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 Table of Contents  
Year : 2021  |  Volume : 26  |  Issue : 2  |  Page : 169-172

An exploratory case study on the use of rational emotive behavior therapy for treatment of illness anxiety

Department of Psychology, Women's Christian College, Chennai, Tamil Nadu, India

Date of Submission30-Mar-2021
Date of Decision26-Jul-2021
Date of Acceptance07-Aug-2021
Date of Web Publication02-Feb-2022

Correspondence Address:
J Nandini
Research Scholar, Department of Psychology, Women's Christian College, Chennai, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jmhhb.jmhhb_76_21

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Illness anxiety disorder is characterized by preoccupation with having or developing a serious illness accompanied by maladaptive safety or avoidance behavior that impairs the persons everyday functioning. It deteriorates the quality of life of the individual. Cognitive behavior therapy is often a good treatment choice. Here, I present the efficacy of rational emotive behavior therapy in addressing the irrational beliefs of the client and its effectiveness in alleviating behavioral and cognitive symptoms of illness anxiety.

Keywords: Anxiety, illness anxiety, rational emotive behavior therapy

How to cite this article:
Nandini J. An exploratory case study on the use of rational emotive behavior therapy for treatment of illness anxiety. J Mental Health Hum Behav 2021;26:169-72

How to cite this URL:
Nandini J. An exploratory case study on the use of rational emotive behavior therapy for treatment of illness anxiety. J Mental Health Hum Behav [serial online] 2021 [cited 2022 Dec 9];26:169-72. Available from: https://www.jmhhb.org/text.asp?2021/26/2/169/337175

  Introduction Top

Illness anxiety disorder is new to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) and classifies people who have anxiety about having or developing a serious illness.[1] It has been estimated that 25% of people who were previously diagnosed with hypochondriasis according to DSM-IV will be diagnosed with illness anxiety disorder.[1] Excessive media consumption has exponentially increased cases of illness anxiety, and therefore, it is salient to explore treatment options to combat the same.[2] The current models of the disorder identify beliefs, family history, and past experience as major contributing factors but the below case highlights the role of media in the onset and maintenance of the illness anxiety disorder.[3] While there is a growing body of research on the implications of social media in mental health, studies restricted to the specific role of media in illness anxiety are scarce with Google Scholar search revealing no concrete results on the same. Thus, the case report may offer directions for future research to explore these two variables. The case report also aims to provide insight into the applications of rational emotive behavior therapy (REBT) in treating illness anxiety. The effectiveness of specific disputes and thought challenges that may work with illness anxiety could endorse the efficacy of REBT.

  Case Report Top

The client is a 28-year-old male, educated (graduate level) and working in an IT company. He is married with a 3-year-old son and lives with his spouse and parents.

The client presented with preoccupation of having a cardiac problem, mild somatic symptoms with no organic basis (ruled out though medical exams repeatedly) but more closely linked to sympathetic arousal stemming from anxiety. There was excessive health-related behavior and adaptive avoidance. He presented with physical symptoms of anxiety (palpitations, breathlessness, tightness in the chest, and dizziness) surrounding the fear of having cardiac problems that may end in a heart attack and untimely death for the past 4 years. His symptoms surfaced after being exposed to the media frenzy surrounding the death of a renowned politician. Repeated exposure to the news of the politician's hospitalization and death sensitized him to other related news of untimely death among young adults due to cardiac infraction. This was followed by repeated hospital visits and checkups despite no indicators of an illness. The client reported spending a major portion of the day checking his heart rate using a wearable electronic heart rate monitoring device. He started monitoring the minor fluctuations and was alarmed by any changes noted. This led to more anxiety symptoms further exacerbating his heart rate and sympathetic arousal. As the client was unware of the similarity between the somatic manifestations of anxiety and cardiac symptoms, he often ended up confusing his anxiety as the onset of a heart attack and immediately rushed to the emergency to get an electrocardiogram (which never revealed any anomalies).

His fear led to severe avoidance behavior where the client refused to engage in any activity that brought about a fluctuation in his heart rate or made him feel even mildly tired (such as walking for more than 10 min, climbing stairs, playing with his son, eating a full meal, work-related calls that lasted for 30 min, and not willing to endure hunger for more than 10 min). He also engaged in safety behaviors such as wanting his wife/or mother to be around him all day, especially while he is eating, constantly checking his wearable heart rate monitoring device, trying to gather as much information as possible on cases of heart attack (on media) and analyzing their possible causes to protect himself from risk factors, watching online videos and news on heart attacks, and frequently visiting the office doctor to raise concerns about his health and seek reassurance.

Mental status examination was carried out and the following observations were made. He was well groomed. Mild psychomotor agitation such as restless movement with hands was noticed. He appeared prepared for the session and showed receptivity and cordial attitude. His speech patterns revealed normal volume and articulation. No anomalies were noted except for increased rate of speech surrounding health-related issues. Affect congruency was observed with slight over reactions surrounding illness-related information. Feelings of “stress, anxiety, and frustration” were reported. Thought content revealed no hallucinations or delusions. Thought form showed coherence and natural flow. Family history revealed no serious physical or mental health issues. Mental health history revealed that he has been under sertraline (100 mg) and clonazepam (.25 mg) drugs for the past 4 years but with no improvement in symptoms.

Diagnostic assessment

The client's psychiatrist was contacted to gain information on the assessments used and the diagnosis arrived at. The following assessments were employed by the psychiatrist: General Anxiety Disorder-7[3] was used to assess anxiety, Health anxiety Inventory[4] was used to assess DSM 5 criteria for illness anxiety disorder, somatic symptom subscale-8[5] was used to assess the somatic symptom burden.

Diagnostic formulation

The assessments and clinical findings warranted a diagnosis of illness anxiety with many signs of somatic symptom disorder (not enough to make an official diagnosis), and anxiety at clinical levels was also recorded. The client shows excessive concern and anxiety surrounding health-related issues. Health-related behaviors are disproportionate to his somatic symptoms. His manifestations match the “Care seeking type” of illness anxiety disorder. Symptoms have been present for more days than not in the past 4 years and have caused significant emotional distress. His social functioning and sense of agency are impaired. Both environmental factors (excessive media consumption) and personality disposition have contributed to the onset and maintenance of symptoms. REBT can be considered as a therapy choice as it provides room to test the usefulness and evidence of many of the client's irrational thoughts. The prognosis for illness anxiety is poor since it is a chronic condition with waxing and waning symptoms. Intervention can help keep the symptoms in check.

Therapeutic intervention

The client was started on REBT (currently five sessions have been completed). Being a directive therapy, it offered opportunities to present coping statements and alternative thoughts didactically rather than waiting for the client to arrive at them (while he suffered). Since REBT has strong philosophical roots that stress the acceptance of things out of one's control, it is expected to be suitable for dealing with death (uncontrollable variable)-related anxiety. Since the client has the tendency to assume the worst case scenario, other treatment approaches which do not acknowledge this discomfort by choosing “inelegant disputes” (in REBT terminology refers to challenging the probability of an event rather than helping client face the adverse situation if it all it happens) would not be the best choice.

Duration of each session was between 60 and 90 min and spread across 5 weeks. Session one was dedicated to psychoeducating the client about the biology of anxiety and its similarity with cardiac symptoms. The vicious cycle of paying attention to heart beat which in turn leads to worry-anxiety-elevated somatic symptoms was demonstrated. Avoidance behavior (refusing any physical activity which elevates heart rate) as a contributing factor to maintaining the cycle and preventing the client from trying new behaviors was also discussed. Session two dealt with establishing the belief-consequence connection which is the basic tenet of REBT. His irrational beliefs were identified. His Awfulising cognition: “It is terrible when my heart rate increases. Something bad will happen and I'll die” was challenged using functional dispute. The Awfulising was questioned rather than the thought itself. It was replaced with more functional thoughts. Session three addressed his demandingness: “I should get to the bottom of any news on heart attack related death and see what's causing it and do everything I can to prevent it from happening to me.” Dichotomy of control was established to check if his health was fully under his control or if there were contributing factors that were beyond his power. This led to the usage of logical dispute to examine if his demand was possible to be implemented. Healthy behaviors were reinforced but beyond a certain point the need to unconditionally accept difficult life circumstances was stressed. Session four focused on his frustration intolerance when it comes to handling the discomfort of elevated heart rate whenever he performs day-to-day work such as having a full meal and walking. Empirical dispute was used to challenge the science behind his propositions. The lack of evidence despite repeated tests to prove any aberrations was stressed. The need to question whether a thought is an opinion or fact was taught. Session five focused on his cognitive biases such as selective attention and confirmation bias. His need to look for evidence within his body and outside environment that will confirm his belief was highlighted. The need to weigh contradictory evidence without bias was stressed.

Across the five sessions, behavioral assignments were set such as (a) breathing exercises to deal with the discomfort when the wearable device is removed, (b) behavioral experiments to test what happens when he eats a full meal or waits for more than 15 min when he is hungry, (c) collecting evidence from his own past on how certain behaviors are not problematic such as physical activity and eating a full meal, (d) testing to see if the wearable device shows the same level of fluctuation with his son and wife to prove that variations in heart rate are normal.

The virtual medium of therapy did not pose a great challenge in this case, rather it offered a channel to incorporate visual and auditory elements that are seldom used in everyday clinical practice. Slides on the A-B-C-D-E model of REBT allowed the client to navigate the stages more clearly; the use of Jam boards (Google jam board software) presented an opportunity for the therapist and client to collaboratively arrive at coping statements and homework assignments. Video links on “sympathetic arousal” were parallelly watched by therapist and client with the opportunity to pause and highlight certain ideas and clarify doubts. More importantly, it allowed the client to practice certain exercises in the very environment that carries his stressors, this made the generalization of learnings to everyday life easier. These positive aspects of virtual therapy can be revamped and added to routine clinical practice by the use of in-session worksheets, flipcharts, use of gadgets to present slides, videos, and the option to guide the client in his own stress evoking environment when needed.

Outcome and patient perspective

Across five sessions, the client's level of insight had increased rapidly. The health anxiety inventory[4] was administered at the beginning of the 6th session, and a score of 29 was obtained (norm table reveals a mean score of 30 for individuals diagnosed with hypochondriasis).[4] This shows a 14-point reduction from his preintervention score of 43. He is currently following up.

As his understanding of the biological changes of anxiety improved, he shifted his attention toward his thought process. He was responsive to the disputes and collaborated with the therapist to arrive at counteractive rational beliefs. Disputes which questioned the functionality of thoughts allowed him to acknowledge them as “usual worries” and observe them with detachment. There was some reluctance to carry out behavioral experiments which was mitigated by involving his wife in joint experiments and exercises. By the fifth session, he had restricted the use of wearable device to 2 hours per day. While somatic symptoms continued to manifest, he was trying to tolerate them by affirming that “This is because of my anxiety and will pass.” Overall, the client's and family's verbal feedback expressed reduction in anxiety symptoms, less preoccupation with illness-related thoughts, reduction in hospital visits, and improved sense of emotional well-being.

  Discussion Top

This case report is an example of how unchecked media usage can serve as an indirect critical A (in REBT terminology, the salient stressor) and induce catastrophizing thoughts and excessive health-related behaviors in anxiety-prone individuals. However, emotional consequences are often a product of the bidirectional relationship between external and internal factors. In this case, his cognitive biases, neuroticism, and overbearing internal locus of control may interact with excessive media usage to compound the situation. The case offers an interesting instance of complex pathways between exogenous and endogenous variables and the need to acknowledge multiple areas of intervention.

The report also justifies the overall effectiveness of REBT as a transdiagnostic model. Despite his lack of insight and belief in therapy, the psychoeducation offered him a breakthrough in understanding the cause behind his somatic symptoms. This further motivated him to continue to seek help. REBT offered an excellent platform to allow him to connect his thoughts to his bodily changes (B-C connection) with concrete evidence and examples from his routine. Once this realization seeped in, he was open to the idea of restructuring his thoughts. The usefulness of empirical, functional, and logical disputes has once again shown to be effective in this case. REBT has also provided room for distinguishing between influence, control, and out of control situations and encouraged the client to develop a philosophy of acceptance. It offered a medium to challenge his selectiveness in gathering information and questioned the need for an unbiased view of information. It has not only alleviated some of his symptoms but also has provided him with a model that can be self-administered and generalized to various situations.

The case also offers supplementary insights into technology as a double-edged sword. On the one hand, it serves as a testimony for the flexible nature of REBT. The virtual therapy platform offered an interesting opportunity to use several applications such as slide presentations, jam boards, audio and video guides to augment therapy. On the other hand, excessive use of health monitoring device and ready access to unverified news did serve as a hurdle that had to be addressed. This case highlights the need for clinicians to be aware of the advantages and challenges which the age of information technology brings in the treatment of anxiety disorder and how the former can be capitalized to make therapy more effective.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, D.C., U.S.A: American Psychiatric Association; 2013.  Back to cited text no. 1
Pandey S, Parikh M, Mehul B, Vankar GK. Clinical study of illness anxiety disorder in medical outpatients. Arch Psych Psychother 2017;19:32-41.  Back to cited text no. 2
Spitzer RL, Kroenke K, Williams JB, Löwe B. A brief measure for assessing generalized anxiety disorder: The GAD-7. Arch Intern Med 2006;166:1092-7.  Back to cited text no. 3
Salkovskis PM, Rimes KA, Warwick HM, Clark DM. The health anxiety inventory: Development and validation of scales for the measurement of health anxiety and hypochondriasis. Psychol Med 2002;32:843-53.  Back to cited text no. 4
Gierk B, Kohlmann S, Kroenke K, Spangenberg L, Zenger M, Brähler E, et al. The somatic symptom scale-8 (SSS-8): A brief measure of somatic symptom burden. JAMA Intern Med 2014;174:399-407.  Back to cited text no. 5


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