Eleven Emergency Visits for a Heart That Tests Normal: Cognitive Behavioral Therapy for Health Anxiety in a 45-Year-Old, From the Reassurance Cycle to Behavioral Experiments
[Student Name]
University of Phoenix
PMH/503: Psychotherapy For Individuals, Families, And Groups
Week 3 Assignment
[Instructor Name]
[Date]
The client is a composite written for a model paper.
Ms. E., a 45-year-old office manager, has visited emergency departments 11 times in two years for chest pain and palpitations. Each time, electrocardiograms, troponins and once a stress test were normal. She checks her pulse dozens of times a day, reads about heart disease online and asks her husband to feel her pulse. Her Health Anxiety Inventory score is high. Her primary care clinician refers her for therapy. This paper describes the CBT approach.
The Cognitive Model
Salkovskis and Warwick (1986) described health anxiety as maintained by the misinterpretation of normal bodily sensations as signs of serious illness, and by safety-seeking behaviors, such as checking, seeking reassurance and avoidance, that relieve anxiety briefly but prevent the person from learning that the feared illness is not present. They observed that reassurance, though well intended, often increases preoccupation over time.
Ms. E.'s Cycle
When she notices her heart beating faster, for example after climbing stairs, she thinks, "This is a heart attack." Anxiety rises, increasing her heart rate further, which confirms the belief. She checks her pulse, searches online and goes to the emergency department. Normal results bring relief for a day or two, then the cycle restarts. Her checking keeps her attention on her heart, making normal sensations more noticeable.
Every normal test answered the question she asked and strengthened the habit of asking it.
The Evidence for CBT
Olatunji et al. (2014) meta-analyzed CBT for hypochondriasis and health anxiety and found a large effect compared with control conditions after treatment, a Hedges g of 0.95, with smaller but significant effects at follow-up, and benefits for depression as well. Tyrer et al. (2014) randomly assigned 444 patients with health anxiety in medical clinics to adapted CBT delivered by nurses and other clinicians or to standard care and found greater improvement in health anxiety at one year with sustained benefit over two years.
Session Structure
Therapy runs about 10 to 12 weekly sessions, each with an agenda, review of homework, focused work and new homework.
Early Sessions: Engagement and Psychoeducation
I validate that her sensations are real and her fear understandable, then introduce the cognitive model using her own examples. Rather than arguing that she is healthy, I propose a joint experiment: to test whether her problem is heart disease or worry about heart disease, since years of tests have not settled it.
Monitoring
She records sensations, thoughts, anxiety ratings and safety behaviors in a diary, showing how often checking occurs and how it affects anxiety.
Cognitive Work
We examine the evidence for "This is a heart attack," including her normal tests and the fact that her symptoms occur with stress and exertion. We develop alternatives, such as "My heart is speeding up because I climbed stairs and I'm anxious."
Behavioral Experiments
Experiments test predictions directly. Ms. E. runs up a flight of stairs and notices that her heart rate rises and returns to normal without harm. She reduces pulse checking for a week and records whether anxiety rises or falls over time; after an initial increase, it falls.
Reducing Reassurance
With her consent, we involve her husband, who learns to respond to reassurance requests with a kind but brief reminder of the plan rather than feeling her pulse. We also agree on a plan for when to seek emergency care, based on specific red flags rather than anxiety.
Attention Training
People with health anxiety often monitor their bodies closely, amplifying sensations. Exercises that shift attention outward, such as describing the room in detail when anxiety rises, help Ms. E. notice that sensations fade when attention moves elsewhere, weakening the link between attention and alarm.
Online Searching
Searching symptoms online is a form of checking that often worsens anxiety by surfacing rare, frightening conditions. We set a gradual reduction, from several searches a day to none, and replace it with a written note of the worry to bring to therapy.
Addressing Core Beliefs
Later in therapy, we explore beliefs underlying her fear, such as "If I miss a symptom, I will die and my children will be alone." Her father died suddenly of a heart attack at 52, which shaped this belief. Acknowledging this loss and examining how her situation differs is part of the work.
Relapse Prevention
In the final sessions, we write a plan listing her early warning signs, such as increased checking, and the skills that helped, so she can use them if anxiety returns.
Measuring Change
The Health Anxiety Inventory will be repeated at sessions 1, 6 and 12, along with a count of emergency visits and pulse checks per day, giving both symptom and behavioral measures of progress.
Why Not Medication Alone
SSRIs can help health anxiety, and some patients benefit from combining them with CBT. Ms. E. prefers therapy first, and the evidence supports CBT as an effective first choice (Olatunji et al., 2014).
The First Behavioral Experiment in Detail
For the stair experiment, Ms. E. predicts, on a scale from 0 to 100, how likely she is to have a heart attack; she rates it 60. She climbs, notes her pulse and symptoms, waits five minutes and rerates the belief, now 20. Writing predictions before and results after makes the learning concrete and counters the tendency to discount evidence.
Her Children
She worries that her anxiety frightens her children, who have seen her rushed to the hospital. Part of her motivation is to model calmer responses, and we plan how she can talk to them about the work she is doing.
Emergency Plan
We agree on specific symptoms that warrant emergency care, such as chest pain with sweating, shortness of breath at rest or fainting, distinguishing them from the palpitations and brief chest discomfort she experiences with anxiety. A written plan reduces uncertainty in the moment.
Documentation
Session notes record the cognitive model shared with her, the experiments, their results and homework, allowing progress to be traced and helping any covering clinician continue the work consistently.
Her Progress
By session eight, her pulse checks fell from about 40 a day to 5, and she had no emergency visits in six weeks, the longest stretch in two years, and her husband reported calmer evenings at home and far fewer requests to check her pulse at night.
Coordination With Primary Care
I ask her primary care clinician to schedule regular brief visits rather than responding to each worry with new tests, a structure that reduces emergency use.
Conclusion
Ms. E.'s repeated emergency visits reflect the cycle described by the cognitive model of health anxiety: misinterpretation of normal sensations, anxiety and safety behaviors, including reassurance, that maintain the fear. Meta-analytic and trial evidence support CBT, and her treatment uses psychoeducation, monitoring, cognitive restructuring, behavioral experiments and reduced reassurance, coordinated with her primary care clinician.
References
Olatunji, B. O., Kauffman, B. Y., Meltzer, S., Davis, M. L., Smits, J. A. J., & Powers, M. B. (2014). Cognitive-behavioral therapy for hypochondriasis/health anxiety: A meta-analysis of treatment outcome and moderators. Behaviour Research and Therapy, 58, 65-74. https://doi.org/10.1016/j.brat.2014.05.002
Salkovskis, P. M., & Warwick, H. M. C. (1986). Morbid preoccupations, health anxiety and reassurance: A cognitive-behavioural approach to hypochondriasis. Behaviour Research and Therapy, 24(5), 597-602. https://doi.org/10.1016/0005-7967(86)90041-0
Tyrer, P., Cooper, S., Salkovskis, P., Tyrer, H., Crawford, M., Byford, S., Dupont, S., Finnis, S., Green, J., McLaren, E., Murphy, D., Reid, S., Smith, G., Wang, D., Warwick, H., Petkova, H., & Barrett, B. (2014). Clinical and cost-effectiveness of cognitive behaviour therapy for health anxiety in medical patients: A multicentre randomised controlled trial. The Lancet, 383(9913), 219-225. https://doi.org/10.1016/S0140-6736(13)61905-4
How this PMH 503 Week 3 example is structured
The PMH/503 Week 3 work usually focuses on cognitive behavioral therapy for anxiety and depression. This paper applies a specific cognitive model to one client and shows how each element of the model becomes a target for a named CBT technique. Students search this week as PMH 503 Week 3, PMH503 Wk 3 or PMH/503 Wk 3; all three are the same assignment.
PMH/503 Week 3 questions, answered
What does PMH/503 Week 3 usually ask for?
Many sections ask students to apply cognitive behavioral therapy to an anxiety or depressive disorder, describing the model, techniques and session structure.
Why does reassurance not help health anxiety?
Reassurance brings brief relief but reinforces the belief that checking is necessary, so the anxiety returns and the need for reassurance grows.
Does CBT work for health anxiety?
Yes. A meta-analysis found large effects of CBT on health anxiety after treatment, and a trial in medical clinics found sustained benefit over two years.
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