Paul Martin Salkovskis

• Professor (Full) at University of Oxford

Background The COVID-19 pandemic has had a negative impact on the population’s mental health, particularly for individuals with health anxiety (HA) and obsessive compulsive disorder (OCD). This is in conjunction with a significant change in accessibility of face-to-face psychological services which have had to rapidly adapt to the remote delivery o...

Objectives Hoarding difficulties (HD) affect many people and cause upset and danger for the person, as well as friends and family. Previous research found that people with HD feel less adequately socially supported compared with individuals with obsessive compulsive disorder (OCD). This study used the perspective of those offering support to infer...

Background Sudden gains are large symptom improvements between consecutive therapy sessions. They have been shown to occur in randomised controlled trials of internet-delivered psychological interventions, but little is known about their occurrence when such treatments are delivered in routine clinical practice. Objective This study examined the o...

Background Cognitive behavioural therapy (CBT) has, in the space of 50 years, evolved into the dominant modality in psychological therapy. Mechanism/s of change remain unclear, however. Aims In this paper, we will describe key features of CBT that account for the pace of past and future developments, with a view to identifying candidates for mecha...

Excessive reassurance seeking (ERS) is believed to play an important role in maintaining mental health problems, in particular anxiety disorders such as obsessive-compulsive disorder and health anxiety. Despite this, therapists commonly give into patients’ requests for reassurance in clinical settings and are generally unsure how to handle the issu...

Objectives: Unmet interpersonal needs may play a role in excessive emotional attachments to objects for people with hoarding disorder (HD). Previous research indicates that social support (but not attachment difficulties) may be specific to HD. The study aimed to evaluate social networks and support in HD relative to clinical controls with obsessi...

Current views of psychological therapies for trauma typically assume the traumatic event to be in the past. Yet, individuals who live in contexts of ongoing organized violence or experience intimate partner violence (IPV) may continue to be (re)exposed to related traumatic events or have realistic fears of their recurrence. This systematic review c...

Hoarding disorder is a surprisingly common problem which impacts on most areas of life. People who hoard typically have multiple agencies involved in their care due to the complex health and safety impact and risks associated with hoarding. ‘Treatment’ involves finding ways of supporting discarding large amounts, typically underpinned by CBT princi...

Since its inclusion in the DSM-III , various theories and treatment approaches have been developed for generalised anxiety disorder (GAD). Aaron T. Beck was the first to offer a cognitive conceptualisation of GAD in Anxiety Disorders and Phobias: A Cognitive Perspective . This original cognitive model of GAD was initially found to be promising in t...

Objectives: Mental contamination (MC) describes subjective internal feelings of 'dirtiness', which are experienced in the absence of direct physical contact/contaminants. There is evidence of a link between MC in obsessive compulsive disorder (OCD) and the experience of past betrayals. However, it has also been noted that 'perpetrators' also exper...

Objectives: Fear of relapse (FOR) after experiencing psychosis has been found to predict actual relapse; however, potential mechanisms underlying this relationship have not been investigated. Negative appraisals of 'prodromal symptoms' are believed to play an important role in both psychosis and mental health anxiety (MHA). This study aimed to exp...

Background Generalised anxiety disorder (GAD) has been an uneasy member of the anxiety disorders group since its inclusion in the third edition of the DSM . Multiple theories and treatment protocols for GAD and its defining symptom, excessive worry, have comparable efficacy in treating GAD symptoms. Crucially, these theories of GAD and excessive wo...

Introduction: Persistent physical symptoms that are medically unexplained can result in significant functional impairment. The aim of this study was to estimate the prevalence of persistent physical symptoms among people seeking primary healthcare in Reykjavík, Iceland, how they relate to functional impairment, symptoms of depression, general anxi...

Background and objectives Transdiagnostic mechanisms of change (txMOC) specific to cognitive behaviour therapy are poorly understood. Salkovskis (1996) proposed one such mechanism in terms of the shift towards an alternative, less negative view of their problems or cognitive flexibility. This hypothesis has been described as involving a shift in be...

Background There is little research on cognitive factors that characterize the initiation of compulsive washing in obsessive–compulsive disorder (OCD). The present study seeks to contribute to a better understanding of the goals that are salient at the start of compulsive hand washing.Methods Thirty-eight individuals diagnosed with OCD with predomi...

Background: Evidence-based treatment for panic disorder consists of disorder-specific cognitive behavioural therapy (CBT) protocols. However, most measures of CBT competence are generic and there is a clear need for disorder-specific assessment measures. Aims: To fill this gap, we evaluated the psychometric properties of the Cognitive Therapy Co...

Objectives Mental contamination (MC) describes subjective internal feelings of ‘dirtiness’ which are experienced in the absence of direct physical contact/contaminants. There isevidence of a link between MC in Obsessive Compulsive Disorder (OCD) and the experience of past betrayals. However, it has also been noted that “perpetrators” also experienc...

Background Little is known about the impact of interpersonal betrayal experiences on mental health. Research suggests a link between betrayal and mental contamination (MC) within some forms of obsessive compulsive disorder (OCD). This study represents an initial exploration of that link in clinical samples. Aims A measure for assessing perceptions...

Background: Clinical guidelines recommend the use of an intensive version of cognitive behavioural therapy (iCBT) in obsessive compulsive disorder (OCD) when evidence-based treatment has previously failed. This systematic review aimed to 1) assess the efficacy of iCBT for adults with OCD; 2) assess the acceptability of iCBT for adults with OCD.Meth...

Background: The National Institute for Health and Care Excellence (NICE) recommend an intensive version of treatment for service users who have not responded to > 2 treatments for Obsessive Compulsive Disorder (OCD). The views of service users for whom this format of treatment is recommended are unknown. Method: Thirty semi-structured telephone int...

Background: Cognitive Behavioural Therapy (CBT) is an effective psychological treatment for Obsessive Compulsive Disorder (OCD), but not all service users’ benefit from treatment. The factors involved in non-optimal response have been largely examined from the perspective of therapists. The current study explored the reasons for treatment failure f...

Objectives It is well known that mental health problems can recur even after effective treatment, leading to an understandable fear of illness recurrence (FIR) and mental health anxiety (MHA). These may themselves contribute to the process of relapse. This study aims to examine whether people recovering from psychosis have greater FIR than those re...

Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (CFS/ME) is a debilitating condition that affects 0.2-0.4% of the population. Health focussed anxiety is common across medical conditions, and may be relevant in CFS/ME. This study sought to identify the prevalence and impact of health anxiety (HA) in CFS/ME and evaluate the effectiveness of Cognit...

Hoarding disorder (HD) in young people is little understood yet research conducted in adult populations suggests that the onset of HD occurs in early adolescence. There are no empirically based guidelines for how to treat hoarding in young people. This is the first case study adopting a single-case experimental design and hoarding specific measures...

Objective Transdiagnostic cognitive behaviour therapy (TCBT) is an efficacious treatment for anxiety and depression, but its mechanisms of change remain poorly understood. The current study used thematic framework analysis to analyse how patients, recruited in a recent trial on transdiagnostic group CBT (TGCBT), understood the treatment and its mec...

Background: In recent years, cognitive behavioural group therapies (CBGT) have been increasingly deployed as a strategy to increase the efficiency and cost-effectiveness in treatment of common mental health problems. The vast majority of these therapies are disorder specific, but in the last few years there has been growing interest in transdiagno...

People typically delay many years after developing OCD before they seek help. Factors linked to the decision whether to seek treatment have been identified. Decision-making literature suggests that outcomes of decision making are related to the factors which form the focus of attention and awareness. We evaluated whether focussing on enablers for t...

Objectives: 'Mental defeat' (MD) has been identified among people with chronic pain as a type of self-processing related to social role and rank. Research has linked it to anxiety, pain interference and functional disability. The relationship between MD and other cognitive constructs, such as hopelessness and depression, remains poorly understood....

Die Krankheitsangststörung wird aus einer kognitiv-behavioralen Perspektive vorgestellt. Es wird beschrieben, wie durch selektive Aufmerksamkeit, Missinterpretationen von Informationen und körperlichen Veränderungen im Sinne von Bedrohung und daraus folgenden dysfunktionalen Bewältigungsversuchen ein sich aufrechterhaltender Kreislauf entsteht. Vor...

Zwänge galten bis zur Entwicklung verhaltenstherapeutischer Ansätze in den 1960er Jahren lange Zeit als praktisch unbehandelbar. In diesem Kapitel werden Form und Inhalt aufdringlicher und beängstigender Zwangsgedanken sowie offene und verdeckte Zwangshandlungen zu deren Neutralisieren beschrieben. Aus einer kognitiv-behavioralen Theorie des Zwangs...

Background: Multiple sclerosis (MS) is commonly associated with psychological complications. Previous research by Hayter and colleagues (2016) found that in patients with MS, health anxiety (HA) can account for part of the variance in quality of life (QoL) independent of physical and cognitive impairment caused by the disease. MS patients with HA...

Background Health anxiety is an under-recognised but frequent cause of distress that is potentially treatable, but there are few studies in secondary care. Objective To determine the clinical effectiveness and cost-effectiveness of a modified form of cognitive–behaviour therapy (CBT) for health anxiety (CBT-HA) compared with standard care in medic...

Cognitive Behaviour Therapy for Health Anxiety: A Systematic Review and Meta-Analysis – CORRIGENDUM - Volume 45 Issue 6 - K. Cooper, J. D. Gregory, I. Walker, S. Lambe, P. M. Salkovskis

The purpose of the present study was to explore the experience of being asked for reassurance from the perspective of carers of obsessive compulsive disorder (OCD) sufferers, and to examine its relationship to sufferers’ reassurance seeking by a direct comparison with data obtained from the person they normally offer reassurance to. Forty-two indiv...

Excessive reassurance seeking (ERS) is commonly reported in patients who have OCD or health anxiety. Despite its prevalence and associated risk of ongoing difficulties, little is known about the function of ERS. It has been conceptualised as a type of compulsive checking behaviour, but could also be seen as being a supportive maneuver. This study o...

Physical health outcomes for patients with long-term conditions can be significantly affected by their psychological wellbeing; those experiencing psychological difficulties are less able to manage symptoms, have a poorer quality of life, and more frequent hospital admissions. National guidance recommends the assessment and treatment of psychologic...

This chapter provides a practical guide to assessing obsessive-compulsive disorder (OCD) that is both informative to the inexperienced clinician and addresses questions raised by the experienced clinician. It will summarize the diagnostic criteria for OCD, including advice on making a differential diagnosis when presented with symptoms that are ass...

This chapter guides the reader through the process of eliciting a shared understanding of obsessive-compulsive disorder (OCD), working collaboratively with the client—a cornerstone of the cognitive-behaviour therapy (CBT) approach. Step-by-step guidance includes examples of therapy dialogue for key aspects of this process. The emphasis in CBT is ty...

This chapter provides guidance on some of the issues of complexity, using a number of examples, including case illustrations of mental contamination, post-traumatic stress disorder, and perfectionism. There is a detailed consideration of incorporating compassionate mind work on shame. As obsessive-compulsive disorder (OCD) has a great impact on oth...

This chapter provides detailed background information on obsessive-compulsive disorder (OCD) that will give the therapist a clear understanding of current knowledge about the context and causes of this problem. Research evidence on the epidemiology of OCD, impact, and causal factors is presented. Here we introduce the cognitive-behavioural model of...

Background: Cognitive behavioural interventions for excessive reassurance seeking (ERS) typically focus on encouraging individuals to refrain from seeking any reassurance and in some cases banning caregivers (e.g. family members) from providing it. However, this blanket consideration that reassurance is a bad thing that should simply be stopped ma...

Objectives: Obsessive compulsive disorder (OCD) can be hugely disabling. Although very effective psychological treatments exist, many people delay years before seeking help or never seek treatment. There have been clinical observation and short questionnaire studies on why people delay, but little qualitative research exists on this complex subjec...

Aims and objectives The aims of this study were to understand the emotional and psychological experiences of patients with heart failure in a busy NHS service and make recommendations for how best to support this population. Background People with heart failure often experience depression, anxiety and other emotional and psychological difficulties...

Background: Health anxiety (HA), or hypochondriasis, is a psychological problem characterized by a preoccupation with the belief that one is physically unwell. A 2007 Cochrane review (Thomson and Page, 2007) found cognitive behavioural therapy (CBT) to be an effective intervention for individuals with HA. Similar findings were reported in a recent...

Background: There is increasing recognition that perinatal anxiety disorders are both common and potentially serious for mother and child. Obsessive-compulsive disorder (OCD) can be triggered or exacerbated in the postpartum period, with mothers reporting significant effects on parenting tasks. However, there is little evidence concerning their ef...

Medically unexplained symptoms (MUS) are not only common and distressing, but are also typically poorly managed in general medical settings. Those suffering from these problems tend to incur significantly higher health costs than the general population. There are many effective treatments for different MUS; these are almost entirely based on cognit...

While there is considerable evidence that the factors involved in hoarding typically begin to manifest early in life (mostly in adolescence), the majority of those sampled in research studies are in their later years. As so much of our understanding of the psychological factors involved in hoarding is derived from those who are older and more chron...

Background: Repeated checking in OCD can be understood from a cognitive perspective as the motivated need to achieve certainty about the outcome of a potentially risky action, leading to the application of Elevated Evidence Requirements (EER) and overuse of subjective criteria. Method: Twenty-four obsessional checkers, 22 anxious controls, and 2...

One of the puzzles surrounding social phobia is that patients with this problem are often exposed to phobic situations without showing a marked reduction in their fears. It is possible that individuals with social phobia engage in behaviors in the feared situation that are intended to avert feared catastrophes but that also prevent disconfirmation...

Objectives: Psychological difficulties are a common complication among patients with respiratory disease, and are associated with poorer health outcomes and increased use of healthcare. As prevalence studies typically sample patients from community settings, this study aimed to explore the extent and nature of psychological difficulties during acu...

Obsessive–compulsive disorder (OCD) is a relatively common and disabling condition. Objectives To determine the clinical effectiveness, acceptability and cost-effectiveness of pharmacological and psychological interventions for the treatment of OCD in children, adolescents and adults. Data sources We searched the Cochrane Collaboration Depression...

Background: Obsessive-compulsive disorder (OCD) was historically regarded as untreatable. In 1965, OCD was seen as an intractable and deteriorating condition, with little hope of improvement. It was not understood, generally regarded as a kind of "pre-psychotic" state, with sufferers permanently at risk of being tipped over that edge. Treatment was...

Objectives: Multiple sclerosis (MS) is a progressive disease with an unpredictable prognosis. Previous studies have reported health anxiety within the MS population. This study examines the effect of health anxiety on MS patients' quality of life (QoL) and evaluates the potential contribution of cognitive factors in maintaining health anxiety. Me...

Purpose – Many children who are looked after by the state have experienced adverse and traumatic life circumstances prior to being removed from their biological parents. Previous research has highlighted that many of them experience barriers to accessing psychological therapies. The purpose of this paper is to investigate the feasibility of assessi...

It has been suggested that an act of a betrayal by a trusted person is a particularly important "violation" which can lead to feelings of "mental contamination". Most experimental research has used an imaginal task referred to as the "dirty kiss" (an imagined scenario of a non-consensual kiss). The theoretical emphasis in these studies has been on...

Introduction and objectives Health outcomes for patients with respiratory conditions can be significantly affected by their psychological wellbeing; those experiencing psychological difficulties are less able to manage symptoms, have a poorer quality of life, and have more frequent hospital admissions. National guidance recommends the need for the...

Excessive Reassurance Seeking (ERS) is an under-researched and poorly understood behavior that resembles the compulsive behaviors that are typically seen in OCD. ERS can be complex, persistent, extensive, debilitating and may dominate people's interactions. In addition to resembling compulsive checking in OCD it may also have the effect of transfer...

It is often suggested that, in general, co-morbid personality disorders are likely to interfere with CBT based treatment of Axis I disorders, given that personality disorders are regarded as dispositional and are therefore considered less amenable to change than axis I psychiatric disorders. Aims: The present study aimed to investigate the impact o...

Objectives: As people become increasingly physically dependent as they make the transition into older age, they may lose the ability to control bodily functions. Problems with eating, voiding and washing can be linked with feelings of disgust and, given the necessity for some of being assisted with intimate care activities, it has been suggested t...

Background: The development of initiatives to improve access to psychological therapies has been driven by the realization that untreated anxiety and depression are both very common and costly to individuals as well as society. Effective and efficient treatments, mostly in the form of cognitive behavioural therapies (CBT), can be used in ways whic...

Background and objectives: The perception of threat and associated feelings of anxiety typically prompt people to seek safety; reassurance seeking is an interpersonal strategy almost universally used to reduce the immediate perception of risk. Excessive Reassurance Seeking (ERS) is considered to be particularly prominent and unequivocally counter-...

There is concern that diagnostic labels for psychiatric disorders may invoke damaging stigma, stereotypes and misunderstanding. Aims: This study investigated clinicians’ reactions to diagnostic labelling by examining their positive and negative reactions to the label borderline personality disorder (BPD). Method: Mental health professionals ( n = 2...

Many patients want help in considering medical information relevant to treatment decisions they have to make or agree to. The present research investigated whether focussing on particular issues relevant to a medical treatment decision (using an apparently non-directive procedure) could systematically bias a treatment decision. In a randomized desi...

Objectives Diagnosis is ubiquitous in Psychiatry, and whilst it does bring benefits; adverse effects of ‘labelling’ may also be possible. This study aimed to evaluate experimentally whether clinicians’ judgements about a patient with panic disorder were influenced by an inappropriately suggested diagnosis of comorbid borderline personality disorder...

The birth of a pre-term baby is an acutely stressful event for parents. Consideration of the factors which help parents cope with NICU can help achieve the best possible outcome for NICU babies. The study objective was therefore to understand better the factors which support coping. A consecutive sample of NICU parents participated in semi-structur...

Some individuals with Obsessive Compulsive Disorder (OCD) may experience recurrent intrusive distressing images, which may be emotionally linked to past aversive memories. Our aim was to investigate whether Imagery Rescripting was an effective intervention for such individuals with OCD. Twelve cases who experienced intrusive distressing images are...

Background: The development of transdiagnostic standardized measures of psychological distress have contributed to the development of practice-based evidence networks. The translation and validation of such measures cross culturally is important if such research is to be generalized across health care systems in different countries. Method: Tran...

While the benefits of routine outcome measurement have been extolled and to some degree researched, it is surprising that service user opinions on this common therapy practice have largely not been investigated. This study aimed to assess service users’ experiences of completing measures during psychological therapy, with a view to exploring how th...

The Children and Young People's Improving Access to Psychological Therapies (CYP IAPT) programme emphasizes the meaningful contribution session-by-session routine outcome monitoring (ROM) can make to clinical practice and its importance in highlighting services’ effectiveness. Two studies on issues related to the implementation of ROM in children's...

Health anxiety is common in medical settings and can be treated successfully by cognitive behaviour therapy. However it is not clear who might be best placed to deliver this therapy. In a planned secondary analysis of data from a randomised trial of adapted cognitive behaviour therapy for health anxiety we compared outcomes of therapy delivered by...

BACKGROUND: Stiff Person Syndrome (SPS) is a rare neurological condition, characterised by rigidity in the trunk and limbs. Comorbid anxiety is common and known to exacerbate stiffness. OBJECTIVE: This case study examines the extent to which psychological treatment of comorbid anxiety alleviated stiffness in a patient whose condition was exacerbat...

This case study describes the treatment of Mr A, a patient with Stiff Person Syndrome (SPS) whose lower limb stiffening was aggravated severely in public situations by social anxiety. A cognitive-behavioural model was applied to treat this problem, focussing on reducing anxiety and therefore stiffness by addressing rumination, self-focussed attenti...

A cognitive-behavioural model of depersonalisation disorder (DPD) suggests that catastrophic attributions and appraisals, and increased attention to symptoms, play important roles in the development and maintenance of the disorder. Empirical testing of this model was investigated in three groups: 25 patients with DPD, 21 patients with anxiety (obse...

Trauma-focused psychological treatments are recommended as first-line treatments for Posttraumatic Stress Disorder (PTSD), but clinicians may be concerned that the good outcomes observed in randomized controlled trials (RCTs) may not generalize to the wide range of traumas and presentations seen in clinical practice. This study investigated whether...

The relationship between Obsessive Compulsive Disorder (OCD) and Obsessive Compulsive Personality Disorder (OCPD) has been the subject of interest for some time due to the historical assumption that OCPD causes OCD. This study systematically examined the association between OCD and OCPD in terms of prevalence and clinical presentation. The specific...

The aim was to examine the impact of training on cognitive behavior therapy (CBT) formulation skills. Eighty-five clinicians were randomly assigned to two experimental conditions. The experimental manipulation was the timing of assessment of formulation skills, that is, either before or after participation in a training workshop. The preworkshop re...

Cognitive behavioural therapy (CBT) is an empirically grounded approach which typically relies on formulation to guide the shape and course of therapy. Cognitive formulation is widely advocated but poorly understood at an empirical level. This study aimed to characterize how clinicians understand the structure and uses of formulation and how they r...

Objectives: The aim of this study is to improve our understanding of the ways in which a medical consultation style relates to satisfaction and adherence. Design: Participants completed questionnaires about preferred and perceived consultation styles; psychological variables such as satisfaction, anxiety and depression; and questions about takin...

Objectives: The concept of mental defeat (MD) has been applied to describe the deeper impact of pain on the person's sense of self. It describes an intense psychological reaction to pain, whereby people feel that pain has taken away their autonomy and identity. Although MD has been found to characterize Western individuals who are most distressed...

Recent research suggests that hoarding problems may be relatively heterogeneous, with the suggestion that three belief dimensions may underpin hoarding experiences, namely harm avoidance, fear of material deprivation, and heightened "sentimentality" in relation to possessions. The role of these hypothesised belief dimensions in hoarding was evaluat...

The earliest description of behavioral treatment of obsessive-compulsive disorder (OCD) was by Vic Meyer (1966), in a paper titled Modification of expectations in cases with obsessional rituals. This work formed the nucleus of what came to be known as exposure and response prevention (ERP) (Rachman and Hodgson, 1980). This cognitive emphasis in the...

Background: Reassurance seeking is particularly prominent in obsessive-compulsive disorder (OCD) and may be important in OCD maintenance. Aims: This study used a new self-report questionnaire to measure the range of manifestations of reassurance-seeking behaviours, describing their sources from which they seek, frequency, process (how they seek)...

Mental contamination is a phenomenon whereby people experience feelings of contamination from a non-physical contaminant. Rachman (2006) proposes that standard cognitive behavioural treatments (CBT) need to be adapted here and there is a developing empirical grounding supporting the concept, although suggestions on adapting treatment have yet to be...