter the time for the chore in your schedule
9. ___________________, duration: _______, enter the time for the chore in your schedule
10. ___________________, duration:________, enter the time for the chore in your schedule
56
List of ideas of positive activities
Background
Your positive activities strengthen your wellbeing and mood and thereby increase your quality of
life. If you feel stressed because of e.g. too many worries, anxiety, physical discomforts and
increased selective focus on discomforts, you could benefit from distracting yourself from your
disorder by doing positive activities from time to time. You can do positive activities alone or with
other people. Below is a list of ordinary positive activities, which may serve as an inspiration for
you. The positive activities must not be used as displacement activities (avoidance behaviour), e.g.
when you need to work on and solve your problems, e.g. by making your homework.
1. Reading fiction
2. Writing a diary
3. Doing aerobics
4. Riding a horse
5. Buying flowers for yourself
6. Buying books
7. Going to the cinema
8. Going for a run
9. Praising yourself for having done a good job
10. Remembering fun events that you have participated in with friends
11. Listening to music
12. Lying in the sun
13. Laughing
14. Recalling previous travelling
15. Listening to others
16. Reading a newspaper or magazine
17. Doing a hobby (e.g., stamps/model airplanes)
18. Being with friends
19. Planning holidays or other activities that make you happy
20. Meeting new people
21. Eating something delicious/special
22. Practising karate/judo
23. Practising yoga
24. Doing chores
25. Repairing your bike or car
26. Dress sexy or beautifully
27. Enjoying a quite night
28. Taking care of your plants
29. Go swimming
30. Doing exercise
31. Start collecting old things
32. Go to a party
57
33. Consider buying something
34. Play golf
35. Play football
36. Fly a kite
37. Discuss politics, films, books, philosophy etc. with friends
38. Go to a family celebration
39. Driving a motorcycle
40. Having sex
41. Going for a run or a walk in the woods
42. Going camping
43. Singing in the shower or while doing other things around the house
44. Buying or cutting and arranging flowers
45. Going to church/mosque/synagogue
46. Losing weight
47. Thinking of the things, you are good at
48. Take a day off
49. Arrange a school reunion
50. Skating
51. Going sailing
52. Taking a trip abroad
53. Painting or drawing
54. Doing needlework (knitting, crochet, sewing)
55. Sleeping
56. Going for a drive in the car
57. Participating in community work/meetings
58. Going hunting
59. Choir practice
60. Flirting
61. Playing a musical instrument
62. Being creative (pearls, ceramics or similar)
63. Making a present for someone you love
64. Buying a CD with good music
65. Watching boxing
66. Planning a party
67. Cook
68. Climb a mountain
69. Write poems, short stories, books, articles or similar
70. Buy clothes
71. Dine in a restaurant
72. Work
73. Go sightseeing
74. Do some gardening
75. Going to a beauty parlour/hairdresser
76. Play tennis
58
77. Be together with your or other people’s children
78. Watch a play
79. Going to a concert
80. Daydreaming
81. Go for a drive
82. Listen to the radio
83. Watch TV
84. Make lists of chores
85. Ride a bike
86. Take a walk by the sea
87. Buy and/or give a gift
88. Go to the zoo, a park, the botanic gardens or similar
89. Finish a task
90. Go to a horse race/motorbike race
91. Eat candy, cakes, chips
92. Teach somebody something you are good at
93. Take pictures with a digital or regular camera
94. Go fishing
95. Keep a diet
96. Be with animals
97. Fly in an airplane
98. Read nonfiction
99. Play amateur theatre/take drama lessons
100. Be alone
101. Take badminton lessons
102. Take a long and warm bath
103. Go on vacation
104. Pay off on you debts
105. Collect things (coins, stones, etc.)
106. Arrange a date
107. Go on a date
108. Relax
109. Write letters
110. Take the children to an amusement park
111. Dance
112. Go on a picnic
113. Meditate
114. Play volleyball
115. Have lunch with a friend at a cafe
116. Play cards/games (backgammon, chess etc.)
117. Do the crosswords or Sudoku
118. Play a ball game
119. Watch and show photos
120. Play the guitar
59
121. Play pool
122. Buy yourself exquisite things (perfume, shoes, clothes etc.)
123. Talk on the phone with friends
124. Go to a museum
125. Light a candle
126. Receive or give a massage
127. Go to a sauna or steam bath
128. Go skiing
129. Go canoeing
130. Go bowling
131. Do carpentry work
132. Fantasise about the future
133. Take lessons in ballet, tap-dancing, salsa or similar
134. Take care of fish in an aquarium
135. Take an interest in politics
136. Do volunteer/charity work
137. Make a puzzle
138. Go to the beach
139. Rearrange furniture or decorate your home
140. Go to a sports event
141. Go to the disco/a bar
142. Go to a lecture
143. Invite friends for dinner
144. Wash your hair and rub cream on your body
145. Go water-skiing
146. Go shopping
147. Go to the circus, amusement park, Tivoli/fun fair or similar
148. Go to flea markets/boot sales
149. Surf the internet
150. Play PlayStation
151. Chat on the internet
152. Look at the stars
153. Bake a cake
154. Take a foot bath
155. Spend time with your spouse/partner, children and/or friends
156. Pay somebody a compliment
157. Give a hug
158. Talk to relatives, family or a friend
159. Email a friend
160. Write a letter to a friend
161. Call a friend
162. Take a course
163. Go to a lecture
60
164. Sing a song
165. Dance
166. Repair or fix your things (e.g., your bike)
167. Listen to the radio
168. Go to a museum
169. Take care of your looks
170. Learn a new language
171. Go to the library
172. Go to the indoor swimming pool
173. Take a bike ride
174. Go to the gym
175. Do gymnastics
176. Do yoga
177. Visit a friend or invite on home
178. Join a society or club
179. Discus on a blog or debate forum
180. Be politically active
181. Fix your garden
182. Buy a plant
183. Take care of your plants
184. Buy a pet
185. Taking care of your pet
61
List of ideas for your individual positive activities
Guidance
Read the above list of ideas for positive activities and use it as an inspiration, then write your own
list below with your own individual favourite positive activities (minimum 10 activities). Do some
of your positive activities daily. Plan some of them in your schedule.
62
About lifestyle factors
Background
The lifestyle factors Diet, Smoking, Alcohol, Exercise (the so-called KRAM-recommendations) and
Sleep and Network are important factors for the human constitution and health. People with
psychiatric disorders often have an unhealthy lifestyle regarding some of these lifestyle factors.
Usually patients with Health Anxiety do not have significant problems regarding the KRAM-
recommendations, and therefore we enclose the information from the Psychiatry of Region Zealand
regarding the KRAM-recommendations and questions for further evaluation of these factors at the
back of this manual as enclose 5. In Health Anxiety the patients sometimes have trouble with
physical activity and exercise, and we identify and work therapeutically with this problem at
meetings 9 and 10 (avoidance behaviour and exposure). People with Health Anxiety often have
trouble with sleep and social activity related to Network, and therefore information and questions
regarding a closer investigation into these matters are included at this meeting.
Guidance
Read the following information and answer the questions regarding lifestyle factors Sleep and
Network. Then do the same regarding the KRAM-recommendations in enclosure 5 if you have
problems regarding diet, smoking, alcohol or lack of exercise. Assess at each lifestyle factor
whether your lifestyle regarding this particular matter is unhealthy. If this is the case you should try
to change into something healthier over the next few weeks. You may want to use the methods
described under “Troubleshooting” and “time planning” for help. It is not the main objective of this
group therapy course to help you with these kinds of lifestyle changes. Instead, you should see your
contact and have a chat about how to solve problems regarding lifestyle changes.
63
Sleep
Background
Adult usually need between 6-9 hours of sleep every night. It is quite normal to wake up every now
and then while sleeping and that you cannot remember it afterwards. Nightmares do not occur often
and it is normal not to remember your dreams. If you feel rested during the day, the quality of your
sleeps has been good. However, your assessment is affected by your mood and your psychiatric
disorder in general. Sleep disturbances with insomnia, interrupted sleep and early morning
wakening often happens to people suffering from a psychiatric disorder, and most people
experience sleep disturbances, e.g. during stressful periods.
Guidance
To find out if you currently have trouble regarding sleep, please answer the questions below.
Only fill out the Week schedule regarding sleep recording if you despite having followed the advice
on good sleeping hygiene for several weeks (see below), still continue to suffer from sleep
disturbances and wish to receive further professional help to improve your sleep.
Describe and assess your current sleep by answering the questions below:
When do you go to bed?
When do you wake up in the morning?
How many hours do you sleep during the day?
How long are you awake during the night?
How many hours do you sleep overall in a course of 24 hours?
Do you sleep too little or too much?
Do you feel rested when you wake up in the morning?
64
The vicious circle of insomnia
Triggering cause
Poor sleep
Daytime fatigue
Worries about sleep
Activation
(emotions/body)
Mental or social
influence
Biological
influence
påvirkning
65
Causes for sleep disturbances
Poor sleep hygiene 1. Stimulants (coffee, tobacco)
2. Light
3. Noise
4. Food
5. Exercise
Learned insomnia 1. Poor sleeping habits
2. Unrealistic expectations
3. Lack of knowledge
Psychiatric disorders 1. Stress
2. Anxiety
3. Depression
Medication and alcohol
Biological/ Medical disorders 1. Nocturnal urination
2. Pain
3. Chronic bronchitis
4. Reduced heart function
Circadian rhythm disorders 1. Shift work
2. Jetlag
3. Chronic bed rest
4. Senility
Unexplained insomnia
66
Advice on good Sleep hygiene
1. Get up at the same time every day no matter how much sleep you have
had
2. Only go to bed when you are tired
3. Only use the bed and bedroom for sleep and sex
4. Keep the bedroom dark and at a suitable temperature (18-22 degrees
Celsius)
5. Get up and go to another room if you are not asleep within 20 minutes.
Relax and avoid strong light. Only go to bed again when you feel sleepy.
6. If you still have not fallen asleep within 20 minutes, repeat step 5 (if
necessary several times)
7. Avoid sleeping during the day
8. Avoid tobacco, coffee and alcohol (especially before night time)
9. Make sure that you exercise daily during the day time (not within 4 hours
of going to bed)
10. Avoid taking sleeping pills for longer periods (only every now and then
or for no more than 2 weeks in a row)
11. If you have many disturbing thoughts going to bed or waking up, repeat
step 5 and write down your concerns (Thoughts on a Leaf, Meeting 4)
67
Weekly recording of sleep pattern
Week: Hour
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
1
2
3
4
5
6
7
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Symbol: Go to bed Comments:
Wake up [----] Sleep M Medication and stimulants D Disturbances
68
Sleep recording
Fill in the Week schedule regarding sleep recording when needed (5 minutes
every morning)
Use the signs and abbreviations below:
Means the time you went to bed
Means the time you got up
[----] This shows when you fell asleep and when you awoke again
M Medicine and stimulating drugs
D Disturbances
Comments:
You may record other important events during the night in the schedule, e.g.
thoughts, feelings, actions or bodily symptoms
69
Network (your relation with others)
Describe, rate and strengthen your current network
Background
Social relations and common positive activities, mutual social support, care and help are essential
for the quality of life and health of most people. Investigations have shown, that lack of social
network, social activity and loneliness as well as frequent social conflicts are some of the greatest
risk factors for illness and early death. It is therefore always a good idea to try to strengthen your
network. People have different social needs and the subjective assessment of the current network is
therefore important in terms of both quality and quantity.
Instruction
On this card, draw your own current social network. Place yourself in the middle. Draw a circle for
every person you meet up with regularly and to whom you feel close. Write a letter in the circle to
identify the person. Outside the circle, write the whole name next to the letter. As you can see, you
can put your persons in one of 4 boxes. The first one, family, is for your parents and siblings. The
second, other relatives, means your spouse, your children and other relatives. The closer a person is
to you, the closer to the middle of the drawing (this is you) you must place them. When you are
finished look at the drawing and determine if you are satisfied with your current network, or if you
wish to change your network and maybe improve it or reduce your relations with others. Maybe you
can use Troubleshooting and time planning to execute your wanted changes.
Family Other relatives (Parents, siblings) (Spouse, children,
remaining family)
Du står i midten
Friends, acquaintances, Therapists/doctors,
Colleagues patients
You
70
Homework assignments for Meeting 3
1. Train Deep Breathing for about 10 minutes daily for at least the next 2 weeks (possible at
different times during the day). The first week train at home sitting or lying down. Then train
outside your home at increasing stress over time (Relaxation exercise for focus and peace and
quiet).
2. Identify, record and grade 4 times a day during the week on the Week schedule the symptoms
you have felt (0-10) and record the possible trigger that caused a deterioration (possible
stressors) and the way you handled such a critical situation.
3. Make your own list of ideas for positive activities. Use your own positive activities daily also
as a positive distraction from your disorder. Put some of your positive individual activities in
your calendar.
4. Troubleshooting. Make a prioritised list of your current problems. Make time in your schedule
to solve them. Over minimum, the next 2 weeks try to solve at least one problem a week. Use
the technique from the manual. If you have trouble making your daily homework for this
group therapy course, you can use this technique to try to solve that problem.
5. Time planning. Plan your daily chores for the coming week in your schedule and commit to
trying to get the chores done. For minimum, the next 2 weeks use the technique from the
manual.
6. Describe and assess your current lifestyle regarding Sleep and Network. Do the same
regarding the KRAM-recommendations: Diet, Smoking, Alcohol and Exercise in enclose 5,
if you find it necessary. If you have a less healthy lifestyle use the technique for
Troubleshooting and Time planning in the manual to improve your basic lifestyle over the
next 4 weeks. Should you then require further professional assistance to change your lifestyle
regarding some of these factors, you should get in touch with your contact person for specific
professional help when this 12-week group therapy course is done.
7.
71
Meeting 3 – Stress management continued
Schedule and Contents
13.00 - 14.30 Hrs
Since last meeting (ORS, Homework activity)
Review of homework assignments: Possible questions regarding distributed material for Meeting 2.
Deep breathing. Week recording (triggers and handling). Troubleshooting (also Homework
assignments). Time planning. Individual positive activities and their execution. Change of Lifestyle
factors.
15-minutes break
14.45-16.15 Hrs
Progressive relaxation (Relaxation exercise with focus, stretching and silence). Exercise (15
minutes)
Week recording with focus on feelings
Assertion (identify, register, understand and express your feelings and needs honestly)
Assertion and common communication. Exercise (10 min.)
Common positive activities
Homework assignments: Relaxation exercises with Deep Breathing and Progressive relaxation.
Week recording (+ feelings). Assertion and Common communication and their execution. List of
Common positive activities and their execution. Stress management continued with techniques from
Meeting 2.
Rounding off (GSRS, questions, summing up, evaluation)
72
Exercise in Progressive relaxation – a deep form of relaxation (Duration: 15 min.)
Background
Through this exercise, you learn to become better at identifying tensions in your body, so that you
can prevent these tensions to develop into e.g. tension headache or body pain. You also train your
attention through shifting focus on parts of your body. During the relaxation exercise, you are asked
to first observe for approx. 5 seconds, then tighten the muscles for about 5 seconds and finally relax
the shifting muscle groups for about 10 seconds and at the same time be aware of the degree of
tension during the exercise. Through the daily training you learn to identify possible tense muscle
groups and thereby the technique can be customized the situation and possibly prevent constant
tension and pain in a particular muscle group. By doing the exercise daily for several weeks you
may also achieve a more durable and deep relaxation of the whole body. The exercise takes about
10 minutes to do, and we recommend that you perform the exercise once a day for at least the
following 2 weeks to obtain a positive effect. Once you have become better at identifying your
bodily tensions through the exercise, it will be sufficient that you only do the progressive relaxation
in your identified tense muscle groups. Your individually tailored progressive relaxation technique
should afterwards be trained outside your home e.g. at work or in other lightly stressing situations,
so that in the future you can do the individually tailored exercise anywhere when needed.
Instruction and guidance
If the progressive relaxation during the training becomes uncomfortable for you, try going back to
only Deep breathing before you continue the exercise. You may also chose to do the exercise
without tensioning the muscle groups and just continue to observe the muscle group before relaxing
it. Alternatively you can stop doing the exercise altogether and wait for the rest of the group to
finish the exercise. Afterwards the exercise is discussed in the group (patient experiences, possible
difficulties, effect etc.).
Sit yourself down or lie down and free your mind from distractions, maybe you would like to close
your eyes. It is important that you have good support for your arms and legs, so that you can relax
your body and muscles.
We start by performing Deep breathing. Breathe deeply, slowly and evenly. Focus on your breath,
how the air comes in and out through your nose or mouth, feel how the stomach simultaneously
moves slowly up and down. Find your own rhythm in the breathing and let your breathing be calm
and comfortable. You can e.g. count to 5 when breathing in and breathing out at duration for about
8 second per breath. Every time you breathe out try to let go of a little bit of the tension in your
muscles. A little bit more each time. Breathe naturally and comfortably. Now you must alternate in
the mentioned order observe the mentioned muscle group for about 5 seconds, flex the mentioned
muscle group for about 5 seconds and the relax the same muscle group for about 10 seconds.
Furthermore you must during the exercise be aware of the degree of tension of the mentioned
muscle group before flexing, during flexing and then at relaxation.
An example of what is repeated per muscle group:
Now move your attention to your right hand. Be aware of the degree of tension in your right hand
now. Make a fist with your right hand as best you can and keep the tension for 5 seconds. Be aware
of the degree of tension in your right hand during flexing. Relax your right hand and let it rest for
10 seconds. Be aware of the degree of tension during relaxation.
73
Now move your attention to your right forearm (5 seconds). Tighten your right forearm by flexing
the wrist backwards (5 seconds). Now relax your right forearm (10 seconds). Go through all the
muscle groups like mentioned below
Right hand (make a fist)
Right wrist and forearm (wrist bends backwards)
Right upper arm (bend the elbow)
Left hand (make a fist)
Left wrist and forearm (wrist bends backwards)
Left upper arm (bend the elbow)
Right foot (curl your toes)
Right crus (bend the knee, foot pointing downwards)
Right femur (bend the knee, foot pointing upwards)
Left foot (curl your toes)
Left crus (bend the knee, foot pointing downwards)
Left femur (bend the knee, foot pointing upwards)
Buttocks
Stomach (breathe in a little bit)
Back (arch your back)
Chest (shoulders back, chest forward)
Shoulders and neck (shoulders up, draw back the neck a little bit)
Throat (lower jaw down, tilt your head downwards)
Face (tighten)
Forehead (lift your eyebrows)
In the end focus once again on your breathing and take some deep, slow and even breaths. The open
your eyes. End of exercise.
Discussion
74
Week schedule (feelings)
Registration of your symptoms and their degree as well as your feelings and their
degree that may trigger the aggravation and your way of coping in the situation.
Please register 4 times daily every day of the week the symptoms that have bothered you and how troublesome the individual symptoms have been during the day on a scale from 0-10.:
0 1 2 3 4 5 6 7 8 9 10
day
date:
day
date:
day
date:
day
date:
day
date:
day
date:
day
date:
Morning
Afternoon
Evening
Night
Worst degree of the
symptom, e.g., anxiety,
bodily symptoms, cognitive
and general symptoms
No symptoms, e.g.,
anxiety, bodily
symptoms, cognitive and
general symptoms
75
Exercise in Assertion and Common communication (Duration: 15 minutes)
Background
Assertion is the ability to identify, register, understand and express your feelings and needs honestly
and naturally. This means the ability also to distinguish feelings from e.g. bodily sensations and
thoughts and learn to be more attentive to your feelings and express them clearly in the situation
instead of expressing your thoughts and the bodily discomfort, which people suffering from Health
Anxiety are excessively attentive of. Studies have shown that patients with functional disorders
such as Health Anxiety in general have a high degree of alexithymia (see the paragraph Cause of
Illness under General knowledge about Health Anxiety) which is a decreased ability to Assertion.
In popular terms, we all know that it helps to dare to unburden your mind and talk about your
feelings. Sometimes relatives and other people such as caregivers react in a negative manner
towards the patient’s ongoing communication regarding, e.g. a low degree of Assertion, frustration
and possibly distorted illness perception, because the patient communicates less understandably and
perceptively and is harder to help. This creates frustration on both parts and is probably one of the
reasons why many people suffering from Health Anxiety sometimes are in conflict with other
people. The patient communicates to seek understanding, support, care and help which is why
conflicts with other people only makes the situation worse. Working on your Assertion is therefore
an important element on the way to train and improve your Common communication and the
interaction with other people in general.
Instruction (for everyone in turn, duration ca. 10 minutes)
For the past week, you have worked at identifying and registering your feelings related to your
uncomfortable bodily symptoms via the Week schedule. Furthermore, we have generally worked at
increasing your understanding of the multifactorial biopsychosocial basis of your symptoms, why
they occur and continue to exist both through time and in the individual situation with improved
identification of triggers and stressors. This identification and registration of your feelings as well
as improved understanding of their causes are basic elements of Assertion. Now you need to train
the last element of Assertion, which is expressing your feelings in an honest and natural fashion.
You are probably mostly used to communicating your thoughts, concerns and bodily symptoms, but
now you must work at expressing your feelings and expressing them as honestly and naturally as
you can and as close to their occurrence as possible. If you initially find that this is difficult for you,
this is precisely an indication that you need to work on Assertion for a while and that you probably
will profit from doing so. Choose a critical situation from your Week Schedule and express your
feelings regarding this honestly and naturally to the group. You should only try to express your
feelings regarding the situation and avoid seeking assurance that there is something physically
wrong with you. A critical situation means a situation in which you experience uncomfortable
symptoms (body, feelings, thoughts) either through a shift with immediate deterioration in your
condition or if you experience exceptionally persistent uncomfortable symptoms.
Discussion
76
Guidance in Assertion and Common communication, a homework assignment
When you experience a critical situation, identify your feelings and their interaction with the
situation and your bodily symptoms, thoughts and behaviour. Then consult your next of kin and
express your feelings honestly and naturally. Try to avoid expressing your concerns and bodily
symptoms. You may want to ask yourself, which needs your wish to have fulfilled in your relation.
In addition, in the future try to get your appropriate and healthy needs fulfilled. Giving each other a
hug after you have expressed your feeling towards your relatives is a simple and good behavioural
action. In the situation ask your relative for a hug, so that they understand your needs and wishes.
For the next few weeks, make a deal that you will give each other a hug in similar critical situations
and try to avoid discussing your concerns and bodily symptoms related to your condition. If your
relatives ask about your thoughts and bodily symptoms, gently avoid answering these questions and
communicate, that you just want a hug. This way you also work at reducing your excessive focus on
your body and your persistent fear and worries for having or contracting a serious disease.
How did it go?
77
List of ideas for your common positive activities
Background
Good common communication and hugs are examples of common positive activities. Patients with
Health Anxiety often have more conflicts or shy away from contact with others, and therefore they
can sensibly plan common positive activities with their next of kin, relatives or friends. As
homework assignments you have already worked with your Network during general improvement
of Lifestyle factors and improved Common communication which includes planning and executing
of Common positive activities, which again all are assignments that may improve the quantity and
quality of your current network.
Guidance
Below, make a list together with your relatives of your common positive activities. In your
schedules plan some weekly common positive activities and commit to them. You may use the List
of ideas for individual positive activities from before to get ideas for your common positive
activities:
78
Homework assignments for Meeting 4
1. Practice Progressive relaxation daily (10 minutes) for at least the next 2 weeks.
2. On the Week schedule sheet identify, register and grade 4 times a day every day throughout
the week, your experienced symptoms (0-10) and the feeling connected to them (0-10).
Register also the possible trigger for deterioration and your way of managing in this critical
situation.
3. Work at Assertion, i.e. identify and register your feelings when they occur, understand why
they occur in that particular situation, and express them in a good way, honestly and
naturally in the situation. Work at Assertion for at least the following 2 weeks.
4. Train Common communication, where you express your honest feelings as trained under
Assertion instead of expressing your bodily symptoms, thoughts and fears concerning
illness. Ask for support in the form of a hug from the one you express your feelings towards.
If you like, make a deal with your relatives that you receive a hug in similar situations.
5. Make your own list of ideas for common positive activities. Arrange common positive
activities with important people in your network (lover, family, and friends), write in your
time planner and keep the appointments. Plan at least 2 common positive activities a week
for at least the next 2 weeks.
6. Keep working at the techniques for Stress management from Meeting 2 (Deep breathing,
Time planning, Individual positive activities and how to do them as well as relevant
Changes in your Lifestyle factors.
79
Meeting 4 – General management of negative automatic thoughts and
worries
Contents and Schedule
13.00 - 14.30 Hrs
Since last meeting (ORS, Homework activity)
Review of homework: Possible questions for the manual regarding Meeting 3. Relaxation exercises
with Deep breathing and Progressive relaxation. Week recording (+ feelings). Assertion and
Common communication and carrying them out. List of common positive activities and carrying
them out. Stress management continued (techniques from Meeting 2).
15-minutes break
14.45 - 16.15 Hrs
Different way of managing negative automatic thoughts and worries.
Basis for the ”cognitive restructuring” technique, negative automatic thoughts, cognitive distortion,
schemata, the critical situation and the CBT Model (the Basic Model)
Overview of cognitive distortions and basic feelings
Simple management of worries using the techniques ”Room for Thought” and ”Thoughts on a
Leaf”.
Homework: Assess your thought distortion using your recorded thoughts (use the Diagram for
cognitive distortions). Describe a critical situation using the CBT Model (the Basic Model diagram)
and assess your distorted thoughts (write them in the diagram) and your basic feelings (write them
in the Basic Model). Use Room for Thoughts and Thoughts on a Leaf (simple management of
worries). Do relaxation exercises using Deep Breathing and Progressive Relaxation. Continue to
work on stress management.
Rounding off (GSRS, questions, summary, evaluation)
80
Different ways of managing negative automatic thoughts and worries
Simple thought management
Postpone, identify and record your negative thoughts and worries
Sometimes and for some people simple methods help to manage your negative thoughts. For
healthy people it can be enough just consciously thinking of something else, e.g. imagining
something nice, count to 10 or make a positive activity. However, for people with a mental disorder
it often takes a greater effort to manage your negative thoughts. If you have many worries you can
try to diminish them by writing them down (Thoughts on a Leaf), and in this way get them out of
your head and seeing them on paper (place the thoughts on the fallen leaves which drift away with
the current of the river) you may feel at ease. You can also try to postpone the worries and set a
certain short timeframe during the day during which you worry intensely, instead of spending the
whole day worrying (Room for Thought).
Training the attention
Permanent selective attention on your bodily symptoms, a generally increased attention to your
body and yourself, a constant intellectual body scan for signs of danger as well general cognitive
disturbances including reduced concentration and memory are inappropriate and sustaining factors
for Health Anxiety. Retraining your attention is therefore a vital part of the treatment. You can e.g.
train your attention by training maintaining your attention and change your focus for your attention,
this you also train in the exercises Deep Breathing and Progressive Relaxation.
Positive Diary
By simply registering 3 positive events from your day every evening you train how to better you
positive thinking, focus and memory. Improving your self-esteem is also trained by a simple
exercise in which you daily register 3 episodes from your day where you have used some of your
predefined positive human qualities.
Advanced handling of thoughts
Cognitive restructuring of negative automatic thoughts
This is the central way of handling negative automatic thoughts in cognitive therapy. Cognitive
restructuring is a deliberate change of your negative automatic thoughts, images and interpretations
in critical situations to more realistic, balanced, positive and constructive thoughts. This way of
managing takes some learning. Initially the method is trained in writing, but when you have
practiced for a while and learned the method, the idea is to use the method quickly and efficiently
only in your mind when you have a critical situation.
Memory cards and behaviour experiments
Memory cards and behaviour experiments are created therapeutically to continuously training
alternative thoughts, life rules and core assumptions (to prevent improper reaction patterns and
schemata, vulnerable personality traits)
81
Basis for the cognitive restructuring technique
Our cognition
Brain scientists believe that we have 50.000 to 100.000 conscious thoughts a day and that most of
these are automatic. Our conscious thoughts are mostly words or pictures. Most of our brain
processes take place unconsciously. Our brain constantly creates a lot of thoughts which is also
evidence of our unconscious and constant brain activity and a reaction to our senses and the way the
brain processes them, also known as perception. We also try to control our thoughts e.g. in the way
we speak, but we are far from able to control our thoughts completely. It is e.g. almost impossible
to control not thinking at all. It can also be difficult to control what you want to think about as new
automatic thoughts keep occurring leading the thoughts astray. This is a phenomenon known to us
all.
Interrupted thinking at a psychiatric disorder
When we are stressed and psychologically overloaded, e.g. suffering from Health Anxiety, our way
of thinking also known as cognition is disturbed and therefore even more difficult to control, and
you may experience sustained reduced concentration, reduced clarity of thought and speech,
difficulty in finding the right words, reduced overview and memory difficulties.
The psychiatric disorder also includes negative feelings and bodily sensations, and the cognition
and interpretations of situations are therefore often negatively stained, which is called cognitively
distorted, i.e. the thought contents become more negative. In addition, the extent and amount of
negative thoughts and worries are often increased with repeated thoughts and train of thoughts of a
compulsive nature.
The critical situation
Within cognitive behaviour therapy, we primarily work with the individual current situations in
which you experience a negative shift in your feelings or symptoms or a present situation in which
you experienced a high degree of Health Anxiety, unpleasant thoughts or other strong negative
feelings related to your Health Anxiety. These situations we call critical situations. Working
therapeutically with the critical situations you remember best and which makes you the most
uncomfortable, will give you the best effect. Therefore, it can also be relevant to look at previous
critical situations end then link these previous situations with the present critical ones.
Negative automatic thoughts
Working with the critical situations in cognitive behaviour therapy we especially focus on your
negative automatic thoughts in words or pictures as well as you behaviour i.e. your actions and
managing of the situation. We do this because we have learned that you can learn to understand and
control your thoughts and behaviour better by using various cognitive and behavioural techniques.
At the same time, it is important to link your negative automatic thoughts and your behaviour with
your uncomfortable bodily symptoms and feelings, and this is done using the CBT Model (diagram
Basic Model). Here you investigate and learn to see the link between your thoughts, feelings, bodily
symptoms and behaviour, which you have probably already gained an insight into through your
weekly recordings on the Week diagram.
Schemata
It is called a reaction pattern or schemata if your automatic reaction to thoughts, feelings, bodily
symptoms and behaviour is the same in similar situations and has been for a period of time (e.g. for
more than 2 years). A schemata also includes underlying reaction and thought patterns of
82
underlying assumptions, attitudes, rules of life and core assumptions. This underlying thought
pattern is also called the deeper layer of thinking, where the negative automatic thoughts are the
immediate layer. In people who have not developed a psychiatric disorder it is believed that the
positive and negative schemata are in a healthy balance, or that the positive schemata are dominant.
In people with a psychiatric disorder such as Health Anxiety, the negative schemata are dominant.
When the patient earlier in life developed these schemata, they probably had a natural and healthy
function and there is therefore an understandable explanation for their development. However, later
in life, the same schemata can act inappropriately in relation to one self or the interaction with other
people, and the schemata are now described as immature, unhealthy or inappropriate. Schemata are
the equivalent to personality traits, i.e. a personal and constant way of thinking, feeling, sensing and
acting. Particular vulnerable personality traits are e.g. increased tendency to worry, doubt, distrust
of others, anxiousness, sensitivity, impulsive behaviour, exaggeration, sense of duty and
perfectionism. Schemata and personality traits are developed over time in interaction with your
inheritance and genetics and your environment with living conditions and life events. The
personality, however, is believed to be fully developed before we turn 20, when these traits are
removed from inheritance and upbringing. Therefore appropriate personality traits developed during
childhood may in adulthood appear inappropriately and make you vulnerable. Whether a situation
prompts an automatic negative or positive reaction depends on how we think, assess and interpret a
situation. Do we for instance see the glass as half full or half empty? We interpret situations
differently according to the schemata and personality traits we have developed and according to the
psychological state we are in.
The CBT Model
”The CBT Model” is the name of the model which is at the basis of cognitive behaviour therapy
where a critical situation is analysed on the basis of 4 factors, which are interconnected and
influence each other namely thoughts, feelings, bodily sensations and behaviour. The 4 elements
make a four-sided diamond in the model and practice sheet (the Basic model) in which you describe
and analyse the critical situation, i.e. also the relation of the reaction pattern (the CBT Model) to the
situation
Cognitive distortions
As previously mentioned, how we react in a critical situation also depends on how we interpret the
situation. When we feel pressure and stress in the critical situation or generally throughout the
course of a psychiatric disorder our way of thinking typically becomes more distorted and we
interpret situations in a more negative manner. There intellectual or cognitive distortions can be of
different types as described in the summary of common types of cognitive distortions (see below).
A division of type of cognitive distortion may be helpful when you investigate your own thinking
for possible cognitive distortions and unrealistic interpretations of the critical situation.
Worries and ongoing obsessive thoughts are inflexible, repeated and exaggerated in quantity, and
these inappropriate thought patterns are also rooted in unrealistic interpretations and cognitive
distortions regarding the meaning of the thought pattern. It is advantageous to challenge and
cognitively restructure these cognitive distortions.
Alternative thoughts
In the form are given examples of alternative thoughts, which are more realistic and appropriate
interpretations of the critical situation. The alternative thoughts correspond with the thoughts of
able-bodied people in similar situations, which people with a psychiatric condition interpret as
critical. The alternative thoughts are created through the technique cognitive restructuring.
83
Basic feelings
When we work therapeutically with our feelings through the CBT Model, it is often a good idea to
determine the basic feeling, which your specific feeling is an expression of for you to estimate the
degree (0-10) of the feeling. You will there find a list of examples below of various specific feelings
and there basic feelings.
Instructions for the form The Basic Model
You use the form the Basic Model to analyse your critical situation in the 4 elements of the CBT
Model: thoughts, feelings, bodily assumptions and behaviour and their relation to the situation.
First, your critical situation is described in detail, e.g. using questions to the situation regarding
when, where, which surroundings, who, what happened and how did you react etc. Then you
describe what went through your head during the situation in thoughts and images, how you felt
both specifically and as a basis feeling and your bodily sensations and behaviour and actions in the
situation. The form “Basic model for alternative thoughts and behaviour” can be used to analyse the
interaction between the created alternative thoughts and behaviour and the resulting alternative
reactions in feeling and body.
84
List of common types of cognitive misinterpretations
Name Explanation Example Alternative thought All or nothing =
Black/white thinking
An perception is placed
in one or the other
extremity with no
intermediate
distinctions, e.g.
bad/good;
success/failure
Be aware of words like
always, never,
everybody, nobody,
nothing, everything.
”If I can’t do it
perfectly, I am a
failure”
”If I can’t do it as well
as before I got sick, I
can’t do it at all”
”If I take one step at a
time, I will gradually
reach the level, I was
before”
”Demands of doing it
perfectly prevents me
from starting”
”A professional athlete
with an injury also has
to start from scratch”
Generalization Unwarranted general
conclusion on the basis
of a single event
”I couldn’t do what I
had decided to do
yesterday, and
therefore I’ll never get
well”
”Yesterday was a bad
day. But I have actually
done, what I have
decided to do many
days and I am slowly
but surely progressing”.
Paying attention to
the negative things
You choose negative
events and forget
everything else in the
situation
”My son doesn’t think
the food tastes good. I
can’t cook”
”Everybody else liked
the food. I am a good
cook”
Predictions
The possibility of
something happening
becomes proof that it
will happen
”If I have to practice
now, I will most
certainly become ill”
I cannot predict the
future and therefore I
don’t know if I become
ill. I’m worried that I
will. But that is
different from
knowing”
Disaster thinking Harmless events are
experienced as
disasters
”My heart is beating.
There is something
seriously wrong with
my heart, and I will die
in a minute”
”My heart is beating. I
have had this
experience several
times before without
dying from it”
Bodily over attention Bodily sensations are
interpreted as signs of a
serious physical illness.
”I have a stomach ache.
Didn’t I feel nauseous
yesterday? It’s
probably cancer”
”I have had my
stomach checked out.
There was no sign of
illness”
85
List of the 4 basic emotions (incl. examples of specific feelings)
Anxiety Anger Sadness Joy
fear upset feeling sad satisfaction
anxious frustrated melancholic glad
agitated irritated depressed pleased
nervous grumpy blame unconcerned
impatient bad-tempered shame happy
restless mad ashamed enthusiastic
confused angry hopeless harmonic
tormented furious sorrowful elevated
appalled shocked incompetent cheerful
embarrassed aggressive careless euphoric
PS: There are further 2 defined basis emotions: Disgust and Surprise, but they are not important in
case of the treatment and are therefore left out of the list.
86
Plan for types of cognitive distortion
Make an X in the plan at the cognitive distortions you recognize from yourself, assess e.g. the
thoughts you have registered during the Thoughts on a Leaf and Room for Thought exercises
and in your critical situation. Write down the examples under the type of cognitive distortion
you have found. Then try to make a more realistic interpretation of the situation and make a
more subtle alternative thought to your cognitive distortions.
Name (make an X) Explanation Example Possible
alternative thought All or nothing =
Black/white thinking
You only think in 2
extremist possibilities
(e.g. bad/good;
success/failure) and
overlooks the things in
between
Generalization Simplified general
assumption on basis of
a single event
Negative focusing You choose the
negative events and
forget everything else
in the situation
Predictions and
Thought combination
The possibility that
something can happen
becomes the fact that it
will happen
Disastrous thinking Harmless events are
experienced as
disasters
Bodily over attention Bodily sensations are
misinterpreted as signs
of a serious physical
illness
87
Basic Model
Body
Emotions
Thoughts
Time of day:
Situation:
88
Simple management of negative thoughts and worries using 2 simple techniques
Thoughts on a Leaf
Guidance
When you are troubled by many unpleasant worries or ongoing obsessive thoughts e.g. when trying
to fall asleep or waking up in the middle of the night, put your thoughts down on a piece of paper
e.g. below these lines immediately. Getting the thoughts out of your head and down on a piece of
paper often helps reduce the amount, content and maintenance of these annoying thoughts.
Room for Thought
Guidance
Many patients suffering from Health Anxiety are bothered by constant worries about their health
and perhaps about many other things such as their social situation, family and economy. Instead of
constantly spending your time and energy on worrying, postpone your worries and plan a certain
period a day, e.g. 15 minutes daily from 17-17.15, at which time you worry and think through the
problems, so that you do not have to do this for the rest of the day.
You should start training the technique by also writing down your worries. Then you can work on
them more therapeutically when you learn a more advanced method of thought management. Later
you can perhaps use the technique without having to write things down.
89
Homework assignment for Meeting 5
1. Conduct simple management of negative thoughts and worries using the techniques
”Thoughts on a Leaf” and ”Room for Thought”.
2. Use the plan Basic Model (enclosure 1) and describe one of your previous critical
situations with a detailed description of the situation as well as your thoughts, feelings,
bodily sensations and behaviour in the situation. Determine the basic feeling of your
feelings and put them in the plan Basic Model.
3. Assess your noted thoughts in the exercises above in special reference to possible
cognitive distortion. If your thoughts seem distorted then use the list of types of
cognitive distortions to assess which type of distortion the individual distorted thought
is and put it in the plan, and then try to conduct more realistic and subtle alternative
thoughts to your distorted thoughts.
4. Continue to train your effective techniques for Stress management (Deep Breathing,
Progressive relaxation, Problem solving, Time planning, Individual and Common
Positive Activities, Assertion, Common communication, relevant Changes of your
Lifestyle factors). You are welcome to train Deep Breathing and Progressive
relaxation (customized) outside your home, too.
90
Meeting 5 – Management of negative automatic thoughts using
cognitive restructuring
Schedule and Contents
13.00 - 14.30 Hrs
Since last meeting (ORS, Homework activity)
Review of homework: Thoughts on a Leaf and Room for Thought. Assessment of thought
distortions through notes during Thoughts on a Leaf and Room for Thought as well as from a
critical situation. The critical situation is described using the CBT Model (the form Basic Model) +
assessment of basic feelings. Continued individual effective techniques for stress management.
For therapists: At Meetings 5-8 one full cognitive restructuring for each patient is done
(alternatively divided in subjects (negative automatic thoughts, schemata) short duration) (approx.
45 minutes per patient in all) (restructuring of negative automatic thoughts, inappropriate
underlying assumptions, life rules, attitudes, core assumptions as well as relevant Behaviour
experiments are created and the patient makes individual Memory cards).
PS: At Meeting 5 we recommend as far as possible that the cognitive restructuring is done at the
same level as with negative automatic thoughts and without schemata, so that here the focus is to
teach the patients the basic cognitive restructuring, i.e. creation of an alternative thought to the
absolute worst negative automatic thought.
15-minutes break
14.45 16.15 Hrs
Positive Diary (for improved positive thinking)
Creation of alternative thoughts by cognitive restructuring of negative automatic thoughts (NAT)
Written instruction to cognitive restructuring, the forms Basic Model and the Thought Form as well
as the list of challenging questions are reviewed.
Homework: Write Positive Diary for improved positive thinking. Describe 2 critical situations and
restructure your negative automatic thoughts to alternative thoughts. Continue to train your
effective managing techniques.
Rounding off (GSRS, questions, summary, evaluation)
91
Positive Diary (for improved positive thinking)
Background
Keeping a ”Positive Diary” is a simple and central exercise for improving your basic positive
thinking concerning yourself, other people and the world, with which your mood also improves.
This way you work at generally looking at life through more positive view by training your
attention and memory regarding your positive experiences and activities in everyday life and life in
general.
Guidance
Immediately after the event or at a fixed time every evening, e.g. just before you go to bed, note 3
positive events or activities that you experienced during the day in your Positive Diary. Nice
experiences are not just the great things in life such as celebrating your birthday, being on vacation,
finish an education, get a job, have a lover, have a child, win the lottery because these great events
happens rarely , and few people are so lucky that they experience all of these great events such as
winning the lottery.
It is easier to work on your positive focus and thinking by learning to focus on the small positive
experiences and activities in your everyday life such as smelling a flower, being with nice people,
giving or receiving a smile, giving or receiving a compliment, listening to good music, reading
something interesting, enjoying good food, having a good conversation etc. (in accordance with
your individual list of positive activities). Continued working on keeping a Positive Diary will not
just make your focus and way of thinking more positive, but will also generally improve your
mood. In time, you can profit from recalling your previous positive activities by daily reading your
latest positive activities, which will then inspire you to do future positive activities. It varies from
person to person how long an individual have to work at positive thinking before it has a lasting
positive effect. However, you should practice this exercise in writing for the next few weeks. Then
you can try to do the exercise in your mind only and see if it has the same effect or if you should
continue to keep a positive diary in writing.
92
Guidance to Cognitive restructuring
1. Your critical situation. Describe what you feel is an existing and critical
situation which is related to your Health Anxiety and suffering, in which you
have experienced a particular discomfort or a shift towards negative feelings
(anxiety, anger, sadness), thoughts, bodily sensations or improper behaviour.
Describe the situation in detail e.g. from the questions: when, where, what,
how etc.(Use the form Basic Model, enclosure 1)
2. Automatic thoughts. Identify and write down which automatic thoughts and
images went through your head during your critical situation. Pick the thought
that gave you the greatest discomfort, and assess and note how convinced you
were that the thought was realistic and true (conviction degree 0-100%) (Use
Thought form, enclosure 3) (degree of conviction: 0-100%)
3. Feelings, bodily sensations and behaviour. Describe which emotions, bodily
sensations and behaviour/actions you had during the critical situation. Assess
the degree of basic emotions (0-10)
4. The reality degree of thought. Challenge in a creative manner the reality
degree of your chosen thought by asking yourself what speaks in favour of the
thought being true and what speaks against the thought being true. You can
also ask yourself what the advantages of the thought are and what are the
disadvantages. Ask yourself what you would tell a friend who has had a
similar critical situation and thought and seeks your help. (You can also use
other challenging questions from the next page)
5. The alternative thought. From your evidence in item no 4 assess what was
more realistic to think in your critical situation. This alternative thought is then
more subtle and realistically founded and therefore more constructive and
positive for you. Write down your alternative thought (provided there is a
positive shift in item 6 below), perhaps also on a special memory card, which
you can use continuously and in possibly similar future critical situations.
(Insert your alternative thought in item 8 in the Case summary)
6. Now re-evaluate your conviction degree of your chosen negative automatic
thought (0-100%) and the degree of basic feelings in your critical situation (0-
10) (Thought form). What do you feel in your body now? How would you
react in the situation? Have you sensed any changes in your emotions, bodily
sensations and behaviour? (Use the form Basic Model for alternative thoughts
or behaviour, enclosure 2).
93
Challenging questions for cognitive restructuring (For item 4 in the guidance for Cognitive restructuring):
What speaks for the thought being true?
What speaks against the thought being true?
Is it possible to thing and assess differently in the situation?
How would a good friend assess my thought?
What would I say to a friend who presented me with a similar thought?
What is the most realistic to think in the situation?
What is the worst that could happen in the situation?
How like is it that the worst thing happens?
What could you do if the worst thing happened?
Could you act differently, learn to handle the situation better psychologically or get
help in the situation?
What is the best thing that could happen in the situation?
What are the advantages of having the negative automatic thought?
What are the disadvantages of having the negative automatic thought?
What would happen if I thought of something else?
When and where have I possibly had similar thoughts?
94
The Basic Model
Thoughts
Body
Emotions
Behaviour
Time:
Situation:
95
Basic Model for alternative thoughts and behaviour
Emotions
Alternative thoughts
Body
Time:
Situation:
Alternative
behaviour
96
Thought form for cognitive restructuring
The negative
automatic thought
How much do
you believe in
the thought
(0-100 %)
Which feelings do
you have in
relation to the
thought, grade
them (0-10)
The alternative
thought
Grade the thought
and emotions
based on the
alternative thought
97
Homework assignment for Meeting 6
1. Every evening write in your Positive Diary. Write down your 3 most positive experiences
from the day (to improve positive thinking).
2. Use the form Basic Model (enclosure 1) and describe 2 of your most critical situations, give
a detailed description of the situation and your thoughts, feelings, bodily sensations and
behaviour during the situation. For each of your critical situations answer the given
challenging questions for the most important negative automatic thought. Use the guideline
for cognitive restructuring and the Thought form (enclosure 3) to restructure your negative
automatic thoughts to more realistic, varied and constructive alternative thoughts. Use the
Basic Model for alternative thoughts and behaviour (enclosure 2) to see what happens with
your emotions, bodily sensations and behaviour, when using your alternative thought in the
critical situation.
3. Keep practicing your effective managing techniques.
98
Meeting 6 – Managing schemata with restructuring, cards and
behaviour experiments
Contents and Schedule
13-14.30 Hrs
Since last meeting (ORS, Homework activity)
Review of homework: Positive Diary. 2 critical situations and restructuring of negative automatic
thoughts to appropriate alternative thoughts (assumptions, life rules, attitudes and core assumptions
including relevant behaviour experiments, to be written in the Case Summary item 8. Continue
practicing individual effective managing techniques.
For the therapists: At Meeting 5-8 one full cognitive restructuring for each patient is done
(alternatively dived in topic of a shorter duration) (duration approx. 45 minutes per patient)
(restructuring of negative automatic thoughts, inappropriate life rules, attitudes, presumptions, core
assumptions (perhaps also vulnerable personality traits from the patients’ Individual Illness Model)
and relevant behaviour experiments are created, and the patient then creates personal memory
cards).
15-minutes break
14.45-16.15 Hrs
The deeper layer of the thought (negative thought pattern in schemata). Restructuring of
inappropriate underlying presumptions, life rules, attitudes and core assumptions with memory
cards and behaviour experiments.
Training self-esteem: List of positive qualities (answer questions and ask your relatives what they
think is positive about you). Positive Diary for use of positive qualities.
Homework: Make memory cards with your alternative thoughts and behaviour. Train self-esteem
using a list of your positive qualities (ask your relatives what they like about you) and keep a
Positive Diary using your positive qualities. Keep writing a Positive Diary for improving positive
thinking.
Describe 2 critical situations and restructure your negative automatic thoughts and your
inappropriate underlying presumptions, life rules, attitudes and core assumptions with thought
experiments (therapy guided, possibly also vulnerable personality traits from you Individual Illness
Model). Keep practicing your effective managing techniques.
Rounding off (GSRS, questions, summary, evaluation)
99
Deep layer of thinking (registration) (The related thought patterns to your inappropriate schemata, for theory regarding schemata please
go to previous chapters)
Guidance
On this page write down and collect your critical situations’ negative automatic thoughts and their
deep layers, which are your negative underlying presumptions, attitudes, life rules and core
assumptions (therapy guided, possibly vulnerable personality traits from your Individual Illness
Model), when you become aware of them through cognitive restructuring and group therapy. This
way you will get a broader idea of your negative thought patterns from your inappropriate schemata
(reaction patterns also including emotions, body and behaviour).
Negative automatic thoughts: (Your automatic thoughts and mental images of your critical situations, from the Basic Model)
Inappropriate underlying presumptions, attitudes and life rules: (How you think yourself, others and the world should or must be, think, act etc. most often
unconsciously)
Inappropriate core assumptions: (Your basic and global presumptions concerning yourself, others and the world, most often
unconsciously)
100
Typical inappropriate thought patterns at Health Anxiety
Typical negative automatic thoughts: I have cancer, sclerosis, a heart condition, AIDS, a rare and dangerous disease
I am losing control, I am becoming crazy, I am becoming an invalid, I die
Typical inappropriate presumptions, attitudes and life rules: You are responsible for your own life and therefore you alone must be in control
It helps worrying about your health in order to prevent becoming ill
Bodily changes and sensations are always a sign of illness
Everything can be explained and treated
Examinations by doctors are the only way to explain illness
Doctors do not take me seriously
Doctors often overlook illness
Doctors are incompetent
If the doctor sends me to a specialist it must mean that there is something wrong
I suffer from a rare disease, which is overlooked by doctors
I have a physical condition because I have physical symptoms
I am the only one who knows my symptoms and therefore I know best what is wrong with me and
how I should be treated
I am entitled to especially good care
I cannot handle it if I get ill
I cannot stand the thought that my relatives and I one day will die
If I have unpleasant thoughts, it will happen
I must do things properly, thoroughly, flawlessly and perfectly
I have to be the best
I have to be attentive and control my thoughts, other people and my surroundings
If I get sick or die, my children will not be okay
Typical inappropriate core assumptions: I am weak and fragile
I am good enough
I am powerless
I am always alone
I am always unlucky
I am unique
Other people are perfect
Nobody likes me
You cannot trust others
Other people want to harm me
Nobody will help me
Nobody can help me
The world is an unjust place
The world is an unsafe place, marked by random acts and a dangerous place to be
101
Restructuring of inappropriate underlying presumptions, life rules, attitudes
and core assumptions (schemata)
Background
Restructuring your inappropriate thought patterns in writing does not take long.
Perhaps it has already helped you restructuring some of your negative automatic thoughts during
group therapy and in writing at home. Perhaps it has helped you using memory cards with your
alternative thoughts. Perhaps you have even learnt the technique to restructure negative automatic
thoughts so well, that you now do it in your head during the critical situation, and it is helpful to
you. Cognitive restructuring is both a technique you can do in writing, but also a technique you can
use after a longer period of practicing to change your thought patterns and your way of reacting, i.e.
changing your inappropriate schemata and thereby change yourself into becoming more able-bodied
and perhaps cured.
Changing the deeper layers of thought and possibly inappropriate schemata primarily takes
restructuring of these underlying presumptions, life rules, attentions and core assumptions therapy
guided and in writing. Then you create together with a therapist relevant behaviour experiments to
be trained for a longer period of time to change the immature, unhealthy and inappropriate reaction
patterns. Memory cards with alternative presumptions, life rules, attitudes and core assumptions can
also be helpful in this future long-term training and personal development. Here you change and
develop your personality and how long you have to train depends on the degree of your
vulnerability and your current challenges in the interaction with other people. At the preliminary
doctors’ appointment it was assessed that you have certain vulnerable personality traits or a certain
vulnerable personality structure and/or other ongoing psychiatric disorders, and it will often require
further professional therapy at a later date after the group therapy is ended to effectively treat
possible other ongoing psychiatric disorders such as a certain vulnerable personality structure. You
can discuss this with your doctor at the end of this course treatment.
Your motivation for working at changing yourself is based on your understanding and acceptance
that the improper schemata brought about by at the common therapeutic analysis of your critical
situations, really are yours, that they often are revealed in various current critical situations and that
they are improper for your and for your interaction with other people.
102
Guidance in written restructuring of your improper deeper layers of thinking
It is a little different restructuring your deeper layers of thinking than it is restructuring your
negative automatic thoughts. Actually, all you have to do is start suggesting and create wanted,
realistic and acceptable alternatives to your current inappropriate underlying presumptions, life
rules, attitudes and core assumptions (perhaps you need to restructure your possible vulnerable
personality traits from your Individual Illness Model). They should be your wanted and realistic
goals for your future training of behaviour experiments. If you have an inappropriate life rule
regarding “Everything you do must be flawless” perhaps you could train the alternative life rule ”It
is OK to fail sometimes, as it makes you human”. Alternatively, if you want an even bigger
challenge chose the life rule “You have to fail, because you can only learn from your mistakes”. A
healthier core assumption to the inappropriate core assumption “I’m not good enough” could be “I
am good enough”. Many different behaviour experiments for training your new life rules can be
suggested. The important thing is that they are made for you personally, and that they are in
correspondence with the target factors SMART (memory words) for the goal of the exercise:
SMART stands for the goal being Specific, Measurable, Acceptable, Realistic and Time limited.
As alternatives to the inappropriate underlying presumptions, life rules, attitudes and core
assumptions that have become apparent during therapy suggest new, healthy and appropriate life
rules, attitudes, underlying presumptions and cores assumptions. Also, suggest possible behaviour
experiments for training these new thought patterns (positive schemata) with alternative behaviour.
Alternative core assumptions:
Alternative underlying assumptions, life rules and attitudes:
Alternative behaviour (behaviour experiments):
103
Managing negative automatic thoughts and schemata using Memory cards for
alternative thoughts, presumptions, life rules, attitudes and core assumptions as
well as behaviour experiments
Background
To strengthen your focus, attention an memory regarding your appropriate alternative thoughts,
attitudes, life rules, core assumptions and actions of which you have become aware through group
therapy, it would be a good idea to write them down on an individual memory card (the
paperboard you have been given) and take them with you in your wallet or put them on the fridge.
This way you can use your memory cards of alternative thoughts in future critical situations to
handle the situation better or continuously train your alternative thinking and behaviour.
Guidance
Make small paperboard cards (from the handed out paperboard) and write your relevant (therapy
guided) alternative thoughts, underlying presumptions, attitudes, life rules, core assumptions and
actions (behaviour experiments) on their respective cards. The cards should be of a size that makes
it possible for you to bring them with you everywhere e.g. put them in your wallet, and read them
several times a day. Your alternative thoughts you can use a soothing coping strategy in the critical
situation and read them to yourself at that moment.
Alternatively, you can put the cards on your fridge or make a list of your alternative thoughts and
actions and put the list on your fridge or pin board, so that you are daily reminded of the contents of
the list and thereby continuously train remembering and practicing the content.
104
Positive Diary (for improved self-esteem)
Background
People, who suffer from Health Anxiety, often are hard and critical about themselves, and some
have developed a constantly low self-esteem. Some turn the problems against themselves, are
ashamed of themselves and blame themselves for the problems and the condition. Other emotional
disorders such as sadness and anger are often related to the negative thoughts about yourself, which
result in low self-confidence and self-esteem. In the end, all you have in life is yourself and it is
therefore unhealthy to think negatively and critically about yourself. You are not to blame for
feeling the way you do. Most of our destiny comes down to heritage, environment and coincidence.
However, you can use your free will to actively change your condition through this treatment.
Here is a simple exercise to train your self-esteem and having positive thoughts and feelings about
yourself. It is also a good idea to treat and take care of yourself well with daily positive activities
besides doing your duties and remember to cheer yourself up by acknowledging and rewarding
yourself for your daily chores and activities.
Guidance (2 parts)
1. Make a list below of your 10 best personal strengths, talents, abilities, positive characteristics,
skills or qualities (you can have a look at your noted inner values from Meeting 1):
Questions that may help you identify your positive traits and qualities:
What do you like about yourself?
What have you overcome and achieved in your life, big and small things?
Which skills have you learnt?
What do other people like about you? (Ask your relatives what they like about you)
Which bad qualities do you not possess?
Which qualities and characteristics that you appreciate in others do you possess yourself?
Which of your own actions or characteristics would you appreciate in others?
How would another person who cared for you describe you?
2. Keep a Positive Diary concerning your daily use of positive qualities?
Immediately after a situation or every night put down in section 2 of your Positive Diary at least 3
examples of how you used your positive qualities from the list above. Write down which quality
you used as well as keywords from the situation so that you can recall the situation afterwards. The
aim is that by continued training in the situation you’ll learn to be attentive towards having used one
of your positive qualities (e.g., made a new dish (creative), fixed the shelves at home (practical),
called mum on her birthday (kind), went out with a friend (fun).
105
Homework assignment for Meeting 7
1. Make a list of your positive characteristics or qualities (10). Immediately following a
situation or every night write Positive Diary for training of self-esteem by writing down
daily at least 3 examples of how you have used personal characteristics and qualities from
your list.
2. Every night continue Positive Diary for improved positive thinking (3 positive experiences)
3. Make memory cards with your alternative thoughts and behaviour (therapy guided)
4. Use the form Basic Model (enclosure 1) and describe 2 of your critical situations by giving a
detailed description of the situation and your thoughts, feelings, bodily sensations and
behaviour in the situation. Answer the given challenging questions for each thought in your
critical situations. Use the guidance for cognitive restructuring and Thought Plan (enclosure
3) to restructure your negative automatic feelings to more realistic, varied and constructive
alternative thoughts. Use the Basic Model for alternative thoughts and behaviour (enclosure
2) to see what happens to your feelings, bodily sensations and behaviour when you are using
your alternative thought in the critical situation.
5. Restructure your inappropriate underlying presumptions, life rules, attitudes and core
assumptions (possibly vulnerable personality traits from your Individual Illness Model) to
make new alternative life rules, attitudes, presumptions and core assumptions. Suggest new
behaviour experiments for next meeting. Keep training relevant behaviour experiments
(therapy guided from the meetings) for as long as it takes to change your inappropriate
reaction patterns (schemata)
6. Continue training your other effective managing techniques.
106
Meeting 7 – Cognitive restructuring continued
Contents and Schedule
13.00 - 14.30 Hrs
Since last meeting (HAI and write in the Case Summary, ORS, Homework activity)
Homework: List of positive qualities and Positive Diary for use of the positive qualities (ask your
relatives and friends what they like about you). Describe 2 critical situations and restructure your
negative automatic thoughts and your underlying presumptions, attitudes, life rules and core
assumptions (possibly also vulnerable personality traits from the Individual Illness Model). Write
your therapy guided alternative appropriate thoughts, presumptions, attitudes, life rules and core
assumptions in your Case Summary item 8 and make memory cards with them. Continue to train
relevant behaviour experiments as long as needed to change your inappropriate reaction patterns
(schemata). Other effective managing techniques.
For the therapists: At Meetings 5-8 is made one full cognitive restructuring per patient (alternatively
it can be dived into items with a short duration per item) (total duration approx. 45 minutes per
patient) (restructuring of negative automatic thoughts, inappropriate life rules, attitudes,
presumptions, core assumptions (possibly also vulnerable personality traits) and the creation of
relevant behaviour experiments, and the patients makes memory cards).
15-minutes break
14.45-16.15 Hrs
Continued cognitive restructuring of negative automatic thoughts and schemata.
Homework: Make Memory cards with your relevant alternative thoughts and behaviour
experiments (therapy guided). Keep Positive Diary for improved positive thinking and improvement
of self-esteem. Describe 2 critical situations and restructure your negative automatic thoughts, life
rules, attitudes, presumptions, core assumptions. Write your appropriate alternative (therapy guided)
presumptions, attitudes, life rules, core assumptions in your Case Summary item 8. Continue to
train relevant behaviour experiments for as long as it is necessary to change your inappropriate
reaction patterns (schemata). Continue to train your other learned effective managing techniques.
Rounding off (GSRS, questions, summary, evaluation)
107
Homework assignment for Meeting 8
1. Continue every night to write Positive Diary in which you write down 3 of your positive
experiences from the day (positive thinking) and 3 examples daily on how you used your
positive qualities (self-esteem training)
2. Restructure your therapy guided inappropriate underlying presumptions, life rules, attitudes,
core assumptions (possibly also vulnerable personality traits from your Individual Illness
Model) to alternative healthy life rules, attitudes, presumptions, core assumptions. Suggest
new behaviour experiments.
3. Make memory cards with your therapy guided alternative thoughts, life rules, attitudes,
presumptions and core assumptions and your behaviour experiments.
4. Continue to train your behaviour experiments for as long as it is necessary to change your
inappropriate schemata (make subsidiary aims SMART).
5. Use the Basic Model form (enclosure 1) and describe 2 of your critical situations with a
detailed description of the situation and your thoughts, feelings, bodily sensations and
behaviour in the situation. Answer the given challenging questions for each thought of your
critical situation. Use the guide to cognitive restructuring and the Thought plan (enclosure 3)
to restructure your negative automatic thoughts to more realistic, varied and constructive
alternative thoughts. Use the Basic Model for alternative thoughts and behaviour (enclosure
2) to see what happens to your feelings, bodily sensations and behaviour when you use your
alternative thought in the critical situation.
6. Continue to train your other learnt effective managing techniques.
108
Meeting 8 – Safety behaviour and avoidance behaviour. Managing
safety behaviour using response prevention
Contents and Schedule
13.00-14.30 hrs
Since last meeting (ORS, Homework activity)
Review of homework: Positive Diary for improved positive thinking and self-esteem. 2 critical
situations and restructuring of negative automatic thoughts, life rules, attitudes, presumptions and
core assumptions (possibly vulnerable personality traits). Write the relevant appropriate life rules,
attitudes, presumptions, core assumptions and relevant behaviour experiments in your Case
Summary item 8. Memory cards with relevant alternative thoughts, life rules, attitudes,
presumptions, core assumptions and behaviour experiments. Keep training relevant behaviour
experiments for as long as it is necessary to change your inappropriate reaction patterns (schemata).
Continue to train your other learnt effective managing techniques.
For the therapists: At Meetings 5-8 is made 1 full cognitive restructuring per patient (alternatively
divided into items with a short duration for en single item) (total duration approx. 45 minutes per
patient) (restructuring of negative automatic thoughts, inappropriate life rules, attitudes,
presumptions, core assumptions (possibly also vulnerable personality traits) and relevant behaviour
experiments are done, and the patient makes memory cards.
15-minutes break
14.45-16.15 hrs
Safety behaviour in Health Anxiety and management i with response prevention.
(Make a ranked list for the patient’s safety behaviour, using a patient as example)
Avoidance behaviour in Health Anxiety and managing of exposure
Identify and write down safety behaviour and avoidance behaviour using the Week Plan
Homework: Make a week recording of your safety behaviour and avoidance behaviour. Approx. 4
days before next meeting make a ranked list of all your safety behaviour. Also, use your previous
registrations in week plans and critical situations as well as your individual cognitive illness model.
Then train reducing your safety behaviour from your ranked list – if you feel a worsening in the
situation use the technique for cognitive restructuring of your negative automatic thoughts.
Continue to write Positive Diary for improved positive thinking and self-esteem. Continue to train
relevant behaviour experiments for as long as necessary to change your inappropriate reaction
patterns (schemata). Continue to train your other learnt effective managing techniques.
Rounding off (GSRS, questions, summary, evaluation)
109
Safety behaviour and Avoidance behaviour at Health Anxiety
Managing safety behaviour using response prevention. Managing avoidance
behaviour using exposure
Background
Examinations of patients with Health Anxiety have shown that the behaviour in Health Anxiety
which promptly and for a short term reduces the anxiety, but in the long run maintains the
condition, in general is the same as in other anxiety disorders, namely safety behaviour and
avoidance behaviour.
Safety behaviour in Health Anxiety is divided into 3 fields: Seeking assurance, Checking
behaviour and Safety signals (see Meeting 1):
The safety behaviour becomes morbid when it becomes overly persistent and extensive, e.g. when
doctors and examination results are overly doubted, the constant diagnostic uncertainty is not
accepted, and worries, anxiety and bodily discomfort continue to keep the evil circle of anxiety
going. This only confirms for the patient that the safety behaviour helps reducing the disorder in the
short term, but not that it in the end actually is a part of the problem, and that it maintains the
disorder. The treatment is therefore to gradually prevent that the safety behaviour is implemented,
i.e. that the response to Health Anxiety and its symptoms with safety behaviour are prevented i.e.
managing safety behaviour with a graduated response prevention.
Seeking assurance is the behaviour in which the patient suffering from Health Anxiety strenuously
tries to find out what is wrong with him by seeking knowledge about his condition through e.g.
doctors, medical examinations, relatives and through medical information in books or on the
internet, and continues to seek assurance about their illness, i.e. to have ruled out that they have this
feared often physical illness. This may often be in the form of seeking justice that they suffer from
something most often misinterpreted as a serious physical illness, or that they keep seeking
assurance that they don’t suffer from a serious physical condition because they find it difficult to
accept the uncertainty of life that they could suffer from something, even though the probability
medically is considered very unlikely, or that they in the long run might get to suffer from
something serious and possibly even lethal.
Checking behaviour is the behaviour where patients suffering from Health Anxiety excessively
check the body for possible illness. For example, they look in the mirror for general signs of illness,
weighing themselves, taking their blood pressure and pulse, check for swollen lymph nodes, check
for birthmarks, check faeces and urine etc. It can also be testing and straining the body and check
for possible triggering of symptoms, e.g. pain, dizziness, change of pulse or numbness of arms and
legs etc. It can also be constant monitoring and scanning the body for warning signs of illness.
Safety signals are tools that you bring with you to help or because of anticipation anxiety to ensure
yourself against possible disasters. E.g., bringing a mobile phone with you in order to be able to call
for help if you should suddenly feel ill, e.g. feel the symptoms of an anxiety attack, which is
misinterpreted as an acute heart problem, which could lead to death. Alternatively, a bottle of water
so that you can rinse your throat frequently to get rid of a lump sensation. It may even be crotches, a
wheelchair or an accompanying person brought along to help with or perhaps prevent the disaster.
Other safety behaviour seen in Health Anxiety can be behaviour related to OCD (Obsessive
Compulsive Disorder: Anxiety disorder with obsessive thoughts and obsessive actions).
In this case, inner or outer rituals are conducted as safety behaviour to lessen the anxiety or prevent
disaster. Inner rituals (cognitively) e.g., are fixing something or counting something from private
systems e.g. counting to 3 is a sign of illness is sensed to prevent illness or death either your own or
that of your children (cognitive misinterpretations with magical thinking or thought merger. Outer
110
rituals are e.g., excessively washing your hands (amount of daily washing of hands > 5), fixing
things or cleaning to make sure, you are not contaminated with illness.
Avoidance behaviour seen in Health Anxiety is an excessive avoidance of events that directly
triggers or increases the anxiety and the symptoms. It could e.g. be avoiding physical exercise or
being with sick people who the patient either fears might contaminate him or it may increase the
patient’s conviction of being ill too. A small group of patients with Health Anxiety actually avoid
contact with doctors, hospitals and case histories and medical information in the media, internet and
literature rather than seeking insurance through it as typical avoidance behaviour. Often the patients
also avoid social activities because the e.g. believe that others can see they are ill, or because they
have a reduced social function and desire. Often social avoidance is based on basic problems as
with performance anxiety and social phobia with increased perfectionism and low self-esteem.
When the patient avoids the feared circumstances the distorted cognitions of the fear are not
challenged, such as ”physical exercise will resolve in my lethal heart problem”, ”showing that you
are ill is weak” or ”I will contract other people’s illness”, and this way the distortion and the
behaviour is kept alive. Evidence tells us that to overcome your fear you have to risk exposure to
the things that makes you anxious and the things you fear. This is called exposure. The ease the
process cognitive restructuring of the impairing distorted cognitions (thoughts) connected to
avoidance behaviour is used. Next the patient is gradually exposed to the things, that are normally
avoided from the ranked list (exposure hierarchy) just as in treating of safety behaviour (see
exercise on next page), i.e. things considered tolerated easier are done first. When this exposure no
longer triggers excessive anxiety, the next challenge and exposure on the list is done. Initially the
individual patient is supported by the therapists and the group during the exposure through work in
the group, later the patient is to conduct the exposure at home on his own. The degree of exposure is
also increased gradually, i.e. a graduated exposure is wanted, first through a simple trigger of some
of the symptoms of the condition during group session through the technique called ”interceptive
exposure”, then through experiencing frightening imagined situations through verbally and written
story telling called “imaginary exposure” and finally real life exposure to frightening situations at
first in the company of therapists and the group, then possibly with relatives and then alone which is
called situational exposure. For the exposure to work it has to last long enough for the patient to
experience that the fear, which at first increases, will decrease during exposure. Sometimes
exposure has to be kept up to 30 minutes before the level of anxiety reduces. Then the exposure is
continued until the anxiety is considerable reduced (<50%). Repeated effective exposure lessens the
fear of exposure, fear during exposure and eventually avoidance behaviour towards exposure.
Exposure has no effect if it is managed by another maintaining behaviour such as safety behaviour.
The key is for the patient to personally experience that fear is excessive and unfounded, and that
fear in itself is not dangerous but painful and impairing for a healthy life.
111
Week schedule
Plot in your safety and avoidance behaviour daily 4 times a day:
day
date:
day
date:
day
date:
day
date:
day
date:
day
date:
day
date:
Morning
Afternoon
Evening
Night
112
Managing safety behaviour with response prevention
Guidance (a ranked list is created using a patient as an example, duration: 15 minutes)
Creation of the ranked list for safety behaviour in order to manage safety behaviour with
response prevention
Initially through this exercise knowledge regarding safety behaviour actually maintaining Health
Anxiety in the end even though it reduces anxiety in the short run is tested. You must therefore
work at response prevention for a long while and briefly endure a deterioration of your Health
Anxiety to achieve an improvement of the condition in the end.
This is done by making you aware of your safety behaviour. You have probably already noted some
of your safety behaviour in your previous registrations on the Week schedule and under Critical
Situations on the Basic Model. Use your previous notes from the homework, your individual
cognitive illness model and your future week registration of safety behaviour (after approx. 3 days),
and try to write down all of your safety behaviour below. Perhaps you can ask some of your
relatives what they believe your safety behaviour is.
On the next page you then make a ranked list of all your safety behaviour, writing the behaviour
that you find easiest to drop on the bottom of the list, and the behaviour, that you find the hardest to
let go of on the top of the list, writing the most difficult behaviour at the top. This way you work at
reducing and avoiding your safety behaviour from the bottom of the list. Make a realistic future
training plan (perhaps you can use the techniques Problem solving and Time planning) to reduce
your future safety behaviour. If you experience a deterioration in your condition when you train
response avoidance then handle the situation of the critical situation through written cognitive
restructuring (of negative automatic thoughts) instead of going back to more safety behaviour or
other maintaining behaviour. If your feel inhibited during a behaviour experiment with response
avoidance, make cognitive restructuring of the anticipation anxiety.
113
Ranked list of your Safety behaviour
114
Homework assignment for Meeting 9
1. Make a week recording of you safety behaviour and your avoidance behaviour
2. Every evening continue to write Positive Diary in which 3 of your positive experiences from
that day (positive thinking) and 3 examples of how you use your positive qualities from that
day (self-esteem training) are recorded
3. Approx. 4 days before Meeting 10 make a ranked list of all your safety behaviour
4. Work on response prevention from the ranked list of your safety behaviour. Make the
individual response prevention (a therapeutic milestone) measurable using SMART
(memory card). If you experience a critical situation before or during the response
prevention, make a written cognitive restructuring for the critical situation afterwards before
further response prevention is attempted.
5. Continue to work on your other learned effective coping techniques
115
Meeting 9 – The coping of avoidance behaviour through exposure
Contents and Schedule
13.00-14.30 hrs
Since last meeting (ORS, Homework activity)
Review of homework: Week recording of safety and avoidance behaviour. Ranked list of safety
behaviour. Response prevention of safety behaviour using the ranked list – at deterioration before or
during the situation use the technique to cognitive restructuring of negative automatic thoughts.
Positive Diary for improved positive thinking and self-esteem. Relevant behaviour experiments
against inappropriate schemata. Other learned effective coping techniques.
15-minutes break
14.45-16.15 hrs
Managing avoidance behaviour through exposure
(Make a ranked list of a patient’s avoidance behaviour (1 example))
Interoceptive and imaginary exposure. Exercises (approx. 30 min).
Plan a situational exposure for Meeting 10 (optional, customized for the group)
Homework: Make a ranked list of all your avoidance behaviour according to your Week Schedule,
your past homework for critical situations and your individual cognitive illness model. Work on
exposure through interoceptive exposure together with a relative as well as imaginary exposure by
writing down the course of illness that frightens you the most. Continue to work on Response
prevention from your ranked list. If you have critical situations during the week when you work on
exposure or response prevention, make cognitive restructuring afterwards.
Continue to keep the Positive Diary for improved positive thinking and self-esteem. Continue to
work on relevant behaviour experiments as long as necessary (often months) to change our
inappropriate reaction patterns (schemata). Continue to work on your other learned effective
managing techniques.
Rounding off (GSRS, questions, summary, evaluation)
Reminder that the next meeting, Meeting 10, is approx. 1 hour longer due to situational exposure
116
Managing avoidance behaviour through exposure
Background
As previously described at Meeting 1, avoidance behaviour at Health Anxiety can be avoidance of
internal or external factors, circumstances or situations, which immediately and briefly provokes or
worsens the symptoms of Health Anxiety with unpleasant thoughts (words or pictures), emotions or
bodily symptoms. However, avoidance behaviour is only inappropriate if it is derives from
excessive fear of the symptoms (internal factors) or the external factors such as circumstances and
situations, by which the cognitive distortions are not challenged and reality corrected because of the
avoidance. This way avoidance in the end maintains the suffering.
Internal factors are e.g. negative automatic thoughts and worries, which inappropriately are sought
avoided if they are sought dismissed or pushed away. This way the thoughts are reinforced and
maintained. Try e.g. not to think of a yellow tiger. By trying not to do it, all you can think of is a
yellow tiger! The other internal factors bodily symptoms and anxiety are inappropriately sought
avoided by e.g. staying excessively inactive and rest and thereby avoid physical exertion and sport,
and the physical shape deteriorates, or by fear of fainting, the patient is walking around restlessly.
External factors, circumstances and situations which are avoided in Health Anxiety are typically
about avoiding everything that reminds you of illness, e.g. doctors, hospitals, examinations,
treatments, medicine, sick people, stories on TV and in newspapers about illness, medical
information, sources of infection, e.g. coughing and handshakes with other people. In some people,
suffering from Health Anxiety it is the other way around and their excessive safety behaviour in
some of these situations means they are excessively preoccupied with body and illness, which is
maintained by excessive contact, e.g. to doctors and reading of medical information. Moreover, the
individual patient has individual situations, which are avoided because the patient has learnt that the
particular situation is dangerous because symptoms have occurred suddenly in the past in just such
a situation. The symptoms have in this case wrongly been associated with the situation, which is
now wrongly being feared and thereby avoided. This is often the illness mechanism at panic
anxiety, which is often seen at Health Anxiety.
Avoidance behaviour from other anxiety disorders are often seen along with Health Anxiety. E.g.,
the general avoidance of people because of excessive fear of being put on display, seen through and
criticized, e.g. through triggering of bodily symptoms, e.g. sweating and flushing (social phobia).
Avoiding small closed rooms because of excessive fear of choking (claustrophobia). Avoiding
elevators because of excessive fear of being stuck in the elevator or that it crashes (elevator phobia).
Avoiding handshakes, coughing, public door handles and toilets because of excessive fear of
infection and contamination (OCD). Avoiding leaving you home and find yourself vulnerable in a
crowd or in open unprotected places, e.g. public transportation and squares (agoraphobia) often due
to fear of having a panic attack which cannot be treated there. The inappropriate avoidance
behaviour is treated and managed through exposure i.e. exposing yourself to the factor, which is
avoided, by which the terror of the feared circumstances are tested. As the fear is excessive, i.e. is
due to a cognitive distortion and misinterpretation, continued exposure will reality correct the
misinterpretation and in the long term the body will by continued training and learning unlearn the
excessive bodily reaction which is associated with the misinterpretation, anxiety and avoidance
behaviour. It is often necessary to conduct cognitive restructuring of the misinterpretation (the
automatic negative thought in the particular situation), before the patient is ready for exposure. This
is why we have worked on cognitive restructuring during group therapy before we now start
working with exposure. The patient must be willing to plunge in and take part in exposure to be
able to change and reduce his Health Anxiety in the end. Managing avoidance behaviour must be
done gradually and started with the avoidance behaviour, which is the easiest to attack. The patient
117
makes his own individual ranked list of his own avoidance behaviour for the continued graduated
exposure in which you continue to the next item on the list when the previous one can be dealt with
without triggering essential symptoms and anxiety.
Situational exposure
Exposure is to external situations, which are avoided, is called ”situational exposure”. The patients
ranked lists of avoidance behaviour consists often of external situations, which are avoided.
Situational exposure can be graduated further be initially doing it with a therapist, then with a
relative and finally the patient can do the exposure himself.
Interoceptive exposure
Another grading of exposure takes place in the group where the patient is exposed to the internal
factors of Health Anxiety, the unpleasant bodily symptoms and anxiety. This is done by triggering
the bodily symptoms together in the group. This way the patients will experience that the symptoms
can be controlled and be consciously provoked, and that they are not dangerous but reflects a
natural reaction and not a serious physical illness. This is called “interoceptive exposure” and can
later be performed together with relatives and later by the patient alone.
Imaginary exposure
The next grading will expose the patient for the third internal factor, which is thoughts and images
(imaginary) of feared situations regarding health. This can be done e.g. that the therapist read aloud
one patients’ story; by imagining another patient’s story; by imagining his own story and by writing
down his own story and reading it several times. Again, you can start by first performing the
imaginary exposure, then do it with relatives and finally do it alone and repeatedly until the anxiety
is gone.
Guidance (see ranked list created with a patient as an example, 15 minutes)
Creating the ranked list for avoidance behaviour in order to manage avoidance behaviour
through exposure
Working on exposure is initially also testing knowledge about the avoidance behaviour actually
maintaining Health Anxiety in the long run even if avoided in the short term. You therefore have to
work on exposure for a while (the coming weeks) and briefly endure an increase in your Health
Anxiety for you to gain an improvement in your condition. To do this you have to be aware of all
your avoidance behaviour. You have probably already registered a lot of your avoidance behaviour
in your previous recordings on Week Schedules and in Critical situations using the Basic Model.
Use these recordings, your individual cognitive illness model and the week recording of your
avoidance behaviour up until today, and collect and write down all of your avoidance behaviour.
You can also ask some of your relatives what in their experience is your avoidance behaviour. On
the next page, make a ranked list of all your avoidance behaviour, in which you put the feared
situation, which can expose yourself to the easiest at the bottom of the list, and the situations, which
you find the hardest to expose yourself to at the top of the list in a ranked manner.
118
Ranked list of your Avoidance Behaviour
119
Exercise with interoceptive exposure (Duration: 20 min.) Instruction
Ask the group which bodily symptoms that bothers them the most, and choose the exercise for
interoceptive exposure that fits the most of the patient’s bodily symptoms. Possible obstacles are
managed through cognitive restructuring.
Examples of interoceptive exposure (symptoms and triggers):
1. Palpitations, chest pains: Run for 60 seconds staying where you are
2. Dizziness and disorientation: Turn around for 60 seconds
3. Trouble breathing, choking sensation, dizziness, palpitations, dry mouth, sweating:
Hyperventilate deeply and quickly for 60 seconds
4. Lump sensation in the throat: Swallow quickly 10 times
5. Feeling light headed, blushing, disorientation: Keep your head between your legs for 30
seconds and then lift your head
6. Hypotonia, heart beating, sweating, possible headache: Stretch all you muscles for 60
seconds
Discussion
Guidance Work on relevant interoceptive exposure at home, at first with relatives and then alone
120
Exercise of imaginary exposure (Duration: 10 min.) Instruction
Is the group ready for exposure? When the group is ready, read a former patient’s story:
Guidance
Write down your most feared illness story before next meeting.
You may e.g. describe your worst conceptions of your life from the moment you got the feared
illness, during the illness and possible your disability, your possible death and the following
consequences for you and your relatives. After that you work on exposing yourself by reading that
story aloud to your relatives and later e.g. daily to yourself until the anxiety concerning the story is
diminished considerably.
121
Homework assignment for Meeting 10
1. Continue writing Positive Diary in the evening at which 3 of your positive experiences from
the day are registered (positive thinking) and 3 daily example of how to use your positive
qualities from the day are registered (self-esteem training). You can also try to identify the
situations immediately after they have happened and remember them at night.
2. Make a ranked list of you Avoidance behaviour
3. Work on exposure using an optional interoceptive exposure together with your relatives,
lover, family and friend.
4. Work on exposure using imaginary exposure. Write down your most feared illness story of
how you get ill, disabled and then possible die, and what happens then to you and your
relatives. Read it to your relatives. You can work on further exposure by reading to yourself
daily until the fear of the story is diminished considerably.
5. Continue to work on response prevention from your ranked list of your safety behaviour. If
you have critical situations during the week when you conduct exposure or response
prevention (before or during) write a cognitive restructuring afterwards.
6. Continue to work on your other learned useful managing techniques.
122
Meeting 10 – Managing avoidance behaviour by exposure, continued
Contents and Schedule
13.00-14.30 hrs
Since last meeting (ORS, Homework activity)
Review of homework: Ranked list of avoidance behaviour. Exposure by interoceptive exposure
with a relative. Imaginary exposure by writing the most feared illness story (a patient read out his
story). Continued response prevention from the ranked list. Possible critical situations. Continued
Positive Diary for improved positive thinking and self-esteem. Relevant behaviour experiments
against inappropriate schemata. Other learned useful managing techniques. Getting ready for group
exercise in situational exposure (SMART)
15-minutes break (can be used for transportation)
14.45-16.15 hrs (possibly 1 more hour)
Exercise in Situational exposure (ca. 50 min). Discussion.
Homework: Work on situational exposure from your ranked list of avoidance behaviour (initially
perhaps with a relative). Continue to work on interoceptive and imaginary exposure. Continue to
work on response prevention from your ranked list. If you have critical situations during the week
when performing exposure or response prevention write a cognitive restructuring afterwards.
Continue to keep Positive Diary to improve your positive thinking and self-esteem. Continue to
work on relevant behaviour experiments in the future for as long (possible months) as it is necessary
to prevent your inappropriate patterns of reaction (schemata). Continue to work on your other
learned useful managing techniques.
Rounding off (GSRS, questions, summary, evaluation)
123
Exercise in situational exposure (Duration: ca. 50 min.)
Instruction
A representative situational exposure from the patients ranked lists of avoidance behaviour is
chosen. The behaviour experiment and intermediate objective are carefully prepared from the word
SMART [Specifikt, Målbart, Acceptabelt, Realistisk, Tidsbegrænset]. All the patients must be
motivated and ready for the exposure exercise before it is done. Next, a situational exposure is done
by the group together. The exposure is maintained until the fear of the situation is diminished
considerably (>50%) at all group members (typically up to 30 minutes). Afterwards the experience
is discussed in the group.
Discussion
Guidance
Future situational exposure.
Outside the group meetings, you work on exposing yourself to your feared situations starting with
the items at the bottom of your ranked list of avoidance behaviour. Initially the exposure can be
done with a relative. Before each exposure and behaviour experiment an intermediate objective is
done from SMART. Make a realistic plan (perhaps you can use the techniques Problem solving and
Time planning) to reduce your future avoidance behaviour. The individual exposure is maintained
until the fear is considerably reduced in the situation (>50%, often up to 30 minutes). The
individual exposure is performed frequently (e.g., a few times a week), until it no longer triggers
excessive fear and then you can move on to the next exposure from your ranked list. If you are not
ready for exposure consider what it is, that prevents you from doing it. Possible preventing thoughts
and worries are managed through written cognitive restructuring. If you experience a preventing
worsening of your condition when you work on exposure, then manage the situation afterwards by
written cognitive restructuring (of negative automatic thoughts) of the occurred critical situation
instead of going back to safety behaviour or another maintaining behaviour.
124
Homework assignment for Meeting 11
1. Every night continue to write Positive Diary in which 3 of your positive experiences from
the day is registered (positive thinking) and 3 daily examples of use of your positive
qualities from the day are registered (training self-esteem). You can also just try to identify
the situations immediately after they have occurred and then remember them at night.
2. Work on exposure from your ranked list of your avoidance behaviour possibly initially with
a relative. Initially the individual exposure (a therapeutic intermediate objective) is made
measurable from SMART (memory word). You have to be ready for exposure, which is
done through cognitive restructuring of preventing thoughts. If a critical situation is
experienced before or during exposure, afterwards write a cognitive restructuring for the
critical situation before further exposure is attempted. Avoid safety behaviour during
exposure. Continue the exposure until the anxiety has dropped considerably in the situation.
Move on to the next exposure on the ranked list when the exposure to the current item no
longer triggers excessive fear.
3. Continue to work on interoceptive and imaginary exposure, perhaps still with a relative. You
can continue to work on imaginary exposure by e.g. reading your illness story to yourself
daily or alternatively writing a new story, if you have other fears of dangers to your health.
4. Continue to work on response prevention from your ranked list of safety behaviour. If you
have critical situations during the week when you perform response prevention, make a
written cognitive restructuring.
5. Continue to train your other learned useful techniques.
125
Meeting 11 – Relapse prevention
Contents and Schedule
13.00-14.30 hrs
Since last meeting (ORS, Homework activity)
Review of homework: Situational exposure from the ranked list of avoidance behaviour (initially
possibly with a relative). Interoceptive and imaginary exposure. Continued response prevention
from the ranked list of safety behaviour. Possible critical situations with written cognitive
restructuring. Continued Positive Diary for improved positive thinking and self-esteem. Relevant
behaviour experiments against inappropriate schemata (possible vulnerable personality traits).
Continue other learned useful managing techniques.
15-minutes break
14.45-16.15 hrs
Relapse prevention
Presentation of the exercises and managing technique of the group therapy
The patients borrow their Case Summary in order to overwrite. To be returned at Meeting 12.
Homework: Relapse prevention. Written group evaluation. Continue to work on situational
exposure from your ranked list of avoidance behaviour. Continue to work on response prevention
from your ranked list of safety behaviour. If you have critical situations during the week when
performing exposure or response prevention, write a cognitive restructuring afterwards.
Continue to keep Positive Diary for improved positive thinking and self-esteem. Continue to work
on relevant behaviour experiments in the future as long as (often months) it is necessary to change
your inappropriate reaction patterns (schemata, possible vulnerable personality traits). Continue to
work on you other learned useful managing techniques.
Rounding off (GSRS, questions, summary, evaluation)
126
Relapse prevention (questions for your future plan)
Guidance
Answer the questions below as well and thorough as you can. Take your time. Then make your own
future plan for relapse prevention and for your possible continued training and treatment.
How do you now understand your symptoms, problems and reasons for your Health Anxiety?
How has your condition with Health Anxiety changed since you started therapy?
Has your lifestyle changed since you started therapy?
What is the most important thing you have learned from the group therapy?
What have you found might help you in the short term, but makes your Health Anxiety worse in the
end?
What have you done that has helped you get better?
Which managing techniques have helped you especially and how do they help?
Which symptoms and problems do you still have?
How will you manage or treat the remaining symptoms and problems?
Which managing techniques could you profit from using more?
127
What would it mean in the end if you continue to do what you feel helps you?
How can you make sure that you will continue to use these managing techniques in the future?
Which future situations could make you vulnerable in respect to have symptoms again?
What can you do to prevent or manage these situations?
Which stressors both internally and externally have you become aware of can trigger your problems
and symptoms?
How can you reduce these stressors?
How can you manage these stressors better?
What could be some of the first signs of relapse?
What can you do if you become aware that some of these things occur?
What is important to remember to keep or start doing?
Which preventions could there be for you to use the managing techniques and how can these
obstacles be overcome?
128
Is there anything you need to change now in relation to the list of goals and values that you made
for Meeting 2 (future goals and values)?
How can you achieve these goals and values?
129
Individual Plan for Relapse Prevention 1. In short, describe what has helped you reduce your overload, stress and Health Anxiety (from
both the group therapy and other):
2. Plan which of your useful learned exercises and managing techniques you will continue to use,
and when, how often, how long and how you will use these (use the list of techniques on the page,
make SMART goal):
3. Plan which exercises and managing techniques you will continue to practice because you believe
and hope that they in time also may be useful to you, if you continue practising them:
4. Plan what you can do otherwise to reduce your overload, stress and Health Anxiety (not practiced
in the group, but e.g. through a therapist:
5. Plan what you will do if or when you experience aggravation of your condition (increase
intensity, add what used to work, other):
6. Plan what you can do if your self-help or network support is no longer enough:
130
List of exercises and managing techniques
Seek, ask for and receive help from your network and therapists
(Strengthen courage, openness, presence, humility, trust, acceptance, engagement)
Seek and obtain relevant knowledge (e.g. knowledge from this manual and treatment)
Define goals and values for your life, treatment and continued development and try to accept,
manage and live with what cannot be changed and commit to change, what can be changed
(memory word SMART for goals/intermediate objectives)
Week register with identifying thoughts, feelings, bodily sensations and behaviour related to
changing (critical) situations to gain increased insight to yourself, your interaction with others and
surroundings e.g. for identification of stressors and triggers and inappropriate managing to improve
managing.
Problem solving and Time planning
Positive Diary for improved positive thinking and self-esteem
Individual and common Positive activities (for positive distraction, taking good care of yourself,
improving your quality of life and mood, strengthen your interaction with others and your network)
Assertion (identify, register, understand and express your emotions and needs)
Relevant changes of life style (diet, smoking, alcohol, exercises, sleep, network)
Relaxation exercises (deep breathing, progressive relaxation, awareness training)
Simple managing of worries using the techniques Thoughts on a Leaf and Thought Space
Cognitive restructuring of negative automatic thoughts in critical situations
Restructuring of inappropriate underlying assumptions, attitudes, life rules and core assumptions
(perhaps vulnerable personality traits from your individual Illness model)
Memory cards with alternative thoughts, assumptions, attitudes, life rules, core assumptions and
relevant behaviour experiments
Conduct relevant behaviour experiments to change inappropriate schemata (perhaps vulnerable
personality traits from your Individual Illness model)
Response prevention from ranked list for safety behaviour
Exposure from a ranked list of prevention behaviour
Individual plan for relapse prevention (continued self-training and self-therapy, e.g. books)
131
Homework assignment for Meeting 12
1. Every evening continue to write Positive Diary in which you list 3 of your positive
experiences of the day (positive thinking) and 3 daily examples of use of your positive
qualities (self-esteem training). You can also just try to identify the situations immediately
after they have occurred and remember them at night.
2. Make your written Plan for Relapse Prevention. This is also your future plan for your
continued training and self-therapy after Meeting 12.
3. Write down your evaluation of the entire group therapy (at the back of this manual). Give it
to the therapist; you are welcome to do it anonymously for future optimizing of the
treatment. What was good, what was not so good? Do you have suggestions for changes?
4. Work on exposure from your ranked list of avoidance behaviour perhaps initially with a
relative. Initially make the individual exposure (a therapeutic intermediate objective)
measurable from SMART (memory word). Prepare for the exposure, e.g. through cognitive
restructuring of preventing thoughts. If you experience a critical situation during exposure
make a written cognitive restructuring for the critical situation afterwards before further
exposure is attempted. Continue with the exposure until the anxiety has decreased
considerably in the situation. When you no longer experience excessive anxiety after several
exposures continue exposure to the next item on your ranked list.
5. Continue to train response prevention from your ranked list of safety behaviour. If you have
critical situations during the week when you perform response prevention write cognitive
restructuring afterwards.
6. Continue to train your other learned useful managing techniques
132
Meeting 12 - Conclusion
Schedule and Contents
13.00-14.30 hrs
Since last meeting (Final HAI is introduces to the Case resume, ORS, Homework activity)
Review of homework: Documents from homework activity are collected, attendance is written in
the sheet and then a copy is given to the patients. The Case summary is returned to the patient files.
All relapse prevention plans are mentioned. Continued situational exposure from the ranked list of
avoidance behaviour. Continued response prevention from the ranked list of safety behaviour.
Possibly cognitive restructuring of occurred critical situations. Continued Positive Diary for
improved positive thinking and self-esteem. Continued relevant behaviour experiments for
inappropriate reaction patterns (schemata). Continued other learned useful managing techniques.
15-minutes break
14.45-16.15 hrs
Conclusion (optional support group established (email, possible secure group on Facebook, perhaps
including relatives)). Summary of the course of the group therapy. Oral evaluation of the entire
course. Written evaluation is obtained. Precise time and date for the Booster Session after 12 weeks.
Homework: Follow your Individual Plan for Relapse Prevention
Rounding off (GSRS, questions, summary, evaluation (also of the entire course)
133
Homework assignment for the Booster Meeting
1. Follow your Individual Plan for Relapse Prevention
About the support group (perhaps incl. relatives):
Name and email addresses?
Social media (admin. for secured group)?
134
Booster Meeting – 3 months follow-up
Schedule and Contents
13.00-14.30 hrs
Since last meeting (Follow-up HAI is introduced to the Case Summery, ORS, Homework activity).
Support group, other treatment?
Home work: Relapse prevention
15-minutes break
14.45-16.15 hrs
Continued Relapse Prevention (possible adjustment of plan, possible further treatment after final
doctors visit)
Rounding off (GSRS, summary, questions, evaluation)
135
Individual Plan for Relapse Prevention (adapted) 1. In short, describe what has helped you reduce your overload, stress and Health Anxiety (both
from group treatment and other):
2. Plan which of your useful learned exercises and managing techniques you will continue to use,
and when, how often and how you will use them (use the list of techniques on the next page, make
SMART goals):
3. Plan which exercises and managing techniques you will continue to train because you believe and
hope they in time will become useful to you, if you keep working on them:
4. Plan what else you will do to reduce your overload, stress and Health Anxiety (not trained in the
group, but perhaps with a therapist):
5. Plan what you will do if or when you experience a aggravation in the condition (increase
intensity, add what used to work, other):
6. Plan what you will do if your self-help or network support is no longer enough:
136
Applied literature (recommended to the therapists)
Psychological treatment of Health Anxiety and hypochondriasis. A biopsychosocial approach.
Jonathan S. Abramowitz, Autumn E. Braddock, 2008 Hogrefe & Huber Publishers.
Treating Health Anxiety. A cognitive behavioural approach. Steven Taylor, Gordon J.G.
Asmundson, 2004 Guilford Press.
Treating Health Anxiety and fear of death. A practitioner’s guide. Patricia Furer, John R. Walker,
Murray B. Stein, 2007 Springer Science
Treating Somatization. A cognitive behavioural approach. Robert L. Woolfolk, Lesley A. Allen,
2007 Guilford Press.
Metacognitive therapy for anxiety and depression, Adrian Wells, 2009 Guilford Press.
Schema therapy. A Practitioners guide. Jeffrey Young, Janet S. Klosko, Marjorie E Weishaar, 2003
Guilford Press.
A practical guide to acceptance and commitment therapy. Stephen C. Hayes, Kirk D. Strosahl, 2004
Springer Science.
Cognitive behavioural therapy in groups. Peter J. Bieling, Randi E. McCabe, Martin M. Antony,
2006 Guilford Press.
[Kognitiv terapi og helbredsangst.] Pia Callesen, Lennart Holm, 2008 Sokratisk Forlag.
[Funktionelle lidelser.] Per Fink, Marianne Rosendahl, 2012 Munksgaard.
[At overvinde lavt selvværd.] Melanie Fennell, 2002 Forlaget Klim.
[Psykiske lidelser og adfærdsforstyrrelser.] Klassifikation og diagnostiske kriterier. WHO ICD-10.
[Manual for ACT-gruppeterapi for patienter med helbredsangst.] Trine Eilenberg, 2013 Klinikken
for funktionelle lidelser i Århus.
[Manual for Kognitiv adfærdsbehandling for mennesker med kroniske funktionelle lidelser.]
Andreas Schröder, 2010 Klinikken for funktionelle lidelser i Århus.
137
Appendix
Basic Model (encl. 1)
Body
Emotions
Thoughts
Time of day:
Situation:
Behaviour
138
Basic Model for alternative thoughts and behaviour (encl. 2)
Emotions
Alternative thoughts
Body
Time:
Situation:
Alternative
behaviour
139
Thought form for cognitive restructuring (encl. 3)
The negative
automatic thought
How much do
you believe in
the thought
(0-100 %)
Which feelings do
you have in
relation to the
thought, grade
them (0-10)
The alternative
thought
Grade the thought
and emotions
based on the
alternative thought
140
Week schedule (encl. 4)
Registration of your bodily symptoms, emotions, thoughts, triggers, stressors, way of
managing, safety behaviour, avoidance, activities etc. and their degree. Grading
degree of difficulty for bodily symptoms and emotions (0-10).
(In order to improve identifying and description of specific problems)
Please register 4 times a day every day of the week:
0 1 2 3 4 5 6 7 8 9 10
day
date:
day
date:
day
date:
day
date:
day
date:
day
date:
day
date:
Morning
Afternoon
Evening
Night
Worst degree of the
symptom, e.g., anxiety,
bodily symptoms, cognitive
and general symptoms
No symptoms, e.g.,
anxiety, bodily
symptoms, cognitive and
general symptoms
141
Recording of your Homework activity (encl. 5) (To be handed to the therapists at Meeting 12. The patients may keep a copy)
Guidance:
Continuously, grade your homework activity within the latest week(s) from 0-4: 0 = 0 hrs/week, 1 =
0-1 hrs/week, 2 = 1-3 hrs/week, 3 = >3-6 hrs/week, 4 = > 6 hrs/week. Dot the number below the
equivalent therapy session. In Meeting 2 note your total homework activity between Meeting 1 and
2. In BM (Booster Meeting) note your total homework activity on an average per week since
Meeting 12. At the beginning of every therapy session, you will be asked to register your homework
activity at the meeting. In case of absence, you must remember to register the homework activity of
the latest week. The therapists will hand out this enclosure at Meeting 12 with your total evaluation
of the group therapy. We know, that treatment effect depends on your attendance and homework
activity. This is why we record it in order to assure the quality of the treatment. Remember, it is
recommended that you engage in the treatment for your own sake and not for the sake of the
therapists. Grade your homework activity for the latest week in the specific week from 0-4: 0 = 0
hrs/week, 1 = 0-1 hrs/week, 2 = 1-3 hrs/week, 3 = >3-6 hrs/week, 4 = > 6 hrs/week.
Meeting 2 3 4 5 6 7 8 9 10 11 12 BM
Activity
Records of your attendance activity (by therapists)
Name
Meeting 1 2 3 4 5 6 7 8 9 10 11 12 BM
Date
142
Overall evaluation of the group therapy session (encl. 6) (Anonymous, in writing and handed to the therapists at Meeting 12. The patient may keep a copy)
Hvad var godt og mindre godt ved gruppeterapiforløbet?
(E.g., the meetings, the manual, homework assignments, the therapists, the group, the physical
frame, the overall treatment? Constructive suggestions for improvement are welcome)
The meetings (the therapy:
Good:
Less good
The manual (material):
Good:
Less good
Homework assignments:
Good:
Less good:
The therapists:
Good:
Less good:
The group:
Good:
Less good:
The physical frames:
Good:
Less good
The overall treatment:
Good:
Less good:
Suggestions for improvement:
143
Outcome Rating Scale (ORS) (encl. 7)
Name ________________________Age (Yrs):____ Sex: M / F
Session # ____ Date: ________________________
Who is filling out this form? Please check one: Self_______ Other_______
If other, what is your relationship to this person? ____________________________
Looking back over the last week, including today, help us understand how you have been feeling
by rating how well you have been doing in the following areas of your life, where marks to the
left represent low levels and marks to the right indicate high levels. If you are filling out this form
for another person, please fill out according to how you think he or she is doing.
ATTENTION CLINICIAN: TO INSURE SCORING ACCURACY PRINT OUT THE
MEASURE TO INSURE THE ITEM LINES AR 10 CM IN LENGTH. ALTER THE FORM
UNTIL THE LINES PRINT THE CORRECT LENGTH. THEN ERASE THIS MESSAGE:
Individually (Personal well-being)
I----------------------------------------------------------------------I
Interpersonally (Family, close relationships)
I----------------------------------------------------------------------I
Socially (Work, school, friendships)
I----------------------------------------------------------------------I
Overall (General sense of well-being)
I----------------------------------------------------------------------I
Institute for the Study of Therapeutic Change
_______________________________________
www.talkingcure.com
© 2000, Scott D. Miller and Barry L. Duncan
144
Group Session Rating Scale (GSRS v.3.0) (encl. 8)
Please rate today’s group by placing a mark on the line nearest to the description that best
fits your experience.
Relationship
I----------------------------------------------------------------------I
Goals and Topics
I----------------------------------------------------------------------I
Approach or Method
I----------------------------------------------------------------------I
Overall
I----------------------------------------------------------------------I
Institute for the Study of Therapeutic Change
_______________________________________
www.talkingcure.com
© 2000, Lynn D. Johnson, Scott D. Miller and Barry L. Duncan
Name ________________________Age (Yrs):____
ID# _________________________ Sex: M / F
Session # ____ Date: ________________________
I felt heard, understood and
respected.
I did not feel heard, understood and
respected.
We worked on and talked about what I wanted to work on
and talk about.
We did not work on or talk about what I wanted to work on
and talk about.
Overall, today’s group was right for
me.
There was something missing in today’s
session.
The leader’s approach is a good
fit for me.
The leader’s approach
is not a good fit for me.