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Cognitive and Behavioral Practice 24 (2017) 484-495
www.elsevier.com/locate/cabp

A Case Study of Individually Delivered Mindfulness-Based Cognitive Behavioral

Therapy for Severe Health Anxiety
Christina M. Luberto and Jessica F. Magidson, Massachusetts General Hospital/Harvard Medical School
Aaron J. Blashill, San Diego State University and San Diego State University/University of California San Diego
Joint Doctoral Program in Clinical Psychology

Health anxiety involves persistent worry about one's physical health, despite medical reassurance. Cognitive-behavioral therapy (CBT)
is currently the most widely used, evidence-based treatment for health anxiety. Mindfulness-based cognitive therapy (MBCT) is an
evidence-based cognitive-behavioral treatment approach that may be useful for health anxiety due to its focus on nonjudgmental
awareness and acceptance of physical and emotional events. MBCT has largely been evaluated in a group format; however, the majority
of outpatient CBT providers rely also on individual treatments. No research to date has examined the utility of MBCT delivered as
an individual therapy for patients with health anxiety. The purpose of the current case study is to describe the delivery, acceptability,
and effects of an individually delivered mindfulness-based cognitive-behavioral intervention on health anxiety symptoms for a young
woman with severe health anxiety referred to outpatient behavioral medicine by her primary care provider. The treatment was a
16-session, patient-centered intervention largely delivered using MBCT techniques, supplemented by traditional cognitive-behavioral
techniques. The patient completed a validated self-report measure of health anxiety symptoms (SHAI) at the beginning of each session.
The treatment was found to be acceptable, as evidenced by high treatment attendance and patient feedback. The patient reported
significant cognitive, affective, and behavioral improvements, including a 67% reduction in medial visits. Health anxiety scores on the
SHAI showed a 52% decrease from the first to last session, reliable change index score of 12.11, and fell below the clinical cutoff at the
final session, demonstrating clinical significance. These results suggest that it is feasible to adapt MBCT for the individual treatment of
health anxiety, and that controlled trials of individual MBCT are warranted.

anxiety 1 is a chronic psychological disorder

H EALTH
that affects up to 10% of the general population
(American Psychiatric Association [APA], 2000). Health
anxiety involves persistent worry about one’s physical
health and a preoccupation with the fear of having
or acquiring an illness, which persists despite medical
evaluation (APA, 2013; Salkovskis, Rimes, Warwick, &
Clark, 2002). Health anxiety symptoms result in signifi-
cant distress and functional impairment, as individuals
1
Health anxiety was referred to as Hypochondriasis in the DSM-IV
and is now referred to as Somatic Symptom Disorder and Illness
Anxiety Disorder in the DSM-5. We use the term “health anxiety”
throughout this paper for consistency with previous literature, and to
encompass multiple related conditions that may benefit from a
mindfulness-based approach, particularly given that these diagnostic
changes are new and without established empirical support (e.g.,
Bailer, Kersner, Witthoft, Diener, Mier, & Rist, 2016).
Keywords: mindfulness; health anxiety; Mindfulness-Based Cognitive
Therapy; cognitive-behavioral therapy
1077-7229/16/© 2017 Association for Behavioral and Cognitive
Therapies. Published by Elsevier Ltd. All rights reserved.
either avoid medical visits entirely, or repeatedly visit
medical professionals to alleviate their health concerns
(APA, 2013). Among the latter, the provided reassurance
only lasts until a new physical symptom develops, or it
is not fully trusted at all (Lovas & Barsky, 2010). Health
anxiety is unique from other anxiety disorders due to
greater preoccupation regarding negative consequences
of physical illness (Abramowitz, Olatunji, & Deacon,
2007) and is also distinct from anxiety due to medical
conditions because illness beliefs are inaccurate or
mistaken: individuals are either medically healthy, or
experience anxiety that is disproportionate to their phys-
ical health status (Abramowitz, Deacon, & Valentiner,
2006). As a result of these high levels of health care
utilization, health anxiety is associated with a significant
social burden and increased health care costs, as well
as high levels of occupational disability (Abramowitz,
Deacon, & Valentiner, 2006; Barsky, Ettner, Horsky, &
Bates, 2001; Creed & Barsky, 2004; Mykletun et al., 2009).
Thus, there is an important need for evidence-based
interventions that can effectively treat this disorder.
Cognitive-behavioral therapy (CBT) is currently the most
widely used, evidence-based treatment for health anxiety
 Mindfulness and Health Anxiety Case Study
(Taylor & Asmundson, 2004; Thomson & Page, 2007).
According to cognitive-behavioral conceptualizations,
health anxiety results from maladaptive illness beliefs
that lead to an attentional bias towards health-related cues
(e.g., somatic sensations and changes), catastrophic mis-
interpretations of those cues, and avoidance-oriented
safety-seeking behaviors (Abramowitz et al., 2006). These
safety-seeking behaviors are negatively reinforced because
they temporarily reduce anxiety symptoms; however, they
ultimately serve to reinforce illness beliefs and maintain the
health anxiety cycle by preventing experiential learning and
disconfirmation of anxious thoughts (Abramowitz et al.,
2006). Thus, CBT interventions for health anxiety focus
on changing health-related thoughts (e.g., by estimating
the probability of feared events, examining evidence for and
against catastrophic thoughts), and reducing reassurance-
seeking behaviors (e.g., through behavioral experiments
and exposure exercises; Taylor & Asmundson, 2004). Extant
research indicates that CBT produces significantly greater
improvements in health anxiety symptoms, physical symp-
toms, and overall functioning as compared to active and
no-treatment control groups (Sorensen, Birket-Smith,
Wattar, Buemann, & Salkovskis, 2011; Salkovskis, Warwick,
& Deale, 2003; Thomson & Page, 2007). However, studies
of CBT for health anxiety have also shown relatively low
enrollment rates and high attrition rates, suggesting that
existing treatments are not always acceptable to patients
(e.g., Barsky & Ahern, 2004; Greeven et al., 2007; Visser &
Bouman, 2001).
One challenge of CBT for some individuals with health
anxiety may involve the use of cognitive restructuring.
For patients with health anxiety, targeting the way of
relating and responding to catastrophic thoughts may be
more useful than targeting the content of the thoughts
themselves, given that (a) patients often hold rigid beliefs
about health and illness, which do not permanently
change after corrective information from health care
professionals; (b) the content of thoughts can vary widely
when new physical symptoms are observed; and (c) the
feared outcomes often relate to events that could reason-
ably occur in the future, making them less amenable to
restructuring (e.g., the possibility of developing cancer;
McManus, Surawy, Muse, Vazquez-Montes & Williams,
2012). Thus, teaching patients to “decenter” from these
catastrophic thoughts (i.e., notice them as transient mental
events that are not necessarily accurate or need to be
acted on), rather than challenge the content of individual
thoughts specifically, may be an alternative strategy to
cognitive restructuring in a CBT-based approach.
Mindfulness training is a cognitive-behavioral treat-
ment approach that facilitates cognitive decentering
and is an efficacious treatment for reducing anxiety and
medical symptoms (e.g., Faramarzi, Yazdani, & Barat,
2015; Ferszt et al., 2015; Lengacher et al., 2014; Schoultz,
485
Atherton, & Watson, 2015). Mindfulness training involves
the self-regulation of attention toward present-moment
experiences with an attitude of openness, nonjudgment,
and curiosity (Bishop et al., 2004). It is the process of
noticing the internal or external events happening in
the present moment, including noticing when the mind
has wandered or become entangled with certain stimuli
(e.g., maladaptive thoughts, physical sensations), and
gently bringing the mind back to the moment. Mindfulness-
based CBT interventions, such as Mindfulness-Based
Cognitive Therapy (MBCT; Segal, Williams, & Teasdale,
2002), Mindfulness-Based Relapse Prevention (MBRP;
Bowen, Chawla, & Marlatt, 2011), and Mindfulness-Based
Stress Reduction (MBSR; Kabat-Zinn, 1982), are group-
based programs that integrate mindfulness training with
traditional cognitive-behavioral principles; these interven-
tions have demonstrated medium-to-large effect sizes for
preventing relapse of depression and substance use (Segal
et al., 2010; Witkiewitz & Bowen, 2010), as well as treating
a range of anxiety disorders, mood disorders, and physical
health symptoms (e.g., chronic pain; Chiesa & Serretti,
2011; Grossman, Niemann, Schmidt, & Walach, 2004;
Hofmann, Sawyer, Witt, & Oh, 2010).
Research has recently focused on applying MBCT to
health anxiety specifically. Surawy and colleagues (2015)
recently provided a theoretical rationale for MBCT for
health anxiety, suggesting that MBCT can reduce health
anxiety by teaching patients how to develop a more
accepting relationship with internal experiences and view
their thoughts more objectively (i.e., cognitive decentering).
The ability to notice and accept internal experiences
may help individuals with health anxiety (a) become
aware and accepting of bodily sensations; (b) respond
to these sensations intentionally, rather than react to
them automatically; (c) remain engaged in the present
moment, rather than become carried away with future-
oriented fears; and (d) identify early warning signs to
prevent anxiety from escalating (Surawy et al., 2015). In
line with this theory, the results of two recent pilot studies
of MBCT (delivered as a group therapy) demonstrated
significant improvements in health anxiety symptoms,
which were correlated with improvements in mindfulness
and maintained up to 1 year later (Lovas & Barsky, 2010;
McManus et al., 2012).
These two recent pilot studies suggest the potential
utility of using MBCT to address health anxiety. However,
to date, there has been no examination of MBCT for
health anxiety in an actual clinical practice setting, and no
research using an individual MBCT approach to address
health anxiety. Although it may be a likely assumption
that the intervention would be feasible and acceptable
in individual settings, supported by patients having voiced
a preference for individualized MBCT protocols (Lau,
Colley, Willett, & Lynd, 2012) and evidence to support
486
using an individual MBCT approach for patients with
diabetes and depression (Schroevers et al., 2015), it is
possible that the group setting might provide several
benefits that facilitate the acceptability and efficacy of
these interventions. The application of MBCT to address
health anxiety in individual therapy would be an im-
portant tool for clinicians working in outpatient mental
health settings where the primary modality of treatment is
individual therapy.
The purpose of the current study was therefore to
extend the literature on MBCT for health anxiety by
describing the delivery and feasibility of an individually
delivered mindfulness-based cognitive-behavioral treat-
ment for health anxiety. Specifically, we use a single-case
study design to describe the delivery and implementation
of this treatment in terms of session structure and
content, including transcripts of key interventions 2; the
acceptability of the intervention as evidenced by treat-
ment adherence and patient report; and the preliminary
data to demonstrate effects of the treatment on subjective,
behavioral, and objective outcomes (i.e., scores on a vali-
dated self-report measure of health anxiety symptoms).
We hypothesized that the treatment would be acceptable
to the patient and produce clinically meaningful im-
provements in health anxiety symptoms.
Method
Patient Characteristics
The patient’s identifying information has been altered
to protect confidentiality. “Brooke,” a married Caucasian
woman in her early 30s from the Midwestern United
States with no prior psychiatric history and no current
medical comorbidities, self-referred to therapy, with
encouragement from her family and primary care
provider (PCP), for the treatment of health anxiety
symptoms that were negatively impacting her mood,
interpersonal relationships, and overall psychosocial
functioning. Specific presenting problems included per-
sistent worry about her health and physical symptoms,
and multiple reassurance-seeking behaviors including
searching the Internet for health-related information
(1–2 hours/day, 7 days/week), asking friends and family
for reassurance that she was healthy (multiple people,
multiple times each day), and visiting her PCP or emergency
department (3–4 times/month for the past 6 months).
At the time of treatment, she was working full-time and
had close relationships with several friends who lived nearby.
A few years prior to seeking treatment, Brooke’s mother
experienced significant health problems; shortly thereafter,
Brooke was hospitalized for approximately 1 week for a
medical problem. She admitted that these experiences were
2
All transcripts are examples of possible clinical dialogue and not
direct quotes from the actual patient.
Luberto et al.
frightening and that her health anxiety symptoms started
shortly after these events. Brooke was connected to
short-term, skills-based individual therapy through the
Behavioral Medicine service in the Outpatient Psychiatry
department of an academic medical center by her PCP.
Assessment Measures
MINI International Neuropsychiatric Interview (MINI)
The MINI version 5.0 (Sheehan et al., 1998) is a brief,
structured interview for assessing DSM-IV psychiatric
disorders. It shows good reliability and convergent validity
with other diagnostic interviews (Sheehan et al., 1997).
The MINI was used to conduct a thorough assessment of
Brooke’s psychiatric functioning at the onset of treatment;
specifically, current and past major depressive disorder,
dysthymia, suicidality, mania/bipolar disorder, panic dis-
order, agoraphobia, social anxiety disorder, obsessive-
compulsive disorder, posttraumatic stress disorder, and
generalized anxiety disorder were assessed. Health anxiety
(hypochondriasis or illness anxiety disorder) was not
included in the MINI but assessed through diagnostic
questioning during the same session based on DSM-IV
criteria.
Short Health Anxiety Inventory (SHAI)
The SHAI (Salkovskis et al., 2002) is an 18-item self-
report measure of health anxiety symptoms. Respondents
are asked to select one of four statements rated on a scale
of 0 to 3 that reflect varying degrees of health anxiety
(e.g., “I do not worry about my health” to “I spend most of
my time worrying about my health”). Thus, scores range
from 0 to 54, with higher scores indicating more severe
symptoms. The SHAI demonstrates good reliability and
validity in clinical and nonclinical samples (Abramowitz,
Deacon, & Valentiner, 2007; Alberts, Hadjistavropoulos,
Jones, & Sharpe, 2013; Salkovskis et al., 2002). Brooke
completed this measure at the beginning of each session
to assess her progress over time. Her scores on the full
18-item measure were compared to norms for nonclin-
ical students (M = 12.41, SD = 6.81), clinical populations
(M = 32.53, SD = 9.57), and an overall clinical cutoff value
of 27 for the total score (Alberts et al., 2013).
Case Conceptualization
Brooke was engaged in a maladaptive cycle of mutually
reinforcing thoughts, reassurance-seeking behaviors, and
anxiety-related physical symptoms, which was seemingly
triggered by her and her mother’s recent medical prob-
lems and caused significant distress and impairment.
Her attention was biased toward somatic symptoms, as
she was hypervigilant to physical sensations and regularly
scanned her body for physiological changes. She became
entangled in repetitive and catastrophic thinking in response
 Mindfulness and Health Anxiety Case Study
to these physical symptoms, overly identifying with the
thoughts and taking them literally as fact, despite repeated
evidence to the contrary. She understood that the prob-
ability of the feared outcome (e.g., having a heart attack)
was exceedingly low, but she remained distressed over the
small chance that something catastrophic could happen
to her health. Brooke was unable to tolerate anxiety with-
out reassurance, and unable to apply appropriate coping
mechanisms when anxious. She had a tendency to
negatively evaluate anxiety as unwanted and unacceptable;
as a result, she engaged in repeated efforts to avoid or
suppress the anxiety by visiting health care providers,
researching physical symptoms online, and asking friends
and family for reassurance about her health. These
reassurance-seeking behaviors were negatively reinforced
because they temporarily allayed her concerns, but they
maintained a cycle of fearful responding to internal events
by preventing opportunities for emotional exposure and
experiential learning. Brooke met criteria for DSM-IV
hypochondriasis and DSM-5 illness anxiety disorder. She
did not meet criteria for any other psychological disorder.
We use "health anxiety" as an umbrella term to encompass
both hypochondriasis and illness anxiety disorder.
Two main aspects of Brooke’s specific case led to the
selection of a mindfulness-based approach rather than
traditional CBT. First, Brooke displayed a pattern of
rigid catastrophic thinking and a tendency to become
overly engaged in maladaptive thoughts, and she was
highly intellectualized and knowledgeable about health
and medicine. A mindfulness-based approach focused on
cognitive decentering was thought to be preferable to a
traditional CBT approach focused on cognitive restructur-
ing due to Brooke’s rigid beliefs, her difficulty disengaging
from thoughts, and her own awareness that she could often
become stuck in a cycle of countering her own thoughts.
Additionally, Brooke experienced heightened emotional
reactivity and avoidance in response to bodily sensations,
believing that there was something wrong with her body
that needed to be changed. A traditional CBT approach to
health anxiety utilizes relaxation training, and the concern
was that this approach could reinforce the erroneous
idea that her bodily state needed to be different than it
was. A mindfulness approach instead teaches openness,
acceptance, and nonjudgment of physical sensations, which
reduces emotional and behavioral reactivity. Thus, a mind-
fulness approach focused on acceptance of thoughts and
body sensations was deemed better suited to Brooke than
a traditional CBT approach focused on direct cognitive
and emotional change.
Treatment Delivery
Treatment was largely informed by the MBCT protocol
and integrated traditional cognitive-behavioral techniques,
487
with specific modifications for individual treatment and
health anxiety. In its original protocol, MBCT involves
8 weekly psychoeducational group sessions that integrate
formal mindfulness training with traditional CBT prin-
ciples to help patients become more aware, accepting, and
adaptive in their responding to emotional distress (Segal
et al., 2010). Sessions are informed by a mindfulness theme
(e.g., attachment and aversion, thoughts are not facts)
and utilize increasingly complex mindfulness meditations
during each session. Treatment was delivered by a doctoral
intern in clinical psychology (CML) with formal training
and 4 years of experience facilitating MBCT groups, as
well as an ongoing personal mindfulness meditation
practice for the past 8 years. A licensed clinical psychologist
(AJB) supervised the case and met weekly with the therapist
to discuss the patient’s treatment. As recommended (Segal
et al., 2010; Semple, Lee, & Miller, 2010), the therapist
drew largely from her personal mindfulness experience to
model mindfulness and identify important learning points
for reflection.
Several modifications were made for the current treat-
ment (see Table 1). First, similar to previous CBT for
health anxiety protocols (Greeven et al., 2007; Sorenson
et al., 2011), the length of treatment was extended to
16 core treatment sessions, with additional sessions for
a thorough intake assessment and relapse prevention
planning. Second, sessions did not always include a
formal mindfulness exercise if Brooke presented with
specific insights or difficulties that seemed important
to process. Third, the sequence of treatment was
adapted to meet Brooke’s level of functioning; specif-
ically, given the severity of her health anxiety symptoms,
the body scan was introduced at the midpoint rather
than onset of treatment in order to provide Brooke
with opportunities to develop mindfulness skills by first
applying them to less threatening stimuli (e.g., sights
and sounds in the environment). Fourth, treatment
included one session with Brooke’s husband in order
to help Brooke educate others regarding how best to
respond to her health anxiety symptoms. Additionally,
The Mindful Way Through Anxiety (Orsillo & Roemer,
2011) was used as adjunctive bibliotherapy toward the
end of the treatment.
In general, sessions typically began with a mindfulness
exercise or review of mindfulness practice during the
week. Post-processing of in-session mindfulness exercises
was conducted based on the following questions from the
MBCT mindful inquiry process:
1. What did you notice?
2. How is this way of noticing different than how you
normally notice your experiences?
3. How might this different way of noticing be helpful
for your [health anxiety]?
488 Luberto et al.

Table 1
Summary of Treatment Sessions

Core Session Session Content Standard MBCT Homework Assigned

1 CBT model of health anxiety Raisin exercise Self-monitoring; Pros/cons of
Body scan reassurance-seeking
2 Mindfulness and anxiety Body scan Avoidance pros & cons;
Mindfulness of an object “Walking down the street” exercise Mindfulness of daily activities
Sitting meditation
Pleasant events calendar
3 Mindful breathing meditation Sitting meditation Mindfulness of daily activities;
Non-judgment and health anxiety 3-minute breathing space Pleasant events calendar
Unpleasant events calendar
4 Mindfulness-based exposure exercise Sitting meditation Mindful breathing; Pleasant
Poem (“Wild Geese”) events calendar
Automatic thoughts
3-minute breathing space
5 “Walking down the street” exercise Sitting with difficulties meditation Mindful sitting
Mindful sitting meditation 3-minute breathing space
Poem (“The Guest House”)
6 Mindfulness of thoughts Sitting meditation Mindful sitting; 3-minute breathing
3-minute breathing space Mindfulness of thoughts space; Mindful responding to
3-minute breathing space thoughts
7 Attachment vs. letting go Sitting meditation Mindful sitting exercise; 3-minute
Avoidance vs. willingness Mood and behavior breathing space
Activity scheduling
3-minute breathing space
8 Mindfully sitting with difficulties meditation Body scan Mindfully sitting with difficulties
Course review
Relapse prevention planning
9 Progress review and treatment plan update – Any mindfulness exercise
10 Body scan – Body scan; Mindful responding to
Automatic thoughts, non-reactivity thoughts
11 “What if” thoughts – Body scan; Begin bibliotherapy
Downward arrow exercise
12 Behavioral coping strategies – 3-minute breathing space
13 Avoidance vs. acceptance – Any mindfulness exercise
Cognitive de-centering: using visual imagery
14 Mindfulness-based exposure exercise – Mindfully sitting with difficulties;
Bibliotherapy
15 Family therapy psychoeducation session – Any mindfulness exercise
16 “Coping cards” for family members – Any mindfulness exercise;
Coping cards

Maintenance Session Session Content Homework Assigned

Relapse Prevention Develop relapse prevention plan – Relapse prevention plan
Booster 1 Progress review: experiential learning regarding appropriate vs. – Relapse prevention plan
inappropriate medical visits
Booster 2 Progress review and relapse prevention – Relapse prevention plan
Note. Standard MBCT refers to weekly session content from the 8-week group MBCT protocol; group sessions are typically 90 minutes
(Segal et al., 2010). Bibliotherapy was assigned for homework weekly beginning Session 11. The general recommendation for mindfulness
homework exercises was 15-20 minutes/day.

Mindfulness exercises were assigned regularly for home- direct feedback but, instead, mindfully noted as a symptom
work each week. Any instances of reassurance-seeking of health anxiety, with the physical symptom of concern
during session were deliberately not reinforced through being used as the basis of a mindfulness-based exposure
 Mindfulness and Health Anxiety Case Study
exercise in the moment. Brooke’s identified treatment
goals included subjective (e.g., feeling less anxious, less
worried), behavioral (e.g., decreased medical utilization,
Internet-searching, and reassurance-seeking from friends/
family), and objective improvements (e.g., reduced SHAI
scores).
Session 1 focused on psychoeducation about the
CBT model of health anxiety (Abramowitz et al., 2006).
Catastrophic thoughts and negative consequences of
reassurance-seeking behaviors were highlighted. Session
2 included additional psychoeducation about the nature
and function of anxiety (e.g., the time-limited course,
adaptive value), as well as the definition of mindfulness
and rationale for applying it to the treatment of health
anxiety (e.g., emotional exposure, decentering). Mind-
fulness exercises were introduced in this session with
mindfulness of an external object (i.e., a rock), wherein
the patient was guided in exploring the object with her
sense of sight, touch, and smell, openly and nonjudg-
mentally. Post-processing focused on how nonjudgmental
awareness might interrupt the health anxiety cycle.
THERAPIST (T): What did you notice during that exercise?
BROOKE (B): I was surprised that I was able to look at a rock for
that long without thinking about other things. There were a
lot of colors in the rock.
(T):
You were able to keep your attention focused on the rock,
and your mind didn’t wander as much as you thought it
would.
(B):Right. Sometimes I would think about things about the
rock, like remembering playing outside as a kid, but then you
would say to bring your mind back, and I did.
(T):
How was this way of noticing the rock different than how
you normally notice your experiences?
(B):I usually examine things very critically—when I notice
pain and other sensations in my body, I keep watching it to
see what’s wrong. With the rock, I just looked at it.
(T):So you were more open and less judgmental of what you
were noticing. How do you think noticing body sensations
without judgment might help your anxiety?
(B): If I noticed sensations and didn’t think that they were
bad or dangerous, I probably wouldn’t look them up online,
and would probably stop worrying about them sooner.
In Session 3, mindful breathing was introduced in
order to provide a gentle introduction to mindfulness
of body sensations. Post-processing again focused on the
novelty, difficulty, and potential utility of adopting a non-
judgmental perspective. In Session 4, Brooke presented
with a tingling sensation in her hand and asked for re-
assurance that it could be a symptom of anxiety, rather
than a medical problem. This attempt at reassurance-
489
seeking was mindfully reflected as a symptom of health
anxiety, and the physical sensation was used as the focus
of a mindfulness-based exposure exercise. Brooke was
asked to turn her attention toward the tingling and do her
best to observe how it felt without judgment, allowing
thoughts to come and go and returning her attention
to the sensation whenever it wandered off. She was also
asked to rate her distress level throughout the exercise,
and to report descriptions (rather than judgments) of
the sensations she was noticing. Post-processing focused
on important observations from this exercise, including
the fact that her distress level decreased on its own over
time, and that she was able to experience catastrophic
thoughts without automatically reacting to them in the
moment.
Session 5 introduced mindfulness of thoughts. First,
the idea that thoughts are not facts was taught using
an MBCT guided visualization exercise, which asked
Brooke to imagine what thoughts she would have during
a mildly distressing event, and how these thoughts might
be related to her mood.
(T):Imagine you are walking down the street and you see a
friend on the other side. You wave to them, and they keep
walking without waving back. What thoughts might you have?
(B): I might think that they were mad at me, or ignoring me.
(T):
Ok. How do you think you might feel if you thought they
were ignoring you?
(B): Probably angry or upset.
(T):
That makes sense. What if they didn’t wave back, but you
were in a very good mood that day anyway?
(B): I might not care. I might just think they didn’t see me.
(T): So you might think "they didn’t see me," and if you had
that thought, you wouldn’t really have a lot of emotion about
it. What do you think about that—that the same event can
happen, but your thoughts could be different?
(B): I guess there are different ways to think about the same
thing. Maybe just because you think of it one way, it doesn’t
mean that’s really the way it is.
A mindful sitting exercise that included awareness of
the breath, body, sounds, and thoughts was then practiced
in this session. In Session 6, strategies for responding
mindfully to thoughts were discussed, including noticing
thoughts and intentionally letting them go; mindfully
asking different questions about the thought in order
to gain a broader perspective and relate to the thought
in a decentered way (e.g., “Am I confusing a thought with
a fact?”); and using visual imagery strategies to further
promote cognitive-decentering (e.g., picturing thoughts
as clouds in the sky). The 3-minute breathing space was
490
also taught in this session as a way for Brooke to ground
herself in the moment and create space for choosing her
response to maladaptive thoughts, rather than react auto-
matically to them.
Session 7 focused on discussing the costs and benefits
of attachment as compared to letting go, and emotional
avoidance as compared to emotional willingness. Brooke
related these themes to her experience with health
anxiety symptoms, recognizing that being willing to have
anxiety would necessarily prevent anxiety from being
inherently problematic. To promote emotional willing-
ness experientially, Session 8 introduced mindfully sitting
with difficulties. Brooke identified a current anxious
thought she was having about her health and engaged in
the process of turning her attention toward and attempt-
ing to stay focused on that thought.
(T):So right now you are having the thought, “what if I have a
heart attack?” I am going to ask you to turn toward that
thought and do your best to hold it in your awareness….
notice any sensations in your body that come up, and gently
bring your attention back to the thought… whenever your
mind wanders off, just gently bring it back to the thought
each time. [5-minute exercise.]
(T): What did you notice?
(B): It was hard to stay focused on the thought. I would try to
hold onto it and I would end up thinking about something
else — not anything scary, just like what I was going to do for
dinner or something.
(T):It sounds like your mind wandered off to more neutral
topics, which is often what our thoughts do as a way of
avoiding more frightening thoughts or emotions. What
happened when you noticed you were thinking about other
things?
(B): Nothing really, I just noticed that I wasn’t focused on the
thought of a heart attack anymore so I tried to bring that
thought back and stay with it.
(T):That’s the right idea — just being able to gently redirect
your attention, and being willing to focus your attention on a
frightening thought. What did you notice about the anxiety
during this exercise?
(B): I wasn’t that anxious. Especially toward the end, it was
just like any other thought.
Session 9 served as a midpoint progress review and
treatment plan update, wherein Brooke reported that her
overall anxiety and reassurance-seeking behaviors had
decreased, and she wanted to further focus on mindful
behavioral responding to catastrophic thoughts.
Session 10 introduced the body scan, which served as a
form of an exposure exercise for Brooke. She was guided
through the exercise and, in post-processing, reflected on
how the body scan replaces her typical evaluative stance
Luberto et al.
towards physical sensations with more open observation.
She also observed a tendency to rush through neutral
areas and focus selectively on concerning areas, which was
explored as a potential anxiogenic process. Her enhanced
ability to stay present with ambiguous physical sensations
was also highlighted as a reflection of improved distress
tolerance.
In Session 11, Brooke reported that she finds herself
particularly entangled with “what if” thoughts. Mindful
observation and exploration of these thoughts using
the CBT downward arrow technique helped Brooke
identify that her core fear was that she could have a
medical problem that would result in sudden death,
causing her to miss out on her life. The ways in which
reassurance-seeking behaviors and worry about her
health currently cause her to miss out on her life were
discussed, and the concept of tolerating uncertainty was
explored. The next two sessions (12 and 13) focused on
mindful responding to “what if” thoughts and promot-
ing tolerance of uncertainty through the identification
and problem-solving of behavioral (e.g., photography,
going for walks) and cognitive regulation strategies
(e.g., visual imagery, intentional letting go). Pros and
cons of applying adaptive or maladaptive coping strat-
egies were explored to further enhance motivation for
effective coping.
(T):So the core fear is that you will die soon and miss out on
your life, and right now you are physically healthy and it is
the anxiety that is causing you to miss out on your life. What
do you think this means for responding to your anxiety?
(B): Maybe that I should try to let those thoughts go because
they probably aren’t true and it is hurting me to listen to
them. But sometimes the thoughts are so strong and pull me
in, and it is hard to let them go.
(T): Absolutely— the most frightening thoughts can be the
hardest to let go of. What else could you do when you have
these thoughts in addition to trying to watch them and let
them pass?
(B): I could try to use mindfulness to pay attention to the
moment I am really living in, and notice other things about
the moment. I could go for a walk and pay attention to all
of the other things, like the trees and sounds outside. The
thoughts might still come but I could imagine putting them
on the clouds and watching them float by, like we practiced.
Session 14 provided another opportunity for in-vivo
mindfulness-based exposure exercises, as Brooke presented
with anxiety about a fluttering sensation in her chest. She
was again asked to mindfully notice and sit with the
sensation, providing ratings of distress and objective
descriptions of the sensation. In post-processing, she
reflected that her anxiety was less intense than she had
thought; it decreased over time; and it was difficult to
stay focused on the fluttering sensation. The benefits of
 Mindfulness and Health Anxiety Case Study
intentionally turning toward future difficult thoughts and
sensations in this way were discussed.
The final two core treatment sessions focused on ways to
educate Brooke’s family about how to effectively respond to
her healthy anxiety symptoms. Brooke’s husband attended
Session 15, and Brooke took an active role in educating him
about the CBT model of health anxiety and use of
mindfulness skills for treating the symptoms. In Session
16, Brooke developed “coping cards” to give to her friends
and family members. These cards outlined the types of
behavioral and verbal responses that Brooke would want
from others when experiencing health anxiety symptoms;
in particular, she requested reminders to use her mindful-
ness skills, and asked her loved ones not to provide her with
reassurance about physical symptoms or suggest that she
visit a medical provider.
Three additional sessions then served as treatment
maintenance sessions. One week after the final treatment
session was a relapse prevention session. Brooke identi-
fied the specific mindfulness exercises, cognitive skills,
and self-care behaviors she would utilize into the future
to maintain the progress she made during treatment.
One month later was the first follow-up booster session.
Brooke reported continued improvements in her health
anxiety symptoms and overall functioning. She discussed
a recent event that posed a legitimate threat to her
physical health, and the ways in which this experience
helped her experientially learn the difference between
appropriate and inappropriate medical visits. At the second
booster session another month later, Brooke reported that
she continued to maintain her improvements and
implement her relapse prevention plan effectively.
Results
Acceptability
The current treatment was highly acceptable to Brooke
as evidenced by high treatment attendance and patient
feedback. Brooke participated in 16 sessions of treatment
over approximately a 5-month period, with consistent
and on-time attendance throughout, and only one missed
session. Brooke was regularly engaged in the treatment,
completing almost all of her assigned homework and
independently seeking out ways to facilitate her mindful-
ness practice (e.g., downloading her own smartphone
applications). She reported enjoying the mindfulness
exercises, particularly the 3-minute breathing space,
which she found most beneficial during her busy workday,
and the sitting-with-difficulties meditation, which she
found helped her shift her view of her catastrophic
thoughts about physical sensations to be “humorous.”
Treatment Effects
Subjective Outcomes
Brooke began to report decreased anxiety, greater
awareness of catastrophic thoughts, improved attentional
491
regulation, and fewer reassurance-seeking behaviors by
Session 4. Around this time, she also began to report
improvements in cognitive decentering, stating that she
had become aware of anxious thoughts, rational thoughts,
and “the one who watches the two.” By the midpoint
of treatment, Brooke described a greater awareness
and acceptance of anxiety, as well as other emotions
(e.g., frustration, irritability). She added that the im-
proved awareness, acceptance, and attention-regulation
skills were preventing her from “spiraling out of control”
when experiencing ambiguous physical sensations. At
the completion of treatment, Brooke reported less pre-
occupation with bodily sensations, a greater ability to
“notice thoughts and let them go,” and a greater sense
of “calm” overall. She added that her friends and family
had also noticed and commented on these changes.
Behavioral Outcomes
Brooke successfully reduced her reassurance-seeking
behaviors. She stopped researching physical symptoms
on the Internet by the fourth session, and maintained this
improvement consistently for the duration of the treat-
ment. She also stopped asking friends and family for
reassurance about her health around this time. Moreover,
she made efforts to ensure that friends and family under-
stood her health anxiety and responded appropriately by
encouraging her to utilize her new skills, and refraining
from offering her reassurance or suggesting that she
visit a health care provider. Brooke also considerably
reduced her unnecessary visits to medical providers.
Medical visits were patient-reported and verified by review
of Brooke’s electronic medical record. Over the course of
the 5-month treatment, she had six unnecessary medical
visits, and one medical visit for a legitimate physical health
concern. Most of these unnecessary visits (i.e., four out of
the six) occurred within the first 6 weeks of treatment;
from there, she did not have another unnecessary medical
visit until Session 11, and then Session 16 (see Figure 1).
Overall, her medical visits showed a 67% reduction in
frequency, decreasing from approximately 3 visits/month
pretreatment to less than 1 visit/month posttreatment.
Objective Outcomes (SHAI scores)
See Figure 1 for a plot of SHAI scores across each
session. Overall, Brooke’s scores showed a downward
trend over time. This improvement was shown to be
clinically significant, as evidenced by a final SHAI score
below the overall clinical cutoff of 27 (Alberts et al., 2013);
a 52% decrease in scores from the first to last session
(i.e., exceeding the standard 20% reduction for re-
sponder status; Behar & Borkovec, 2003); and a reliable
change index score of 12.32 (Jacobson et al., 1999).
Additionally, Brooke did not meet DSM-IV or DSM-5
criteria for a health anxiety-related disorder at the com-
pletion of treatment.
492
60 Brooke's Scores
50
SHAI Total Score
40
30
20
10
0
1 2 3 4
Figure 1. SHAI scores at the beginning of each session. Note. Asterisks = reassurance-seeking ED or urgent care visits; Square = medically
necessary urgent care visit. RP = relapse prevention session; B1 and B2 = 1- and 2-month booster sessions, respectively.
Discussion
The current study is the first to report the implemen-
tation of an individually delivered mindfulness-based
intervention for the treatment of health anxiety in an
individual therapy setting. Results suggest that the current
treatment was acceptable and feasible for reducing health
anxiety symptoms in a young woman with severe health
anxiety. These findings are congruent with prior pilot
studies that examined the group MBCT protocol for
health anxiety, and they extend previous research by
providing support for the delivery of mindfulness-based
CBT in individual therapy settings. Thus, these findings
add to the MBCT literature for clinicians by describing
methods for tailoring the delivering of MBCT for health
anxiety in individual settings, and providing evidence for
the feasibility of individual MBCT for health anxiety.
The patient reported several emotional and behavioral
improvements that were consistent with a mindfulness-
based cognitive-behavioral approach and may have
contributed to the observed positive treatment effects.
For example, she expressed that mindfully sitting with
difficulties (i.e., emotional exposures) enhanced her
ability to tolerate distress, and that noticing and accept-
ing internal events helped her to decenter from
catastrophic thoughts and refrain from engaging in
automatic reassurance-seeking behaviors. Thus, consis-
tent with theoretical accounts of mindfulness training
for health anxiety symptoms (Surawy et al., 2015),
previous studies of group-delivered MBCT for health
anxiety (McManus, Muse, Surawy, Hackmann, &
Williams, 2015), and research on specific cognitive and
behavioral techniques for health anxiety (Weck, Neng,
Richtberg, Jakob, & Ulrich, 2015), Brooke was able to
develop a more adaptive, decentered relationship to health
anxiety symptoms without needing to directly challenge the
content of catastrophic thoughts through traditional
cognitive techniques (e.g., probability estimation, direct
Luberto et al.
Clinical Cut-off Mean for Hypochondriasis Mean for Non-Clinical Adults
5 6 7 8 9 10 11 12 13 14 15 16 RP B1 B2
Session Number
cognitive restructuring). Additionally, Brooke reported
decreased reactivity to physical symptoms throughout
treatment, without learning relaxation strategies to inten-
tionally change her physiological state. Taken together,
Brooke experienced several improvements due to treat-
ment strategies that are shared with traditional CBT
techniques (e.g., exposure, distress tolerance) and strate-
gies that are unique to a mindfulness-based approach (e.g.,
cognitive decentering, mindful body awareness).
The magnitude of clinical effects observed for Brooke
was similar to those observed in previous pilot studies
of group-based MBCT for health anxiety. For example,
McManus et al. (2012) found medium-large clinical effects
for MBCT, with 50% of patients no longer meeting
diagnostic criteria for hypochondriasis at post-treatment
and 84% not meeting criteria at 1-year follow-up
(compared to 21% and 24%, respectively, in the
usual-care control group). They also found medium effects
for changes in SHAI scores (d = .34 to .49; McManus et al.,
2012). Lovas and Barsky (2010) found that 30% and 78%
of patients fell below the clinical cutoff on measures of
health anxiety at posttreatment and 3-month follow-up,
respectively. Given that Brooke’s improvements similarly
seemed to increase more toward the end of treatment
(e.g., fewer emergency department visits), these findings
collectively suggest that a mindfulness-based approach
might be particularly useful for promoting and maintaining
long-term benefits.
Importantly, this is the first study to demonstrate that
an individually delivered mindfulness-based cognitive-
behavioral intervention, largely informed by the MBCT
protocol, can be useful for treating health anxiety.
Indeed, Brooke’s improvements occurred in the absence
of group-based processes that could otherwise play a
role in the efficacy of these interventions. There are
several reasons to suspect that mindfulness-based inter-
ventions could be less effective in individual settings. For
 Mindfulness and Health Anxiety Case Study
example, given that mindfulness training involves culti-
vating a new approach toward experiences that can
seem counterintuitive, the group setting might provide
support, shared learning, and normalization of barriers
and challenges, helping patients remain open and en-
gaged in the process (Griffiths, Camic, & Hutton, 2009).
The group setting could also be important for promoting
increases in cognitive flexibility, as group members learn
experientially from others that there are several differ-
ent ways to think about similar experiences. Despite the
fact that the existing evidence base almost exclusively
supports the use of mindfulness-based interventions
developed and delivered as group therapies, with only
one other study to date examining individual MBCT
(Schroevers et al., 2015), clinicians are currently ad-
ministering mindfulness-based interventions in individ-
ual therapy settings (Schroevers et al., 2015). Thus, the
current findings can inform clinical practice and add to
the paucity of research on individualized mindfulness-
based interventions by providing preliminary evidence
that these treatments can still be helpful without group-
based components.
There may also be benefits to delivering mindfulness-
based interventions individually for health anxiety. The
individualized approach provides the ability to tailor
treatment to meet the patient’s needs and current level of
functioning. For example, given the severity of Brooke’s
baseline symptoms, we chose to introduce the body scan
exercise later in the treatment after Brooke developed
a general foundation of mindfulness skills, rather than
initiate the treatment with this exercise as done in the
original group protocol. The individual setting also
allowed for further exploration of core fears and beliefs,
which led to important insights that might otherwise have
been neglected in a group setting. For highly anxious
patients and those with health-related fears in particular,
the individual setting avoids the possibility that patients
will inadvertently reinforce or trigger one another’s
anxious concerns, helping treatment to progress more
smoothly. Logistically, individual therapies may also be
more feasible for clinicians to administer, as it can be
difficult to recruit enough participants and coordinate
multiple schedules with group interventions.
Modifications could also be made to the current
protocol based on the specific patient. For example, it
might be possible to deliver mindfulness-based CBT for
health anxiety in fewer sessions by not reserving sessions
for family members if unnecessary. Future protocols
could also include mindful stretching exercises to provide
exposure to a wider range of physical sensations, or frame
informal mindfulness exercises (e.g., mindful walking,
mindful eating) as behavioral activation interventions for
patients with comorbid mood difficulties. As mindfully
sitting with difficulties and cognitive decentering appeared
493
to be most helpful for Brooke, future protocols might
focus on retraining these key interventions. Brooke did
not report that any of the mindfulness interventions
were unhelpful, though the body scan was the most
challenging practice initially, even when introduced half-
way through treatment.
It is worth noting that Brooke’s SHAI scores showed a
nonlinear pattern of change consistent with cognitive-
behavioral theory. That is, although the frequency of ED
visits decreased overall, remaining ED visits tended to
occur after increases in scores, and led to temporary
decreases in scores. Thus, although the overall frequency
of ED visits decreased over time, the structure of the
behavioral pattern was more resistant to change. Provid-
ing direct feedback and psychoeducation about weekly
SHAI scores during sessions might have helped Brooke
gain insight into these patterns, anticipate increases in
symptoms, and plan ahead to refrain from acting on
increased symptoms at those times.
It is also important to consider how participating in
mindfulness-based interventions could serve as reassurance-
seeking for patients with health anxiety. Given the
increasing media attention and popular literature focused
on mindfulness for health and well-being, it is possible
that patients with health anxiety could be seeking mindful-
ness practice as another method to try to prevent illness.
Clinicians should be aware of this possibility and could
attempt to control for this potential confound by assessing
patients’ familiarity, prior experience, and expectations
of mindfulness practices at the onset of treatment. For
patients who are familiar with mindfulness and suggest
that it seems like a way to prevent physical illness, clinicians
could reiterate that, in the current treatment, mindfulness
is primarily a tool for simply becoming aware of the present
moment, and a key treatment goal is to disengage from
behaviors that are primarily intended to provide reassurance
about health status. Clinicians should also consider when
a patient’s efforts to extend treatment or avoid termina-
tion could be conceptualized as a form of reassurance-
seeking, and discuss any concerns about termination
with the patient. For Brooke specifically, concern about
the possibility of ignoring important physical symptoms
(i.e., through nonjudgment and nonreactivity) was more
salient than the idea that mindfulness training itself
could improve her physical health, and she was confident
and comfortable about terminating treatment once her
goals had been met. Future studies should further ex-
plore this possibility and how diverse patients with health
anxiety experience mindfulness-based treatments.
There are several limitations to the current study worth
noting. First, the current study reports preliminary find-
ings from a single case study, the results of which cannot
generalize to other individuals or groups, nor does it
imply efficacy or effectiveness of the approach. Future
494 Luberto et al.
research should consider more rigorous research methods,
including a multiple baseline approach or a randomized
trial design to further examine the efficacy and effective-
ness of individual MBCT for health anxiety. Second,
although Brooke’s SHAI scores showed a large and
clinically meaningful decrease over time, ultimately falling
below the clinical cutoff, her final score did not meet
all possible criteria for clinical significance (e.g., it was
not within one standard deviation above the mean for
age-matched peers without health anxiety). This final score
may reflect Brooke’s baseline functioning. Alternatively,
because this score is somewhat inconsistent with Brooke’s
subjective reports and behavioral improvements, it is
possible that it reflects measurement difficulties rather
than a true limited treatment effect. Indeed, several items
on the SHAI are more consistent with a traditional,
change-oriented CBT approach, and would not be sensitive
to adaptive changes from a mindfulness-based perspective
(e.g., “I am aware of aches and pains in my body all the
time”). Lastly, as is typical for many severe cases within
a CBT framework, the current treatment was relatively
long due to Brooke’s very severe baseline functioning.
However, the length was similar to other CBT protocols
for health anxiety (e.g., Greeven et al., 2007).
Overall, the current study suggests that it is feasible
to deliver mindfulness-based cognitive-behavioral inter-
ventions in individual therapy settings for the treatment
of health anxiety. Future research should examine the
efficacy of individually delivered mindfulness-based inter-
ventions for health anxiety, as well as for other psycho-
logical problems, using larger randomized controlled
designs. Additionally, it may be informative to conduct
dismantling studies that elucidate the effective compo-
nents of MBCT interventions; comparative effectiveness
studies that examine MBCT alongside more traditional
CBT or “third-wave” CBT interventions (e.g., Acceptance
and Commitment Therapy); and longitudinal mediation
studies that examine purported mechanisms of MBCT
effects, including improvements in mindfulness, cognitive
decentering, body awareness, and distress tolerance.
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The authors have no conflicts of interest to disclose.
Address correspondence to Christina M. Luberto, Ph.D., Depart-
ment of Psychiatry, Massachusetts General Hospital, 15 Parkman
Street, Boston, MA, 02114; e-mail: cluberto@mgh.harvard.edu.
Received: September 25, 2015
Accepted: October 1, 2016
Avaliable online 29 October 2016